Abington-Jefferson Health, Abington, Pa., a two-hospital system that became part of 14-hospital system Jefferson Health in 2015, began its patient safety journey 20 years ago. But it was seven years ago that the organization realized it needed to incorporate just culture practices into its overarching high-reliability strategy in a much more robust manner in order to continue making progress.
The catalyst for the decision to zero in more intentionally on just culture was an adverse event that led to a nurse being disciplined for giving a wrong medication to a patient. “When we looked more deeply at the event—an investigation that included interviews with many other staff in the unit—we saw that the error was due to ‘drift in practice’ that had gradually taken place across the unit rather than the fault of one individual,” explains Doron Schneider, MD, chief patient safety and quality officer at Abington Hospital. “That deeper look at the event through the just culture lens forced us to approach just culture more rigorously.”
Highlights of that more methodical approach include formal training in just culture for all managers, and the use of a uniform just culture algorithm for responding to and managing safety events with frontline employees. Today, all new managers receive the same training when they join the organization. The work on just culture development initiated at Abington-Jefferson Health has served as a model for initiatives across Jefferson Health’s other hospitals and outpatient facilities as well.
“Just culture as part of our larger safety strategy allows us to see that many of the events that harm people are the result of a system or process and not the result of human error. That recognition allows us to identify and address systemic problems accordingly,” says Schneider.
While stressing that just culture is much more than an algorithm—that it involves a whole way of thinking about organizational behavior—“having an algorithm for decision making allows us to reduce variation in how we respond to events and brings consistency to how just culture is applied in our institution,” he says.
Recently, an adverse event occurred after a nurse mistakenly gave the wrong medication to a patient. The nurse was disciplined, not for the medical error itself, but for documenting the patient’s chart with inaccurate information.
Misperceptions regarding the reasons for the disciplinary action led to concerns among the unit’s staff about the sincerity of leadership’s commitment to learning from errors rather than punishing them. Schneider’s open clarification of the reasons for the disciplinary action, via messages on the system’s intranet, provided an excellent opportunity to reinforce to staff the organization’s ongoing commitment to reporting and transparency.
Constancy of purpose and consistency over time in engaging with frontline employees, and celebrating their good catches and event reports, are key to developing the trust required to create and sustain a high reliability patient safety movement, says Schneider. Toward that end, Abington Hospital distributes quarterly highlights of key safety improvements made as a direct result of frontline employee involvement.
“Just culture does not magically spring up after a weekend retreat or reading a few articles,” Schneider stresses. It can only occur in an environment in which employees repeatedly experience the organization’s unwavering commitment to reporting and learning as an integral component of a larger strategy in high reliability.
Susan Birk is a freelance healthcare writer based in Chicago.
The catalyst for the decision to zero in more intentionally on just culture was an adverse event that led to a nurse being disciplined for giving a wrong medication to a patient. “When we looked more deeply at the event—an investigation that included interviews with many other staff in the unit—we saw that the error was due to ‘drift in practice’ that had gradually taken place across the unit rather than the fault of one individual,” explains Doron Schneider, MD, chief patient safety and quality officer at Abington Hospital. “That deeper look at the event through the just culture lens forced us to approach just culture more rigorously.”
Highlights of that more methodical approach include formal training in just culture for all managers, and the use of a uniform just culture algorithm for responding to and managing safety events with frontline employees. Today, all new managers receive the same training when they join the organization. The work on just culture development initiated at Abington-Jefferson Health has served as a model for initiatives across Jefferson Health’s other hospitals and outpatient facilities as well.
“Just culture as part of our larger safety strategy allows us to see that many of the events that harm people are the result of a system or process and not the result of human error. That recognition allows us to identify and address systemic problems accordingly,” says Schneider.
While stressing that just culture is much more than an algorithm—that it involves a whole way of thinking about organizational behavior—“having an algorithm for decision making allows us to reduce variation in how we respond to events and brings consistency to how just culture is applied in our institution,” he says.
Recently, an adverse event occurred after a nurse mistakenly gave the wrong medication to a patient. The nurse was disciplined, not for the medical error itself, but for documenting the patient’s chart with inaccurate information.
Misperceptions regarding the reasons for the disciplinary action led to concerns among the unit’s staff about the sincerity of leadership’s commitment to learning from errors rather than punishing them. Schneider’s open clarification of the reasons for the disciplinary action, via messages on the system’s intranet, provided an excellent opportunity to reinforce to staff the organization’s ongoing commitment to reporting and transparency.
Constancy of purpose and consistency over time in engaging with frontline employees, and celebrating their good catches and event reports, are key to developing the trust required to create and sustain a high reliability patient safety movement, says Schneider. Toward that end, Abington Hospital distributes quarterly highlights of key safety improvements made as a direct result of frontline employee involvement.
“Just culture does not magically spring up after a weekend retreat or reading a few articles,” Schneider stresses. It can only occur in an environment in which employees repeatedly experience the organization’s unwavering commitment to reporting and learning as an integral component of a larger strategy in high reliability.
Susan Birk is a freelance healthcare writer based in Chicago.
The Promise and Practice of a Just Culture
Leaders whose organizations have made big safety gains will tell you that a high-reliability safety culture is one of shared learning characterized by an atmosphere of trust. Members of the workforce feel safe speaking up when they make an error or encounter circumstances that could lead to harm.