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Bill Klaproth (Host):  So, as an employee, do you know what a just culture is? And why is that important to you? And why is it important to the Hero journey? Well, let’s find out with Tennile Ramsay, Patient Safety Officer an UMUCH. This is the Hero podcast from UM Upper Chesapeake Health. I’m Bill Klaproth. Tennile, let’s start with this. So, what is just culture?

Tennile Ramsay, MS, RN, CNL (Guest):  Oh I’m glad you asked. So, a just culture is an environment where our frontline team members are treated justly. It’s about being fair and how we respond to our team members when a mistake is made or when something goes wrong. It’s all about us being consistent with how we treat our team members in response to when things happen. And what it’s not is oftentimes, just culture gets labelled as a free pass or free-for-all. It is not that. It’s actually a culture where there’s a balance between accountability and it’s really shared accountability and it’s continuous learning. And it’s creating that balance so that we have open and honest reporting when mistakes are made, and we learn from those mistakes so that we can do continuous improvement and make things better for the patients that we serve.

Host:  So, this is what I’m hearing. Let me know if this is right. A just culture requires open and honest reporting which promotes learning, so you are constantly improving and oriented towards patient safety. And that all starts with shared accountability. Is that right?

Tennile:  Absolutely. So, that whole shared accountability; traditionally in healthcare, we really didn’t have the shared accountability and there’s even a body of work, Dr. Lucian Leape who is really is considered one of the forefathers of the patient safety science. Years ago, he talked about the greatest impediment to safety in healthcare was that we kind of punished our team members when they make mistakes. And that is true. There used to be this punitive environment that we did with our frontline team members when they made a mistake, not accounting for any system opportunities or any environmental issues that may have contributed to that. Because we needed to start thinking systems whereas could someone with that same training make this mistake.

So, when that shared accountability comes in it is ensuring that we as an organization are ensuring that that team member has everything that they need to be successful to do their job every day, every time consistently. And the team member in turn, is accountable to the decisions they make and for reporting those mistakes if they happen or for reporting anything that they see that could cause a mistake so that we can proactively fix it. and so, that’s really important in a just culture. So, that shared accountability goes both ways. We’re accountable as an organization to the team member; the team member is accountable to the organizations and the patients that they serve.

And all of that will contribute to this continuous learning where we are continuously learning from what isn’t working, how can we prevent it, and what do we do from systems engineering perspective to engineering the process so that it works for the end-user, the human being and eliminating some of these human factors that sometimes we see that lead to failures in healthcare and leading to medical errors which is the third leading cause of death in the United States.

Host:  That’s a good point. In all businesses, sometimes the system is at fault, it’s not just and only the employee and too many times, people get punished without changing the system and that only perpetuates the problem rather than solving it. Is that what you’re saying? Is that right?

Tennile:  Absolutely. And when we don’t do that, we don’t fix it and it’s allowed to happen to someone else and it could actually result in a patient getting harmed. So, we want to eliminate that. So, just culture helps us to think differently when we see something go wrong. And there are actually three behaviors in just culture that we look at.

The first being human error. The second is at-risk behavior and the third is reckless behavior. Human error is something you inadvertently do, it’s a mistake, it’s a lapse. You didn’t mean to do that. I love using the example and I share this example. A friend of mine posted on social media that she accidentally put cayenne pepper in her oatmeal instead of the cinnamon. And if you think about that, they look very similar in a container. And some brands they have the same container, same labeling except what it’s called. And you can easily make that mistake. That’s human error. Anyone can make that mistake. But when we see human error; one we want to console our frontline team members because they are going to be horrified that they made that mistake and what we need to do is really do process improvement.

How can we prevent that person from putting cayenne pepper into the oatmeal? Can we put it in a different container? Can we label it different so it’s easy to distinguish? So, we really have to start looking at things in a different lens. I use the example for at-risk behavior is like when you started to drive. At-risk behavior is a behavioral choice where the risk is not recognized or is believed to be justified. When we first started driving, we had our hands on 10 and 2, we did the speed limit, we didn’t chase the yellow light, we did all of these things but now today, after we’ve been driving for years and years; we are exceeding the speed limit, we’re driving with our coffee in our hand, we are doing our own makeup behind the wheel, we are doing all those things and as human beings we drift. And we do, we all engage in at-risk behavior because you know what, it’s human nature. We will justify it.

Justifying exceeding the speed limit to arrive to work on time. I’m putting my makeup on behind the wheel because I need to look a certain way when I arrive. So, we justify that. And we may not recognize the risk involved. And so when we see that in health care, what we want to do is we want to coach the team member and make sure that they know that this is at-risk behavior and that it could cause harm.

You know you driving and doing your makeup or drinking your coffee and eating could result in an accident. It could. It’s at-risk. So, we always want to coach the team member. We also want to assess the system wide behavior because if one person is doing it, someone else could be doing it and it could recognize that there is system issue that we need to do process improvement. And that’s where we can engage with our frontline so that we solve those issues.

And then the last behavior is reckless behavior. And that’s when it’s just conscious disregard of the unjustifiable risk of harm. And we rarely see this. We only see about one percent of error related to this type of reckless behavior. And so, that is not tolerated at all in a just culture. You can expect disciplinary action when we see that. So, those are the types of things that we have to in a just culture, think about what we see. we have to think a little differently.

Host:  Those are good to know, three important behaviors that all employees should be aware of. Human error, at-risk behavior and reckless behavior. Now I know you have an algorithm to help you with this. Can you explain that to us?

Tennile:  Yes. So, we developed the algorithm to be a guide. It’s not black and white but it’s a guide to leaders. Because what we noted and what we heard in 2015 when we started this just culture journey; we assess our safety culture every two years. And then the safety culture what we heard is that we had a very punitive culture where again, team members did not feel that they were always responded to in a fair manner every time consistently. And so, what we heard from our frontline team members is that one department might be disciplined more harshly than another. And so we want to eliminate that because when you see that, it doesn’t create trust. And when you don’t have trust, team members don’t want to report. And when they don’t report, we can’t proactively do process improvement and fix things proactively.

So, it’s all about creating this environment so this algorithm, what this does is helps us to eliminate what we call that bias. And it’s related to the outcome. Traditional health care what you would see is that someone made a mistake and I’ll use nursing for example. I’m a nurse, I gave a wrong med to a patient and nothing happened. So, it’s like no harm, no foul. Nothing happened. But then another nurse might make that same mistake and their patient dies and she loses her job. Well when people see that, without us looking at the system and what lead to it and is there some process reengineering that we could do to fix it; they would just lose their job. Well then when people see that they think well I’ve got to support my family; they don’t want to report.

And so what this algorithm does is eliminate that bias. And so, there are a couple of things that are looked at in this algorithm. The first test that is evaluated in the algorithm is deliberate harm. It asks was the action deliberate. Because we are looking at this, is some engaging in reckless behavior. That’s really what we are looking at there.

Then there’s the fitness for duty test that we look at. We look at where they fit for duty, we they under the influence, where they on some medication that could have impaired them that day? We look at that. Then there’s the foresight or procedural rule test. And so we look to see was the policy or procedure, was it used, was it available, did they know about it, was it accessible? We look at did they violate a policy or procedure. So, we’re kind of looking at these things and then there’s also the substitution test where we are asking would another individual from the same profession, possessing comparable qualifications or experience behave the same way in the same circumstance.

Because you want to look at that. Is this human error, is this at-risk behavior? We are looking at those. And we lastly look at is there a pattern of unsafe actual rule breaking. Because we don’t want to continue to see someone make risky – engage in risky behavior time and time again without us being accountable as an organization to provide a safe environment for our patients and other team members. So, we look at that. And so, again, looking at that at-risk behavior, are we going to console, are we going to coach, and are we going to discipline. We look at that throughout the algorithm.

And so, it’s a clear way and a clear guide to help the leaders get to okay, this is at-risk behavior, so I’m going to coach, I’m going to do process improvement. No, this is human error. I need to console. No, this is reckless behavior, I need to discipline. So, it really helps to guide the leader in really looking at these things that occur under those three behavioral lenses.

Host:  And those three are really important so the employee gets the right feedback or further training so console, coach or discipline. So, I think I know the answer to this, but if you could put this into your own words; why is just culture important to the Hero journey?

Tennile:  So, just culture is absolutely important to the Hero journey. So, the three components that we look at in Hero not just in that engagement but that culture of continuous improvement. It’s your safety culture and that’s that transformational leadership. And the key leg is the safety culture and for us, in that safety culture, we’re talking about a just culture because we want to create this environment that really supports being a highly engaged and reliable organization. And in order to do that, we have to have that environment where our team members feel safe. They have to feel safe in reporting. Because they have to trust us as an organization to provide everything that they need every time so they can do their job and serve our patients to give that compassionate high quality and effective care every time to every patient.

And so we have to create that environment and without that, we won’t be highly engaged or reliable. We will see harm and the goal is to get to zero harm. So, in order for us to do that, we have to create that environment where our team members trust that they do have that shared accountability where again, we as an organization are accountable to them; they’re accountable to us in their reporting, they are seeing that improvements are being made based on what they are reporting and again, that we are learning. So, it is absolutely essential. If we don’t have that, we will never be a high reliability organization and we won’t get to zero harm.

Other industries have created this and they’re not necessarily in the business of healing like we are and so, this is important for us that we create this environment, this just culture so that we can get to zero harm. So, that’s why this is really essential to the Hero journey. I almost say it’s the most important piece of the Hero journey.

Host:  Well, I think it’s very easy to see why just culture is very important to the Hero journey and UMUCH by improving patient safety through shared accountability as you’ve explained to us. Tennile, thank you so much for your time today.

Tennile:  Thank you.

Host:  This is the Hero Podcast from UM Upper Chesapeake Health, a podcast for internal communications. Please check back for our next episode soon and thanks for listening.