BWFH Just Culture team shares best practices at Culture of Safety Workshop
The Academic Medical Center Patient Safety Organization (AMC PSO) recently invited Brigham and Women’s Faulkner Hospital’s Just Culture team, along with Paul LeSage from SG Collaborative Solutions, LLC and Brigham and Women’s Hospital’s Just Culture team, to present at the Culture of Safety Workshop for the AMC PSO member hospitals. The AMC PSO is an organization authorized by federal legislation which enjoys peer review protection by statute in order to identify and trend patient safety events across institutions, and to provide an opportunity to share the results of best practices across its membership.
The two-day workshop held at CRICO’s offices was led by LeSage, who presented a sustainable reliability model as a framework for improving risk mitigation and safety culture, including staff engagement and empowerment. His presentation introduced the concept of using risk probability analysis for building effective action plans and how to integrate Just Culture through the adverse event reporting and investigation processes. A case review session helped attendees apply the core concepts from the presentation.
Director of Clinical Compliance, Risk Management and Credentialing Joanne Locke was there to represent BWFH. “We were invited to talk about how we have expanded the Just Culture concept and the commitment at the community hospital level,” she says.
In her presentation, Locke noted that BWFH has gone so far as to integrate Just Culture into RL Solutions, our online patient safety reporting system. Director of Patient Safety, Quality, Infection Control and Accreditation Christi Barney and Patient Safety Consultant Tayla Hough have developed prompts within the online safety reporting system to encourage use of the Just Culture methodology by managers and directors. When a staff member enters a report into RL Solutions, they are asked if they would like a Just Culture consult. “Paul [LeSage] says we’re the only healthcare institution that has come so far as to embed Just Culture into the online safety report and to collect and trend data. Prior to this only the airline industry has successfully developed the ability to collect and trend data of this type,” explains Locke.
Of particular interest to participants was the SG Collaborative Solutions model, also referred to as Collaborative Culture of Safety, which looks first at the system issues that contributed to an adverse outcome or near miss event, and then examines how the individual employee makes behavioral choices within the confines of the system. Locke says, “The integration of system contributors and employee choices is an important advance for healthcare because previously healthcare institutions often viewed adverse events with an eye toward punishing employees for choices that place patients at risk of harm. Now institutions look at the event holistically to determine whether the institution’s systems placed its employees in a situation that drove them to make choices that increased the risk of error and patient harm.” This involves approaching investigations with a sense of curiosity rather than criticism to determine whether the employee was facing competing priorities to patient safety such as production or efficiency that may have contributed to an employee’s decision to forget a policy or use a short cut that increases the risk of harm.
In 2017, the Just Culture Steering Committee at BWFH is being transformed into the Just Culture Advisory Council with the goal of maintaining awareness of the culture change and improving hospital-wide use of the methodology. The committee is developing a worksheet for managers that will help them to use the algorithm as well as offering live support.
BWFH will also continue to share best practices. The Just Culture team has been invited to present an introduction to Just Culture methodology to the BWFH’s council for PCAs, USTs and MHAs about the Just Culture methodology. Later, they will meet with the Center for Medical Simulation to talk about how Just Culture methodology might be applied to the debriefing sessions following simulation scenarios.