I met Tina Hilmas last March in Washington D.C. when presenting at a professional conference. Tina was the next speaker and had an intriguing topic involving culture and home care. Her presentation was so interesting that I decided it had to be shared with you, my readers. Here are the highlights of what Just Culture is and what it means for home care.
Just Culture is about improving patient safety. Tina got interested in patient safety when working in the Neonatal Intensive Care Unit. Later as Director of Nursing in a large home care agency, she attempted to introduce the concepts of Just Culture in her new workplace. In 2014, Tina joined the team at the Center for Patient Safety, where she works with organizations across the continuum of care (including home-based care). She promotes the concepts of Just Culture to improve the safety and quality of care. The Center for Patient Safety is a nonprofit organization devoted to reducing preventable harm and creating a healthcare environment safe for all patients and providers.
Traditionally, the culture in healthcare is one of punitive response to medical error. If no harm is done to the patient, no one reports the problem for fear of repercussions. This means that the same mistakes are likely to happen again because the system which allowed them to occur isn’t reviewed until an error causes harm to a patient. This type of reactive approach gets in the way of improving patient safety. What is needed is a proactive approach to evaluates the organizations systems and processes.
When performing an after-action report following a clinical error, using the lens of Just Culture, allows your organization to take a different approach. There are three questions to ask:
- Is it human error? For example, the nurse administered the right medication but in the wrong concentration. When performing an investigation, it was noted that the medication had two different concentrations which were stored side by side. The solution to prevent such an error from reoccurring might be to rearrange the storage to prevent accidental grabbing of the wrong concentration.
In the case of human error, Tina reminds managers that it is very important to support and console the employee who made a true mistake.
- Is it an at-risk behavior? In this case, the healthcare worker knew the procedure but it didn’t reflect real-world workflow and needed a “workaround.” An example of at-risk behavior is when an organization implements the use of an Electronic Health Records (EHR). The organization puts forth a policy that requires the healthcare provider to review a patient’s allergies in the EHR but the system isn’t set up for the healthcare provider to easily access a patient’s allergies. This creates an environment where, to save on time and effort, the practitioner relies on the patient’s recall of their allergies. If the patient has dementia this practice could set the scene for a potential drug reaction. Usually, in this type of scenario, when an investigation is completed it is discovered that more than one provider is drifting from the actual policy. The solution to avoid future at-risk behavior in this scenario would be to modify the EHR so that a patient’s allergies show up immediately upon opening the patient’s electronic record. The organization should also counsel the employee not only on the importance of following policy but also on the need to communicate when a process isn’t working so it can be evaluated before drift occurs.
- Is it reckless behavior? An example of this type of scenario is when a provider practices under the influence of drug or alcohol and makes a mistake that causes harm to the patient. In this scenario, disciplinary action would be the appropriate response.
Looking at home care specifically, the transfer from facility to home-based care is a key cause of medical errors. Important patient information can be lost. Specifically, medication reconciliation is a major challenge when a patient transitions home. The patient’s medication in the home can be very different from what the discharge paperwork shows. The patient also may not understand what condition their new medications treat. This can lead to duplication of medications such as those used to treat diabetes and also anti-coagulants.
In a culture where the players are willing to reach out to partners in the healthcare continuum, these errors are less likely to happen.
Here are some ideas Tina shared to reduce the risk of medication errors when patients are discharged to home-based care:
- Meet the patient in the hospital before discharge and schedule a meeting with the Discharge Coordinator and your clinical staff.
- Schedule regular conference calls between hospital discharge coordinators and your clinical staff to review upcoming transfers.
Tina notes that even though these visits aren’t reimbursed, they are a good investment to prevent possible hospital re-admission and ensure a better transition to home-based care.
Just Culture has a positive impact on turnover and employee morale. A non-punitive approach to errors along with an open and transparent environment encourages workers to stay with your agency. Organizations who have implemented Just Culture have seen a return on their investment up to $70,000 savings on marketing, hiring and training new staff for large organizations. But even smaller structure will experience the benefit of Just Culture for their staff.
Employees clearly appreciate the focus on learning rather than punishment when an error is made. Organizations that the Center for Patient Safety has worked with the state that when employees do make a mistake, even if they receive counseling/disciplinary action they tend to stay with the organization. The employees state they appreciate the education and the opportunity to expand their learning. “Nurses and caregivers don’t intend to cause harm. 99% of errors are made by well-intentioned healthcare providers only trying to help their patients,” says Tina.
Tina Hilmas, RN BSN MS CPPS is the Assistant Director at The Center for Patient Safety. For more information on Just Culture and how to implement it in your agency, contact her via email (or call her at (573) 636-1014.
