Download Provider Implementation Tool Kit MAPS Just Culture

MAPS Just Culture: Provider Implementation Tool Kit
Planning Phase
Early Implementation Phase
Making Good Progress Phase
MAPS
MAPS Just
Just Culture:
Culture: Provider
Provider Implementation
Implementation Tool
Tool Kit
Kit
Planning Phase
Early Implementation Phase
Making Good Progress Phase
Testing concept, raising awareness and
engaging organization-wide leadership
1. Convene a Just Culture Steering Committee to test the concept.
2. Garner Leadership Support.
3. Identify a Just Culture champion.
4. Identify an interdisciplinary Just Culture team.
5. Perform organizational Just Culture Gap Analysis and/or
organizational safety culture baseline survey.
6. Review results of Gap Analysis and/or culture survey and identify
next steps to move forward
7. Engage organizational wide leadership (CEO, CMO/CCO/VP medical
affairs, directors of nursing, risk management, human resources,
pharmacy, and other potential stakeholders such as labor).
MAPS
MAPS Just
Just Culture:
Culture: Provider
Provider Implementation
Implementation Tool
Tool Kit
Kit
1. Convene a Just Culture Steering Committee to test the concept.
A small group of key individuals within organization
convene to discuss and evaluate the value of the
organization adopting a Just Culture. Small group
should include CEO, Chief Medical/Nursing Officer,
Director of Safety, Director of Human Resources.
MAPS statement of Learning, Justice, and
Accountability
MAPS Just Culture story/timeline
Example Just Culture Goals
Example Just Culture Timeline
Steering Committee Discussion Outline
A. Key individuals attend Just Culture training and/or watch
introductory video.
B. Steering committee discuss MAPS statement on Justice,
Learning, and Accountability and how it applies to their
organization.
C. Discuss and develop strategic direction including engaging key
stakeholders
D. Develop organizational goals
E. Develop organizational timeline
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Creating a Fair and Just Culture: One
Institution’s Path Toward Organizational
Change. The Joint Commission Journal on
Quality and Patient Safety, October 2007
Volume 33 Number 10
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MAPS
MAPS Just
Just Culture:
Culture: Provider
Provider Implementation
Implementation Tool
Tool Kit
Kit
2. Garner Leadership Support.
Goals and timeline are approved. Executive
committee and/or board approves organizationspecific statement of Justice, Learning, and
Accountability.
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Patient Safety and the “Just Culture”: A Primer
for Health Care Executives David Marx, MERS,
April 2001
Dana-Farber Cancer Institute Principles of a Fair
and Just Culture
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MAPS
MAPS Just
Just Culture:
Culture: Provider
Provider Implementation
Implementation Tool
Tool Kit
Kit
3. Identify a Just Culture champion(s).
If practical, organization is encouraged to have 2 or
more champions, each representing a specific area
or profession (e.g. one administrative, one clinical).
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Description of Just Culture champion
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MAPS
MAPS Just
Just Culture:
Culture: Provider
Provider Implementation
Implementation Tool
Tool Kit
Kit
4. Identify an interdisciplinary Just Culture team
Encourage team to include medical staff,
administrator, human resources, risk management,
patient safety/QI, front line clinical staff.
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MAPS
MAPS Just
Just Culture:
Culture: Provider
Provider Implementation
Implementation Tool
Tool Kit
Kit
5. Perform organizational Just Culture Gap Analysis and/or
organizational safety culture baseline survey.
This will allow the steering committee to understand
the current organizational perceptions relative to how
people are treated when things go wrong and also
provide a review of organizational policies that will
impact the implementation of Just Culture. Gather
baseline data (e.g. would employees report a safety
event or perception if employees are held
accountable for workplace behaviors). Plan to
resurvey, at a minimum, annually.
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AHRQ Culture of Patient Safety Hospital
Survey and tool kit
The University of Nebraska Medical Center
Rural adapted version of the AHRQ tool
Bryan Sexton Safety Attitude Questionnaire
and Safety Climate Survey is available at
the University of Texas website-note there
are copyright instructions
AHRQ 2008 hospital benchmarking study
Available June 1: Outcome Engineering’s
gap analysis self assessment tool
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MAPS
MAPS Just
Just Culture:
Culture: Provider
Provider Implementation
Implementation Tool
Tool Kit
Kit
6. Review results of Gap Analysis and/or culture survey
and identify next steps to move forward.
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MAPS
MAPS Just
Just Culture:
Culture: Provider
Provider Implementation
Implementation Tool
Tool Kit
Kit
7. Engage organizational wide leadership (CEO, CMO/CCO/VP medical
affairs, directors of nursing, risk management, human resources, pharmacy,
and other potential stakeholders such as labor)
Topics to consider include: Just Culture, risk
management and safety, event reporting and
investigation, managing system design, and
managing behavior.
A.
B.
C.
D.
E.
Condensed PPT presentation
Patient Safety and The Just Culture DVD
$25 at www.justculture.org
Just Culture Community Web education, no
charge at www.justculture.org
View OE introductory video
Complete OE Web education
Share data/learning from Just Culture Gap Analysis.
Review organizational goals and timeline.
Discuss facility-specific scenarios
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MAPS
MAPS Just
Just Culture:
Culture: Provider
Provider Implementation
Implementation Tool
Tool Kit
Kit
Early Implementation Phase
Engaging medical/credentialed staff
management, clinical staff, and all
other employees
1. Engage medical and other credentialed staff.
2. Develop orientation training for managers.
3. Develop orientation training for clinical staff.
4. Develop orientation training for all other employees
5. Evaluate existing policies and procedures.
6. Establish system to learn about potential risk.
7. Establish process to educate and communicate to patients and
families
MAPS
MAPS Just
Just Culture:
Culture: Provider
Provider Implementation
Implementation Tool
Tool Kit
Kit
1. Engage medical and other credentialed staff.
A. Present Just Culture to your medical/credentialed
staff
1.
View OE introductory video
2.
Have a medical leader from an organization
that has implemented Just Culture speak to
your medical/credentialed staff
B. Incorporate Just Culture into peer review
process.
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Draft Peer Review newsletter article
Physician Peer Review Flow Chart: Flow
Chart attempts to show how Physician
Peer Review is integrated into the
management of the organization.
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MAPS
MAPS Just
Just Culture:
Culture: Provider
Provider Implementation
Implementation Tool
Tool Kit
Kit
2. Develop orientation training for managers.
Hold organizational wide just culture training for all
applicable management. Establish a process for
managers to consistently work with human resources
prior to any disciplinary action.
74 slide PPT presentation
Just Culture Algorithm™ 3.0 –
www.justculture.org 10-pack $59
Case studies: AHRQ Web M&M rounds on
the web
Case studies for rural facilities: The
University of Montana- Missoula: Patient
Safety in Rural Settings
Newsletter example: The Criminal Edition.
The Just Culture Community.
January/February 2007;1-6
Just Culture Community Web education:
www.justculture.org, no charge
Newsletter: The criminalization of human
error part II: the culpable organization.
Marx D. The Just Culture Community.
Summer 2007:2-3.
Patient Safety and The Just Culture
(Booklet) - 30-pack $49
Just Culture for Healthcare Managers™
workbook $79 at www.justculture.org
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MAPS
MAPS Just
Just Culture:
Culture: Provider
Provider Implementation
Implementation Tool
Tool Kit
Kit
3. Develop orientation training for clinical staff.
Hold organizational wide introductory just culture
training for clinical staff. Timing of staff education is
important i.e. not so early that the manager practices
haven’t had time to take hold, yet not too late that
staff don’t know their role or consequences.
Example newsletter content: Our long
journey towards a safety-minded just
culture. Part I: Where we've been. ISMP
Medication Safety Alert! Acute Care
Edition. September 7, 2006;11:1-3.
Our long journey towards a safety-minded
just culture. Part II: where we're going.
ISMP Medication Safety Alert! Acute Care
Edition. September 21, 2006;11:1-2.
Creating a Safe Culture, AORN, Volume 79,
Issue 2, pages 412-414 S. BEYEA
Frontline staff presentation by Carol
Diemert, MNA, March 2008
will be available: Outcome Engineering
Safe Choices training- a 30 minute video
for all staff, available at
www.justculture.org
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MAPS
MAPS Just
Just Culture:
Culture: Provider
Provider Implementation
Implementation Tool
Tool Kit
Kit
4. Develop orientation training for all other employees.
Hold organizational wide just culture training for all
other employees as appropriate to their functions.
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MAPS
MAPS Just
Just Culture:
Culture: Provider
Provider Implementation
Implementation Tool
Tool Kit
Kit
5. Evaluate existing policies and procedures.
Key organizational documents have been evaluated and reviewed
for inconsistencies. A timeline has been developed to revise policies
and procedures to incorporate language from the MAPS Statement
of Learning, Justice, and Accountability and the just culture
concepts/language, including the three just culture behaviors
(human error, at–risk, reckless). Duties of managers are explicit (this
is about seeing risk, designing safe systems and
coaching/mentoring of staff). Duties of staff are explicit (the
processes, but also looking for risk, reporting hazards and making
safe behavioral choices)
Tips to Implementing Policies that Support
Just Culture
Model Occurrence policy
HR model policy will be made available
These policies/procedures include:
- Quality and patient safety plan
- New Employee orientation
- Job descriptions
- Discipline policies
- Incident/Occurrence reporting
- Patient safety event/error reporting
- Sentinel event investigation policy and process
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MAPS
MAPS Just
Just Culture:
Culture: Provider
Provider Implementation
Implementation Tool
Tool Kit
Kit
6. Establish system to learn about potential risk.
A. Perform routine employee safety rounds
B. Establish good catch/near miss reporting system.
There is a process in place for staff to report
risk/events.
C. Conduct routine risk assessment: There is a
process in place to assess risk.
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MAPS
MAPS Just
Just Culture:
Culture: Provider
Provider Implementation
Implementation Tool
Tool Kit
Kit
7. Establish process to educate and communicate to patients and families.
MAPS Patient Safety: Your Role Brochure
Joint Commission’s Speak Up campaign
brochure
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