Pa Patient Saf Advis 2011 Dec;8(4):138-43.
Gap Assessment of Hospitals’ Adoption of the Just Culture Principles
Authors

Denise M. Barger, BA, CPHRM, CPHQ, HEM
Patient Safety Liaison
Southeast Region—Delaware Valley South

William Marella, MBA
Program Director
Franchesca J. Charney, RN, BS, MSHA, CPHRM, CPHQ, CPSO, FASHRM
Director of Educational Programs

Pennsylvania Patient Safety Authority

Background

Patient safety experts recognize that a healthcare organization’s culture exerts a critical influence on staff response to patient safety issues, as well as on staff members involved in those events.1,2 Willingness to report both actual and potential adverse events can be a strong indicator of the organization’s attitude toward patient safety generally and a key to its perception and treatment of staff involved in adverse events. Organizations with strong safety cultures have robust reporting mechanisms to identify risks and effective systems for evaluating causes and taking action to address process weaknesses. They develop and reinforce the perception among staff that reporting is accepted, expected, and nonpunitive. In the alternative “blame and shame” environment, adverse events go unreported and process failures are not identified, causes go unaddressed, and the cycle of event-blame-punishment is often repeated to the detriment of patients and healthcare staff alike.

Many healthcare organizations have made the transition from the punitive culture that dominated thinking in the years before the Institute of Medicine’s landmark report To Err Is Human to the nonpunitive stance that many hospitals now take toward reporting. Some hospitals, such as those in the Department of Veterans Affairs system, have evolved to a view that does not punish individuals for reporting or committing human errors and mistakes and instead choose to identify the reasons for the error and to change the underlying process that either caused or contributed to the error.3 Recognizing the inevitability of human error while still holding staff accountable for individual actions is the cornerstone of the just culture approach that has been articulated by Outcome Engineering president David Marx. Outcome Engineering has developed an algorithm for assessing the role of human behavior in individual events, as well as a methodology for evaluating an organization’s culture and commitment to a just culture that can be used by hospitals and other facilities.4

In the Pennsylvania Patient Safety Authority’s 2007 survey of Pennsylvania healthcare organizations reported in the Authority’s 2008 annual report, facilities were asked whether their internal policies and procedures related to adverse event reporting incorporated just culture principles.1 Statewide, 118 hospitals and 82 other facilities (including ambulatory surgical facilities [ASFs] and birthing centers) responded to the survey. The majority of hospitals that responded (70%) reported some level of implementation of a just culture, and 59% reported that the just culture model was fully implemented hospital-wide. The remaining 30% of hospitals reported that the principles were not yet implemented. Similar results were found among responding ASFs and other facilities, with 72% reporting some or partial implementation and 28% having not adopted the just culture approach.

The Authority wanted to ensure that Pennsylvania facilities fully understood the tenets of a just culture and sought out Outcome Engineering to discuss the survey results. That discussion was the genesis for the Pennsylvania Just Culture Project. The project, which began in spring 2010 and concluded with a report of gap survey results in February 2011, tested whether Pennsylvania facilities have more verbal commitment to just culture than is codified in facility policies and reflected in facility handling of adverse events and staff error. Indeed, during the process of identifying hospitals interested in participating in the project, many shared the view that they might have overstated the extent of their implementation.

Methods

The Authority partnered with Outcome Engineering in early 2010 to assess the degree to which a just culture was implemented in Pennsylvania. The Authority challenged Outcome Engineering to devise a method that could be used on a larger scale and that would protect hospitals’ confidentiality while assessing their adherence to a just culture’s essential tenets. Meanwhile, the Authority invited all Pennsylvania hospitals to consider participating in the project and, ultimately, 10 hospitals volunteered. Hospital patient safety officers (PSOs) were engaged to lead the assessment effort in each facility and the gap analysis and be the conduit for communicating results. The hospitals represented different regions of the commonwealth and ranged from large urban hospitals to smaller community hospitals.

The just culture self-assessment tool developed by Outcome Engineering was based on two existing survey tools: a gap analysis and a benchmarking survey. Outcome Engineering developed the tool specifically for this project to address concerns that traditional methods of assessing a hospital’s culture might breach confidentiality and required a significant time commitment. The just culture self-assessment tool comprises two parts:

Part 1 measures organizational culture through 13 questions about organizational policies, adverse event investigations, and human resources actions. This section is completed by the PSO after reviewing a representative sample of documents related to these three areas.

Part 2 measures the perceptions of leaders about the organization’s culture through 20 questions about critical behavioral markers, such as system design, coaching, reporting, responses to human error, responses to reckless behavior, severity bias, equity, and transparency. This section is completed by 10 to 15 leaders within each organization. Recommended respondents include the chief nursing and medical officers, PSOs, and directors or managers of human resources, quality assurance, and risk management departments. (No information identifying individuals by name, position, or title was collected.)

Participating hospitals received their survey forms in January 2011 and were given three weeks to complete the survey tasks. The surveys were then reviewed and scored by Outcome Engineering working with Authority staff. Results were tabulated and presented to the participating hospitals in late February 2011. After completing the self-assessment, each hospital received a confidential report presenting its results compared with the average results of the other deidentified participating facilities. This report explained the significance of each attribute examined in the tool and provided guidance on how to improve attributes on which the facility scored low.

The survey tool is available to Pennsylvania PSOs on the Authority’s secure PassKey website. The Authority’s regional patient safety liaisons can assist facilities in the use and scoring of the assessment.

Results

The two parts of the tool were scored separately. Part 1, which evaluated the hospitals policies and practices, contained elements that could produce a maximum score of 22 points for each hospital. Only one of the participating hospitals scored well—it earned 20 points, indicating compliance with key just culture tenets in policies, human resources practices, and investigation documentation. Two hospitals met the required adherence on approximately 50% of the scored items, while the majority of hospitals (seven) met just culture expectations on fewer than 50% of the elements.  Six hospitals scored below 5 of a possible 22 points. All 10 participating hospitals as a group scored 62 of a total 220 points (see Table 1).

While none of the just culture principles was consistently present across all 10 hospitals, elements most widely adopted included not disciplining employees for human errors in the absence of reckless choices, taking disciplinary action with employees who have made reckless choices, and placing employees on notice of disciplinary action when repetitive human errors or repetitive at-risk behaviors are present and not caused by system performance shaping factors and not correctable through changes in work choices, remedial education, or coaching. However, only one hospital reported that their policies define human error, at-risk behavior, or reckless behavior. If staff do not understand the distinctions between these types of errors—or the distinctions management makes among them—human resources actions may appear arbitrary. Other principles of the just culture model that were not widely adopted were distinguishing between discussions aimed at coaching versus counseling, requiring explanations in event reporting systems for human errors and at-risk behaviors, and emphasizing both system design and management of employee behavior.

Part 2 involved a series of 20 statements to be evaluated by key leaders in the organization to assess their perception of the organizational culture. For each statement, response categories were presented on a five-point Likert scale ranging from “strongly disagree” (-2) to “strongly agree” (2) with a neutral value (0) for “neither agree nor disagree.” Most statements were worded positively, with “strongly agree” being the preferred response. Those statements worded negatively were scored in reverse. The maximum number of points available for each hospital was 40. Results of this section are presented in Table 2.

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