Just and Accountable Culture (JAC): An Introduction Maureen S Padilla, DNP, RN, NEA-BC Yvonne Chu, MD, MBA Sr. VP and Chief Nurse Executive Chief, Ophthalmology Service, BT Hospital Co-Chair, Just & Accountable Steering Committee Co-Chair, Just & Accountable Steering Committee
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Just and Accountable Culture (JAC): An Introduction · Just and Accountable Culture (JAC): An Introduction Maureen S Padilla, DNP, RN, NEA-BC Yvonne Chu, MD, MBA Sr. VP and Chief
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Just and Accountable Culture (JAC): An Introduction
Maureen S Padilla, DNP, RN, NEA-BC Yvonne Chu, MD, MBASr. VP and Chief Nurse Executive Chief, Ophthalmology Service, BT HospitalCo-Chair, Just & Accountable Steering Committee Co-Chair, Just & Accountable Steering Committee
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Objectives• Describe the four cornerstones of a Just and
Accountable Culture.
• Compare the components of a Just and Accountable Culture with the perceived culture related to evaluation of incidents, accountability, and communication at Harris Health System today.
• Identify 3 expected outcomes related to implementation of Just and Accountable Culture.
• Describe the three elements of evaluation used to determine accountability for behaviors and what type of “management” action each may incur.
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Dr. Lucian LeapeProfessor, Harvard School of Public Health
Testimony before Congress onHealth Care Quality Improvement
The single greatest impediment to error prevention in the
medical industry is “that we punish people for making
mistakes.”
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Group Scenario
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Outcome/Severity Bias
When an organization allows the severity of the outcome or level of harm to drive its
response to an event
• punish when someone doesn’t deserve it
• allow risky behaviors to continue unchecked
• overreact to singular events while underreact to risk
Survey Results
TRAGIC EFFECTS OF OUTCOME BIAS
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Learning Culture in Healthcare
OR staff does not stop action of
surgeon
Surgeon punctures
patient’s bowel
WHY?
WHY?Surgeon uses new
equipment w/o approval and
training Increased risk of patient
harm• 70-80% of human
error go unexplained
• 70-90% of at-risk behaviors go unexplained
A Cause of the Behavioral Choice
Behavioral Choice The Undesired Outcome
Human Error
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Harris Health Culture (Current State)
Evaluation
• Inconsistent – varies by manager
• Inequitable
Accountability
• All or none
• Blame and shame mentality
• Hit or miss –contributing factors may be missed
Communication
• Closed - final outcomes unknown
• Staff fearful of being blamed
* in regards to errors
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Just Culture is about…
• Creating an open, fair, and just culture
• Creating a learning culture
• Designing safe systems
• Managing behavioral choices
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Harris Health Culture of Safety
Life Wings
Just Culture
Patient
how we prevent errors
how we react toand manage errors
Hand Hygiene
Time Outs
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B A L A N C E D A C C O U N TA B I L I T Y
JustCulture“People make errors, which lead to accidents. Accidents lead to
deaths. The standard solution is to blame the people involved.
If we find out who made the errors and punish them, we solve the problem, right?...”
Humans will make
“Wrong. The problem is seldom the fault of an individual;
it is the fault of the system.
Change the people without changing the system and the
problems will continue.”
The goal is to LEARN from
and make system changes as needed to prevent reoccurrence