benefits of "just culture"
223070614
The Infusion of Just Culture into Simulation: Benefits for Safer Practice
Barbara R James Ronda M Christman
147226691
Just culture's "line in the sand" is a shifting one; an empirical investigation of culpability determination
Abstract Just culture has been propounded as a necessary part of safety management to ensure open reporting. However, research has focused on the measurement and benefits of just culture without examination of the processes of culpability determination in organizations. An online survey asked 3136 aviation maintenance personnel from one company to judge the appropriate level of discipline in three incident scenarios. Five pieces of "mitigating" contextual information were subsequently presented per scenario and the participants given the opportunity to re assess their response. Participants distinguished between scenarios, determining discipline in line broadly with just culture culpability principles. Most pieces of additional information resulted in lowered discipline levels. The pattern of response to the sequence of information was similar across geographical, job role and level of experience variables, but the level of initial and final discipline proposed differed. North American sites were more severe than European, engineers and managers more lenient than operational staff and experienced personnel more lenient than their juniors. The findings demonstrate that, at least in this organization, participants think about culpability broadly in line with just culture ideology, but that who gets to draw the line (Dekker, 2009) is critical. The findings are also broadly in line with the Path Model of Blame (Malle et al. 2014) though it is a descriptive model of blame which is less elaborate and nuanced than the prescriptive ones of just culture (Reason, 1997; Baines Simmons Limited, 2011) The study provides a foundation for the empirical investigation of just culture.
Sam Cromie Franziska M Bott
14621329
EXPLORING A JUST CULTURE APPROACH IN RAIL SAFETY REGULATION
SUMMARY Victoria's rail safety regulator, Transport Safety Victoria (TSV) is exploring the value, benefits and implications of a just culture approach for rail organisations and regulators. Modern rail safety regulation aims to promote continuous improvement in the management of rail safety. Achieving this outcome relies on good regulatory decision making driven by legislation and policies based on prevailing societal values. These decisions should be guided by regulatory good practice, supported by findings from safety science research. The just culture approach seeks to balance the need to hold people accountable for their actions while facilitating opportunities to learn from accidents. The just culture concept has been applied in industries such as aviation and healthcare and has been the subject of enquiry in the fields of human factors and sociology. While not explicitly identified, the principles underpinning just culture have also been considered in regulatory and legal theory. This paper explores the literature and offers some observations from the regulator's perspective on why and how a regulator might adopt a just culture approach, the impact on adoption within industry, and the barriers that may prevent effective adoption by the regulator. A proposition is made that the regulator's ability to employ the full spectrum of the regulatory toolkit (from influencing and education through to administrative sanctions and prosecution) to achieve improved system safety may be enhanced by the incorporation of a just culture perspective. The benefits and challenges of such an approach are discussed.
Elizabeth Grey Stacey Berhardt Raymond Misa
33118774
Disclosure of Adverse Events and Errors in Surgical Care: Challenges and Strategies for Improvement
The disclosure of adverse events to patients, including those caused by medical errors, is a critical part of patient centered healthcare and a fundamental component of patient safety and quality improvement. Disclosure benefits patients, providers, and healthcare institutions. However, the act of disclosure can be difficult for physicians. Surgeons struggle with disclosure in unique ways compared with other specialties, and disclosure in the surgical setting has specific challenges. The frequency of surgical adverse events along with a dysfunctional tort system, the team structure of surgical staff, and obstacles created inadvertently by existing surgical patient safety initiatives may contribute to an environment not conducive to disclosure. Fortunately, there are multiple strategies to address these barriers. Participation in communication and resolution programs, integration of Just Culture principles, surgical team disclosure planning, refinement of informed consent and morbidity and mortality processes, surgery specific professional standards, and understanding the complexities of disclosing other clinicians' errors all have the potential to help surgeons provide patients with complete, satisfactory disclosures. Improvement in the regularity and quality of disclosures after surgical adverse events and errors will be key as the field of patient safety continues to advance.
World Journal of Surgery
Lauren Lipira Thomas H Gallagher
167576129
System for Reporting and Analysing Incidents
Incident reporting is a key safety tool in high risk sectors, including healthcare. To be effective, an incident reporting system must be well constructed and reporting encouraged and supported. The presence of a fair and just culture in the workplace, where reporting is seen as a means of improving patient care, and not a tool to punish others, encourages open and honest reporting. This chapter outlines the rationales, benefits, issues, and features essential for an incident reporting system for radiology and medical imaging by using the Radiology Events Register (RaER) as an example. The challenges limiting incident reporting and the possible solutions are also presented.
Catherine Mandel William B Runciman
153723842
What Is Your Museum's Economic Footprint?
Abstract Across the United States, museums are considered an integral part of the community fabric and an important factor in the quality of life, "Arts and culture helps foster creativity, bridges class divides, retains college graduates, recruits companies, and raises the quality of life."1 But across the nation, museums contribute far more than just culture they drive local and state economies. Nationally, the arts and culture sector generates $166.2 billion in economic activity, including $104 billion in household income and $29.6 billion in tax revenue annually; it also supports 5.7 million jobs.2 Knowing one's economic footprint permits institutions to concretely demonstrate their positive economic impact on a community, which is increasingly important for museums and cultural attractions as they endeavor to demonstrate the many benefits they offer communities.3 And, in a time of economic recession and increased demand and requirements for funding, this information provides power. Further, a positive economic footprint imparts authority to museums when talking with local and national politicians, funders, and community members. Arts and cultural organizations not only contribute to the educational health of communities; they generate funds that add to the economic health of local, state, and national communities as well. This paper examines the Denver Metro Community as a case study for understanding the value and importance of identifying one's economic footprint. However, the formulas included in the paper can be applied to any area of the country and to any museum, allowing each institution to determine their individual economic footprint.
Laureen Trainer
71177040
Second Annual Nursing Leadership Congress: "building the Foundation for a Culture of Safety" Conference Proceedings
Abstract In September 2006, 75 nurse executives met in Asheville, N.C. to develop practical tools and recommendations for "Building the Foundation for a Culture of Safety," the theme of the second annual Nursing Leadership Congress. The Congress is sponsored by McKesson and Intel in collaboration with the American Organization of Nurse Executives, Institute for Safe Medication Practices, National Patient Safety Foundation, and Joint Commission Resources. Plenary speakers included David Marx, JD, president of Outcome Engineering and an expert on helping organizations create a "just culture." Representatives from Children's Hospitals and Clinics of Minnesota in Minneapolis/St Paul and Overlook Hospital in Summit, N.J. touched on several aspects of patient safety, from developing a road map and engaging physicians to workload management and rapid response teams. Researcher Monique Lambert, PhD, shared highlights of studies that Intel is conducting aimed at maximizing the benefits of technology in clinical work practice while minimizing the risk of introducing new sources of errors. Joseph Grenny shared techniques outlined in his 2 best selling books on "crucial conversations" and "crucial confrontations." The cornerstone of the Nursing Leadership Congress is the roundtables. This year, participants broke into groups to brainstorm around 5 topics: disclosure and team building, reflections of culture in large scale clinical implementations, measuring change, effecting change, and mentoring. This article presents highlights from both the plenary sessions and roundtables.
Diane C Pinakiewicz Judy L Smetzer Pamela Austin Thompson Pam Steinbach Mary Beth Navarra Monique Lambert
58590507
The Association Between Organizational Culture and the Ability to Benefit From "Just Culture" Training
Objective This study aimed to determine whether there was an association between the organizational culture and the hospital's readiness to benefit from "Just Culture" training. Methods The "Just Culture" Assessment Tool and the Competing Values Framework surveys were administered before and 6 weeks after a structured "Just Culture" training session to 172 care providers and administrators on similar units at two community for profit hospitals of compatible size and offering comparable services in suburban communities. Data were analyzed for significance using IBM SPSS software. Results At baseline, there was a significantly higher percentage of problematic responses (PPRs) for hospital 1 as compared with hospital 2. Administrators and managers reported significantly fewer PPRs than frontline staff. In addition, the archetypal organizational culture for hospital 1 was found to be more hierarchical, whereas the culture for hospital 2 was found to be more group oriented. Six weeks after the completion of "Just Culture" training, there was a 0.02% overall reduction in PPRs at hospital 1 as compared with a 62.01% overall reduction in PPRs at hospital 2. There was also a significant increase in the Group Culture Score, a significant decrease in both the Hierarchical Culture and Rational Culture scores for hospital 2 as compared with hospital 1. Conclusions There was a significantly greater reduction in PPR on the "Just Culture" Assessment Tool in the hospital with the more group oriented organizational culture. Given the cost and effort required to conduct "Just Culture" training in an organization, it seems to be important to address the organizational culture before the implementation of this type of training.
Journal of patient safety
Donal David
212535852
Promoting Just Culture For Enhancing Safety Culture In Aerodrome Airside Operation
Just culture is an important issue, where its implementation would affect a clear benefit to improve safety. The implementation of Just culture is closely related on how to encourage front line officers, where front line officers are often in direct contact with hazards and could provide key information about aviation safety problems and potential solutions. This research aims (1) To review the safety policy and reporting system, (2) To promote just culture in airside operation, and (3) To analyze the effect of promoting just culture to enhance safety culture. The research starts with early analysis using gap analysis to know the maturity of safety management system manual, and questionnaires, to evaluate the individual performance regarding to safety and just culture. Gap analysis using (CASR Part 139 08, 2015) about acceptance of implementation Aerodrome SMS while questionnaire taking 76 officer as a samples and test using Bivariate Pearson Correlation. This pre analysis results the implementation of just culture according to the organization's commitment is not stated clearly in safety policy statement and have not been promote to all employee. From the questionnaire, I found that most officers did not understand the essential of safety, have not known safety reporting system, and afraid of reporting due to blame culture. The technical solutions are by design new safety policy based on (ICAO Doc. 9859 3 rd edition, 2013) evaluate the reporting system and conduct workshop in airside operation. The result shows safety knowledge increase to 90% while the safety reporting system has increased in 84%
Direstu Amalia
195761293
Supportive networks, healthier doctors and 'just culture' Managing the effects of medico legal complaints on doctors.
BACKGROUND When an error leads to possible patient harm and a complaint, the impact on doctors and patients can be profound. Doctors may respond in ways that risk harm to themselves, colleagues and patients, including withdrawing from peers, risk avoidance practice and even suicidal ideation. OBJECTIVE This article discusses current research and public discourse on the impact of complaints on doctors' personal and professional lives, as well as the way complaints and the fear of complaints affects doctors' clinical practice. It suggests strategies to ameliorate these effects before a complaint is made. DISCUSSION When colleagues support one another and collectively reflect on their practice within a culture focused on patient safety, doctors facing complaints or presented with an error are less likely to isolate themselves and fear the worst. Using a common adverse event, the author discusses how analysing minor errors and near misses can benefit patients, practitioners and practices.
Australian journal of general practice
Penny Browne Georgie Haysom