What comes to mind when you think about the term "just culture"? Consider the following dilemmas:
Two nurses select the wrong medication from the dispensing system. One dose reaches a patient, causing him to go into shock, and the other is caught at the bedside before causing harm. Do we treat these nurses in the same way?
A nurse loses custody of a yet unlabeled specimen but chooses not to report the incident out of fear of discipline. Do we forgive the breach, given the nurse's fear?
An entire surgical team defends skipping the presurgical timeout on the basis that no adverse event occurred. Do we condone this violation?
These are just a few examples of dilemmas that might be addressed with the philosophy of a just culture. Just culture refers to a values-supportive model of shared accountability. It's a culture that holds organizations accountable for the systems they design and for how they respond to staff behaviors fairly and justly. In turn, staff members are accountable for the quality of their choices and for reporting both their errors and system vulnerabilities (Griffith, 2009).
A just culture recognizes that individual practitioners should not be held accountable for system failings over which they have no control. A just culture also recognizes that many individual or active errors represent predictable interactions between human operators and the system in which they work. However, in contrast to a culture that touts no blame as its governing principle, a just culture does not tolerate conscious disregard of clear risks to patients or gross misconduct, such as falsifying a record, performing professional duties while intoxicated, etc.
Dr. Lucian Leape, a member of the Quality of Health Care in America Committee at the Institute of Medicine and adjunct professor of the Harvard School of Public Health, stated that the single greatest impediment to error prevention in the medical industry is "that we punish people for making mistakes." Leape (2009) indicated that in the healthcare organizational environment in most hospitals, at least six major changes are required to begin the journey to a culture of safety:
We need to move from looking at errors as individual failures to realizing they are caused by system failures
We must move from a punitive environment to a just culture
We must move from secrecy to transparency
Care must change from being provider-centered (doctor-centered) to being patient-centered
We must move our models of care from reliance on independent, individual performance excellence to interdependent, collaborative, interprofessional teamwork
Accountability must be universal and reciprocal, not top-down
People make errors, which lead to accidents. Accidents lead to deaths. The standard solution is to blame the people involved. But if we find out who made the errors and punish them, are we solving the problems? No. The problem is seldom the fault of an individual; it is the fault of the system. Changing the people without changing the system will perpetuate the problems.
How can we change systems to encourage individuals to report errors and learn from their mistakes? A just culture seeks to create an environment that encourages individuals to report mistakes so that the precursors to error can be better understood in order to fix the system issues. Individual practitioners should not be held accountable for system failings over which they have no control. In a just culture, individuals are continually learning, designing safe systems, and managing behavioral choices. Events are not things to be fixed, but opportunities to improve understanding of the system.
How do you get started with a just culture initiative and ensure that all staff members feel free to report errors? There needs to be an administration that supports the concepts of a just culture and encourages staff to report errors. Highly reliable industries foster mindfulness in their workers. Mindfulness is defined by Weick and Sutcliffe (2001) as being composed of five components:
A constant concern about the possibility of failure even in the most successful endeavors
Deference to expertise regardless of rank or status
An ability to adapt when the unexpected occurs (commitment to resilience)
An ability to concentrate on a specific task while having a sense of the bigger picture (sensitivity to operations)
An ability to alter and flatten hierarchy as best fits the situation
Health organizations are now writing and promoting just culture policies and documents. The Joint Commission leadership standards (Schyve, 2009) address leadership and safety specifically relating to the organization's governing body (the CEO and senior management and medical and clinical staff leaders). The Joint Commission (formerly JCAHO) suggests instituting an organizationwide policy of transparency that sheds light on all adverse events and patient safety issues within the organization, thereby creating an environment where it is safe for everyone to talk about real and potential organizational vulnerabilities and to support each other in an effort to report vulnerabilities and failures without fear of reprisal.
Regular monitoring and analysis of adverse events, open discussions of safety risks and barriers to safety, and ensuring that caregivers involved in adverse events receive attention that is just, respectful, compassionate, supportive, and timely are also addressed in the standards.
Rather than only react to the actual harm involved in a discovered event, an organization with a just culture assesses the daily risk inherent in its organization and works toward maximum reliability to prevent future adverse events, relentlessly improving both system design and the quality of collective behavioral choices. One of the defining qualities of a just culture is its commitment to values, including learning cultures, open and fair cultures, safe system design, and effective management of behavioral choices. A just culture fosters an environment in which employees hunger for knowledge and eagerly seek to understand risk at both individual and organizational levels (Griffith, 2009).
A just culture is one component of an accountable care organization (ACO). These organizations have a reporting, just, and flexible culture focused on improving safety and reliability through behavioral accountability and process design. Safety in ACOs is a core value. The focus is not on blame, but transparency. They provide high-value accountable healthcare delivery for patients, communities, and the providers they serve. We should all want to be part of an ACO.
References
American Nurses Association. (2010). Position statement on just culture. Accessed April 3, 2010, at http://tinyurl.com/3a73yox.
Griffith, K.S. (2009). "Column: The Growth of a Just Culture." The Joint Commission Perspectives on Patient Safety 9 (12): 8–9.
Leape, L.L. (2009). "Errors in medicine." Clinica Chimica Acta 404 (1): 2–5.
Schyve, D.M. (2009). "Leadership in healthcare organizations: A guide to Joint Commission leadership standards." Accessed April 22, 2010, at www.jointcommission.org/NR/rdonlyres/48366FFD-DB16-4C91-98F3-46C552A18D2A/0/WP_Leadership_Standards.pdf.
Weick, K.E. & Sutcliffe, K.M. (2001). Managing the Unexpected: Assuring High Performance in an Age of Complexity. San Francisco: Jossey-Bass.
Barbara A. Brunt, MA, MN, RN-BC, is the director of nursing education and staff development at Summa Health System, a multihospital system in Akron, OH.
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Nearly half of U.S. physicians say language and cultural barriers are at least minor obstacles to providing high-quality patient care, according to a study released by the Center for Studying Health System Change, a nonpartisan policy research organization located in Washington, DC.
The study highlights the need for healthcare providers to address non-English-speaking patients, especially as the percentage of non-English speakers rises.
The latest U.S. census data, collected in 2000, says 47 million residents over the age of five (18% of the total population) speak a language other than English at home. In 1990, 31.8 million residents (14%) reported they did not speak English at home, and in 1980, 23.1 million residents (11%) did the same.
Considering communication is at the heart of what staff members do, staff leaders should treat solving the problem of language and cultural barriers as a top priority.
Such obstacles "can lead to wrong clinical paths and poor outcomes, even disastrous outcomes," says Barbara Bogomolov, RN, MS, BSN, manager of refugee health and interpreter services at Barnes-Jewish Hospital, a member of BJC HealthCare, in St. Louis.
Use interpreters to bridge communication gaps
Patients rely on staff—such as nurses and case managers—to explain forms such as the Important Message from Medicare, provide instruction on performing post-discharge tasks, and ensure their concerns are met. However, many facilities lack resources to address non-English-speaking patients, says Bria Chakofsky-Lewy, RN, supervisor of Community House Calls/Interpreter Services at Harborview Medical Center in Seattle.
Harborview has used its Community Health Calls program to help bridge linguistic and cultural barriers for 16 years.
Originally established to serve the county's East African and Cambodian refugees, the program has since expanded to provide services to patients that speak Spanish, Vietnamese, and Somali.
Harborview employs 50 state-certified medical interpreters that speak 26 languages and serve a patient population that speaks 80 languages. Harborview had more than 100,000 interpreter encounters in 2009.
When Harborview has a patient that speaks a language that is not in its medical interpreters' repertoire, it gets help from an outside interpreter service agency. Facilities that do not have interpreters on staff should at the very least have access to a strong telephone interpreter service, says Bogomolov. Facilities should never rely on a patient's family members or a bilingual staff member in another department to provide interpretive services. "There are issues of bias, performance, patient safety, and confidentiality," she says.
The National Standards on Culturally and Linguistically Appropriate Services (CLAS) do not allow a patient's family members to interpret medical instructions unless the patient specifically requests that they be allowed to do so.
For more information on the CLAS standards, visit the U.S. Department of Health and Human Services' Web site at http://hcpro.com/url/1230.
Facilities can also take advantage of interpreters as a source of cultural information. "It's not all about language. We are used to Western-educated patients understanding their rights and obligations to make choices for themselves, but many [patients] come from cultures where that is not normal or appropriate," Bogomolov says.
Tip: Staff should have a pre-conference with interpreters before they interact with patients. During that time, interpreters will learn what the expectations are for the medical encounter, and they can alert healthcare providers of any cultural barriers that may obstruct those expectations.
Choose an interpreter
Interpreters should have credentials or some other means of displaying competence in both languages. Keep in mind good interpreters don't necessarily provide word-for-word translations. Sometimes medical terms have no direct translation.
"There is no word in Somali for MRI," Chakofsky-Lewy says.
Although they do not need to possess a strong clinical competence, interpreters should have enough familiarity with medical terminology to be able to create word pictures that the patient can understand.
To make sure that patients comprehend the information, it is best to ask them to explain what they have been told in their own words, Chakofsky-Lewy says.
Document encounters with non-English speakers
The Joint Commission (formerly JCAHO) is developing hospital accreditation standards that aim to advance effective communication and cultural competence.
The Joint Commission plans to release those standards this year for use in 2011. In the meantime, it has created a crosswalk between the CLAS standards and existing Joint Commission standards, which is available at http://hcpro.com/url/1229.
During its regular accreditation, The Joint Commission will review the medical record to evaluate a facility's ability to facilitate non-English speakers.
Facilities should develop a process to make sure that they properly document encounters with non-English speakers, Bogomolov says.
When patients are registered or admitted to Barnes- Jewish, they are asked what race and ethnicity they identify with and what language they prefer to use for communicating with healthcare providers.
Staff enter these data into patients' permanent records, so the questions are asked only once, and information flows down to the inpatient charts.
Based on the data, staff can determine whether interpretive services are required to bridge cultural or linguistic barriers.
"There should never be a situation where you cannot communicate with a patient," Bogomolov says.
This article was adapted from one that originally appeared in the April 2010 issue ofCase Management Monthly, an HCPro publication.
Over the past five years, rapid response teams (RRT) have been brought to the forefront of American hospitals. In 2004, the Institute for Healthcare Improvement (IHI) launched its 100,000 Lives Campaign, of which RRTs were a focal point, and in 2008, The Joint Commission added a National Patient Safety Goal requiring hospitals to have a process to recognize and respond to patients who are deteriorating. Those requirements are now located in standards PC.02.01.19, HR.01.05.03, and PI.01.01.01.
Both of these initiatives sparked interest in RRTs among hospitals, especially at St. Anthony Central Hospital (SACH) in Denver, which began to develop its own RRT in conjunction with the IHI initiative.
However, in 2008, SACH officials began to notice a trend of patients who were meeting the criteria for RRT, but for a variety of reasons, the team was not called.
A subgroup of 17 missed opportunities (including deaths) was identified in the first half of 2008. With the help of simulation training and debriefing interviews, SACH was able to lower that number to nine for the second half of 2008 out of 2,400 trauma-related admissions for the year. That number was cut again for 23 total missed opportunities and no resulting patient deaths out of about 2,400 trauma-related admissions in 2009.
Education and simulation training
In 2008, Pamela Bourg, RN, MS, ANP, CNS, director of trauma services, first noticed a trend developing across the trauma patients at SACH. There were particular instances where patients met the criteria for an RRT, but nurses were not calling a team to follow through.
Bourg teamed up with two colleagues, Julie Benz, RN, MS, clinical nurse specialist, and Melissa Richey, RN, BS, clinical nurse for trauma services, to educate the staff at SACH to be more knowledgeable about when to call the RRT and more comfortable in doing so.
Working with the Wells Center in Colorado, a facility that provides state-of-the-art patient simulation tools, Bourg, Benz, and Richey rented a simulation-training dummy.
"Wells Center supplied us with the simulation mannequins, along with the nurse driver," says Bourg. "But we were able to use our own nurse educators and advance practice nurses to help facilitate the groups."
The nurse driver helped run the simulation, but SACH staff wrote the script for the missed opportunity scenarios. During the simulation training, a nurse performed an assessment of a patient. Then, based on what the nurse observed, he or she called an RRT.
"The purpose of the simulation training is to help the nurses recognize the signs and symptoms, identify the patients at greater risk, and then distinguish if they need to call an activation of the RRT," says Bourg.
The staff members at SACH first participated in the simulation training in July 2008. Between August and December 2008, the women analyzed missed opportunities that took place after the simulation training and saw a drop in the number.
Results not typical from simulation training or education
Bourg's team discovered that when the nurses appropriately identified a patient in need of an RRT, there were acute changes in the patient's condition. But when the changes to the patient were not as acute and more subtle, the nurses did not notice them quite as readily.
Even though the number of missed opportunities decreased toward the end of 2008, as 2009 began, Bourg watched the numbers increase, despite staff members having gone through simulation training. "We sat down and knew there were other issues we needed to identify because the numbers were increasing," she says.
At first, Bourg thought it might have something to do with new graduates working at SACH. But after looking at things more closely, she discovered that other factors contributed to the missed opportunities.
"In addition to the huge changeover we saw at SACH, staff members who had been with us for over two years were failing to activate an RRT," says Bourg.
In hopes of improving the number of missed opportunities, Bourg and her colleagues went back and began interviewing staff members who failed to activate an RRT. They developed a debriefing tool using a variety of nursing literature to help understand why nurses were failing to activate the RRT.
"We try to make sure that when a missed opportunity presents itself, we contact the nurse within 24 to 48 hours to ask them more about the situation," says Bourg.
When a nurse has a missed RRT opportunity, an advance practice nurse conducts a debriefing interview, not the manager.
During the interview, the nurse is asked questions about what was going on at the time of the missed opportunity, what kind of patient report he or she received from the previous nurse, whether there were competing priorities, and so on.
"We are not trying to assign any blame," says Bourg. "We are trying to create a culture of safety so people are willing to come forward and give us the information to help make our practice better." In addition, staff went through simulation training again in July 2009.
More ways to encourage the activation of RRT
IHI faculty member Kathy Duncan says the education SACH provides for nurses is a good way of cutting down on missed opportunities. It is also helpful to take opportunities to encourage staff members and let them know that by calling the RRT, they did the "right thing."
For example, one facility Duncan worked with had a trophy that rotated between units based on which unit had the most calls for an RRT and the least amount of codes.
"Staff members may work for three months and never call a team, but if they see a graph showing the calls other units have made, or see fellow staff members getting gift cards to coffee shops for calling the most RRT, it reminds them that the rapid response system is still in place and rescuing patients," says Duncan.
Even if it is not clear what is wrong with the patient, but there are some subtle changes, it's important to communicate to staff that it is always good to have another set of eyes on the patient, says Duncan.
"If the RRT comes in and assesses the patient occasionally, additional information can be gathered or there can be a quick consult or discussion of opportunities to help the patient," says Duncan.
This tactic is also beneficial because if for some reason the nurse calls the RRT again, the team will know the patient has had previous issues and may work more quickly to assess and intervene.
Looking to the future of missed opportunities
Bourg says SACH will now use simulation training with staff every quarter, as opposed to once per year.
"The simulation training has provided the most bang for the buck," says Bourg. "It has shown staff members to no longer consider the least-case scenario, but to instead look into the worst-case scenario."
Even though SACH saw a reduction in missed opportunities in 2009, the number was still too high, she says. "In 2010, we look to better our number and eventually get down to zero."
I'm familiar with order sets and eMAR. I understand root cause analysis and composite scores. I can recite our hospital's infection rates, patient satisfaction scores, and average length of stay.
I was clueless about nursing and the healing power of a touch, a word, a smile.
Ten days as a patient in Doylestown Hospital were an education. As I went from sick to sicker to surgery and recovery, fleeting moments with nurses and techs were lessons in the meaning of health "care."
It was obvious from the start. I was in the ER with abdominal pain. A CT scan was ordered. When the contrast agent returned with the force of a fire hydrant, a nurse and tech consoled me and contained the mess. When I stopped long enough for a deep breath, Annemarie was already wiping the perspiration from my brow.
Similar acts of compassion were offered weekdays and weekends, day and night.
There were the two nurses who were downright cheerful soon after a physician seemed a bit uncomfortable describing an NG tube. Morgan, my nurse for the day, recruited Kathy for help. Kathy exchanged pleasantries while Morgan surreptitiously measured the length of the tube that would be necessary. Then Morgan produced a water cup and straw, describing what I would do. Kathy, meanwhile, was setting up the GOMCO.
What happened next happened quickly and I am thankful I didn't quite understand what an NG tube does until that moment. I witnessed a little celebration through my tears—two nurses had done something important, they did it on one try, and they included me in the party.
There was more joy seven days later when Kimberly removed the NG tube. I saw the relief on her face before I experienced mine.
Another Kathy was visibly upset when she found an empty urinal at my bedside six hours after she removed the Foley. She didn't know that Joe, the PT, had measured and dumped it moments before. When I told her, she looked as though I had given her flowers.
Others took similar personal interest in my condition.
Day three after bowel resection I began laps of the halls to awaken my bowel. The Winter Olympics were underway, and nurses, PTs, unit clerks, charge nurses, and physicians were soon cheering me on. On a pass by the nursing station where Rosemary was working, I overheard her say, "That's my patient." It felt good to hear it.
I wanted an ice cold Diet Coke since I awoke after surgery. Moments after the surgeon ordered a clear liquid diet "and a Diet Coke," Terry and Daniella, my nurse and PT, exclaimed "Surprise!" at my door and delivered the soft drink.
Throughout my stay there were nurses and techs who seemed to walk on cats paws in the middle of the night, fresh water when I hadn't asked for it, clean socks on the bed when I came out of the shower.
Some patients will remember annoying sleep disturbances to check vital signs and repeated questions about name and birth date.
But most patients will remember that a stranger offered compassion and tenderness they only previously experienced at the hands of their closest family members and dearest friends.
With appreciation to all the nurses (Julie, Dianne, Whitney, Joann, Shannon, Jessica, a third and fourth Kathy) and techs (Shelia, Alison, Jessie, Brenda, Lisa, Stephan, Dee, Barb, Angela, Livingston) not mentioned in the article.
Ron Watson is director of communications for Doylestown Hospital in Doylestown, PA.For information on how you can contribute to HealthLeaders Media online, please read our Editorial Guidelines.
The handful of doctors, nurses, and physician assistants on the overnight shift at St. Vincent's Hospital Manhattan have not yet been given instructions on exactly how to shut down the Greenwich Village institution at 8 a.m. April 30, the Wall Street Journal reports. About 3,500 people will lose their jobs as New York City's last Catholic acute-care center closes after more than 160 years in business. Since the board decided to shutter the debt-ridden hospital, services have been farmed out, patients transferred, and staffing has fallen, the Journal reports.
Roughly 5% of the patient population is complex. Those complex patients typically have a chronic physical issue (e.g., diabetes, renal disease, cancer) and a behavioral health issue (e.g., schizophrenia, depression, anxiety).
Although a small percentage of the patient population is complex, they account for more than half of healthcare costs, says Rebecca Perez, RN, CCM, CPUM, president and owner of Carative Health Solutions in High Ridge, MO.
The separation of physical and mental health services
Hospitals primarily treat patients solely for their physical ailments, ignoring underlying mental health problems. With no incentive for reimbursement, facilities often address a patient's mental health only as an afterthought.
However, an untreated mental condition can prevent patients from properly managing physical health, thus causing the patient to be readmitted to the hospital.
The debate over healthcare reform centers on the effort to reduce costs, and that means reduced readmissions. Addressing the needs of this small, expensive segment of the population could help curb healthcare spending.
"Case managers really are the best professionals when it comes to coordination of care and being advocates for patients, which is why integrated care is a perfect adjunct for what a case manager already does," Perez says.
Integrated care training
Perez is part of a growing movement addressing the mental health needs of complex patients by using an integrated care management model.
"The thinking is coming full circle again where we need to treat the patient as a full person and not just treat a disease," says Perez.
Perez and Roger G. Kathol, MD, CPE, president of Cartesian Solutions, Inc.?, work with the Case Management Society of America's Integrated Care Management Training Program to train case managers. Participants learn how to assess a patient's mental health as part of their interaction with complex patients. This enables case managers to ensure that the patient's care plan includes services that address his or her behavioral and psychological needs.
"Integrated case management is not necessarily designed for every patient a case manager touches," Perez explains. "It is designed to work with those that are the most complex."
Recognizing how this population's mental health contributes to their physical health goes a long way in preventing readmissions, improving patient satisfaction, and enhancing overall quality of care.
The chronic illness demonstration project
The New York State Department of Health is addressing complex patients with a chronic illness demonstration project. The project identifies patients that are most likely to be readmitted due to several concurrent medical conditions.
Hudson Health Plan, a provider of state-sponsored managed healthcare services based in Tarrytown, NY, partnered with Beacon Health Strategies, a company that specializes in assisting health plans and providers to meet behavioral healthcare needs, in order to participate in the project.
Hudson's new program, the Westchester Cares Action Program (WCAP), was designed to assist clients selected through the chronic illness demonstration project using the integrated care management model.
"We believe that good primary care will lead to prevention of ED visits and readmissions," says Sheilah McGlone, RN, CPUM, CCM, director of case management and utilization review at Hudson Health Plan and co-director of the WCAP.
The WCAP's case managers use the INTERMED-Complexity Assessment Grid (IM-CAG) tool to help evaluate complex patients. The INTERMED Foundation developed the IM-CAG tool to help case managers create a detailed profile of the patient and identify barriers in the following four domains:
Biological. Does the patient have any chronic illnesses?
Psychological. Does the patient have a history of or currently show signs of psychological issues such as depression, anxiety, or substance use?
Social. Does the patient have access to social support services? Does he or she have a stable living arrangement?
Health system. Has the patient had difficulty assessing services? Did he or she have a bad experience with providers?
The case manager shares the results of the assessment with the treatment team as well as the patient to improve coordination of care.
Case managers obtain information by conducting through interviews with patients. Based on their responses, a case manager assigns patients a score and a color designation. The colors correspond to the following categories:
Red is an area of extreme vulnerability that requires immediate action
Orange is an area of moderate vulnerability that should be a part of the treatment plan
Yellow is an area of mild vulnerability that should be monitored
Green is an area that requires no action
"The IM-CAG tool helps formulate a care plan based on priority levels," says Alan Boardman, LMSW, co-director of the WCAP from Beacon Health Strategies.
For example, if a patient is homeless, the case manager can make the "residential stability" field red.
The three-year demonstration project is still in its first year and is currently focused on assessing patients and developing care plans. Boardman and McGlone say they have not begun measuring the program's success. Nevertheless, they hope the project will help make the integrated care model the preferred method for handling complex patients.
Integrated care in action
Hospital case managers do not need to be experts in mental health to be effective in the integrated model, says Perez. She encourages case managers to become familiar with basic mental health issues and seek advice from experts when dealing with complex patients.
But in order for integrated care to work, case managers need to be willing to address behavioral problems when signs are apparent. For example, if a patient is not progressing through rehab as quickly as anticipated, perhaps depression or some other behavioral problem could be slowing the process.
Identification of the mental health problem is only the beginning of the process. "You can't just say [to the patient], 'You need to go get counseling,' " Perez says. Instead, case managers need to take the time to help the patient discover the problem as well as establish relationships with physical and mental health providers for better communication.
Hudson Health Plan tries to facilitate effective communication between hospital case managers and mental health providers as part of its demonstration program.
Some mental health providers may be hesitant to share information about their patients because of confidentiality concerns. In that case, tell the provider that you are not requesting detailed notes, just basic information that you can use to support the patients' needs, Perez says.
Although the reimbursement model does not lend itself to coordination between mental and physical health, a sharp case manager can make a big difference in the care of complex patients. The willingness to address behavioral health issues and their effect on patient outcomes will help case managers meet departmental goals and better serve their patients.
This article was adapted from one that originally appeared in the April 2010 issue of Case Management Monthly, an HCPro publication.