Level of harm not factor when deciding to punish
(Editor's note: This month's Healthcare Risk Management includes the second of a three-part series on the "just-culture" approach to improving patient safety. Last month's issue included stories on how the just culture approach works and some potential problems with implementing it. This month, HRM include a discussion of the types of behavior that can result in discipline, tips for implementing a just culture, and the criteria for deciding when to punish an employee. The following issue will include a report on one hospital's experience in adopting a just culture.)
Adopting a just culture instead of a nonpunitive or blame-free culture means you have to be ready to discipline employees for some behavior that can threaten patient safety, but how do you know when punishment is appropriate?
For starters, it doesn't depend on the patient's outcome or the level of harm done to the patient, says Geri Amori, PhD, ARM, FASHRM, a consultant with The Risk Management & Patient Safety Institute (RM&PSI) in Lansing, MI, and past president of the American Society for Healthcare Risk Management (ASHRM). She spoke on this topic at the most recent annual meeting of ASHRM with Margaret Curtin, CPH, also a consultant with the institute.
They say the just culture approach avoids the old "blame-and-shame" management style that can drive errors underground, but it also allows for the discipline of employees who recklessly disregard safety rules. Instead of promising that you won't punish employees as long as they report errors, a just culture tries to distinguish between an honest mistake or systemic problem and a more willful act of disobedience, Curtin explains.
Timeliness is important in reporting patient safety issues under a just culture, Amori says. You should require a report prior to the end of the shift when the event or near miss was discovered, she says. Failure to do so can increase the likelihood that punishment is the appropriate action to take.
These other factors can lead to discipline under a just-culture approach:
- The employee repeatedly fails to participate in the detection and reporting of events and near misses.
- The employee is directly involved in sabotage, malicious behavior, chemical impairment, or criminal activity.
- The employee fails to respond to educational efforts and/or fails to participate in the education process or other preventative plans and activities.
- False information is provided in the reporting, documenting, or follow-up of an event.
- There is a reason to believe that a violation of a state or federal regulation or law may be involved.
In general, she says, an employee's behavior can be categorized as human error, at-risk, or reckless behavior, and the last category may justify punishment.
"Accountability" is the key word in a just culture, Amori says. When discussing problem situations with an employee, the focus should be on keeping the agreements that the employee and the employer made regarding patient safety. Blaming someone for a problem can elicit an emotional reaction, but the accountability perspective helps the employee look at the systemwide problem analysis and what role he or she can play.
Accountability is about responsibility, Amori says. "It focuses attention on the problem and how to improve performance," she says. "Blame is more likely to focus on the person and punishment."
Adopting a just culture instead of a nonpunitive or blame-free culture means you have to be ready to discipline employees for some behavior that can threaten patient safety, but how do you know when punishment is appropriate?You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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