Everyone hates errors in medical care, from nurses administering medications, to surgeons installing stents, to aides taking blood pressure.
But often, when errors are discovered in many organizations, disciplinary action can be humiliating or even harsh. That can make employees afraid to report errors made by themselves or by colleagues.
But a new way of approaching the issue, known as “Just Culture,” replaces that harshness with a holistic, team-based methodology that encourages openness about errors, coupled with enhanced training and supervision for when mistakes do occur. In short, it’s about building trust among staff and examining inevitable mistakes from a number of perspectives before forming judgments about their causes. The approach is picking up converts, and you can count The Vancouver Clinic among them.
HONEST MISTAKES VERSUS PURPOSEFUL ERRORS
This fresh way of thinking about errors doesn’t mean that people aren’t held accountable for willful safety violations or big-time negligence, says Alfred Seekamp, MD, chief medical officer of The Vancouver Clinic. No one is above the law. What it does mean is that people aren’t blamed for honest errors, some of which occur because of systemic issues in an organization or because of other factors outside their control. Everyone in an organization that employs Just Culture principles should, through training, be able to recognize what acceptable and unacceptable behaviors look like.
“We want safe processes,” says Dr. Seekamp. “So we in health care need to look at how we can eliminate variations and create processes that are safe. And one of the ways to do that is to foster a culture in our organization where people feel comfortable reporting things, whether it’s an error or a near miss.”
Just Culture is all about creating a system that encourages people to inform their organization about problems and hazards without fear of punishment or prosecution, Seekamp says. Too often, he says, a lack of trust prevents employees from telling management about risks, which means that safety issues go unchanged or unchallenged.
Some things remain fluid as the program rolls out. Determining exactly what should be reported remains an important and fundamental question. For example, double-checking insulin doses is a standard process of care. If a second nurse finds an error, is this a reportable event? Officials at The Vancouver Clinic say they’re seeking more clarity on exactly what workers should report, so they’re not buried in data. They’re also drilling down on the level of detail required, and how long people should take to report events.
ENGINEERING PRINCIPLES ADAPTED FOR HEALTH CARE
Intertwined with the notion of Just Culture at The Vancouver Clinic is that of “Lean” engineering principles. Made famous by Toyota, Lean principles generally embrace system improvements by adopting processes that add value, while at the same time reducing anything that adds waste. Continuous improvement, learning, and adaptability are the keys to success under Lean principles.
“It’s all a part of our innate culture, which is patient-focused,” Seekamp says. “We promote the voice of every team member, to make sure everyone is heard.”
The Vancouver Clinic began it all with a pilot project on how to best capture adverse events. Data gathered through the pilot were used to identify safety hazards, and develop interventions to mitigate those hazards and evaluate whether the interventions actually reduced harm. Incident reports initially came from departments that included Ob-Gyn, sleep medicine, urgent care, the patient-service center, the ambulatory surgery center, and the laboratory.
“We look at any potential trouble and do problem-solving in the huddles.
If something can’t be solved there, it gets elevated to the managers,
then all the way up the line, from the IT department to the CEO if necessary.”
Alfred Seekamp, MD
Chief Medical Officer, The Vancouver Clinic
AN ASSIST FROM AVIATION
In health-care organizations employing Just Culture, employees are encouraged—and sometimes even rewarded—when they report safety issues and errors. That philosophy grew out of a similar movement in aviation safety, where even a minor error can prove catastrophic.
Medicine is increasingly about teamwork, Dr. Seekamp says. That teamwork starts with providers, who gather in morning huddles held before the workday begins. In those huddles, staff members go over how the day is looking, and identify any lingering issues from the day before.
“We look at any potential trouble and do problem-solving in the huddles,” Dr. Seekamp says. “If something can’t be solved there, it gets elevated to the managers, then all the way up the line, from the IT department to the CEO if necessary.”
They want to solve individual problems, of course, but also implement solutions across the organization that will improve quality, outcomes and patient safety. “If there was a mistake made—say the wrong medicine was prescribed to a patient—we want to console the person who made the mistake, coach them if their behavior was part of the issue, and then figure out a solution so it doesn’t happen again, if appropriate,” Seekamp says.
Take something as easy, and as crucial, as handwashing. “We want to support people,” Seekamp says—and if people aren’t washing up per the policy, the organization wants to figure out the problem, rather than play “gotcha.”
“If people are not doing washing,” Seekamp says, “we will have a conversation with them about the risk of illness. But we’ll also do a deeper dive: are we making it easy for people to sanitize their hands? We look at the reasons why it might not be happening, and we fix it if there are issues. However, once you coach someone and they keep not doing it, you do need to hold people responsible.”
The Just Culture principles will be part of the job from the earliest days for all employees—all new hires will be trained in it. Every current employee will be trained in it as well.
A LABORATORY FOR CHANGE THAT’S JUST THE RIGHT SIZE
The Just Culture philosophy appears to be working well for The Vancouver Clinic. “We’re uniquely positioned to try it,” Seekamp says. “We’re physician-owned, and we’re large but not huge, with 300 providers and 1,000 staff. We’re small enough that we can really develop an integrated culture. Providers join us because they believe in the group model. It’s much like a family, and in a family, people think about their kids and spouses before their own self-interest. That’s really what we want to promote, and it’s how we get better. And it’s part of the professionalism in medicine, of continually working to get better.”
Gayle Seifullin, Director of Quality and Medical Affairs for The Vancouver Clinic, recalls one concrete example of Just Culture in action that began on the clinic floors, among frontline staff.
“We had difficulty with a syringe we were using—it was leaking,” Seifullin says. Rather than staff just living with it or being afraid of being accused of using the syringe incorrectly, they reported the issue, which was eventually escalated to the highest levels of the organization. A task force was assigned to investigate the problem and determine if it could be quickly solved, or if it was something that would take more time. As the task force worked, they reported their findings and thoughts so those investigating the problem knew where the issue stood. Eventually, clinic staff worked with the vendor and removed the faulty syringe, replacing it with a better model.
“In medicine, people really take ownership of their work, and they feel
embarrassed when something goes wrong—even if it’s not their fault."
Alfred Seekamp, MD
Chief Medical Officer, The Vancouver Clinic
“That’s a true model of a culture that encourages reporting,” Seifullin says. “Is everything solvable? That I can’t speak to. But this is how our Just Culture model works.”
It’s not always straightforward, Seekamp concedes. “Culture work is always difficult,” he says. “In medicine, people really take ownership of their work, and they feel embarrassed when something goes wrong—even if it’s not their fault. But when we dig deeper into an incident, we can see process issues, and that can let us solve problems across the organization. If it’s a problem in surgery, it’s probably also a problem in internal medicine or in Ob-Gyn. We want to solve these problems across the organization, because when we do, we improve quality, outcomes, and patient safety.
“We’re always a work in progress, continually evolving, and this is just another part of how we’re trying to get better.”