Just Culture Application Consoling Employees

1. Just CultureApplicationConsoling Employees Stephanie Sobczak & Jill Hanson Quality Improvement Managers WHA

2. Today’s Call • Guest Speaker Chris Baker, St. Mary’s Hospital • Application – Consoling • Case examples using the Just Culture algorithm •  Next 30 days • Courtesy Reminders: • Please place your phones on MUTE unless you are speaking (or use *6 on your keypad) • Please do not take calls and place the phone on HOLD during the presentation.

3. Saint Mary’s HospitalMadison Guest Presenter Chris Baker, RN, PhD, MBA Administrative Director Quality and Safety Systems

4. Q & A with Chris Baker • Could you briefly review St. Mary’s Just Culture journey for us? • Perhaps the biggest shift in Just Culture is treating near misses with similar importance and attention that we give to harmful outcomes. How have you done this at St. Marys?

5. Q & A with Chris Baker • How do you encourage front-line staff to report near misses? • Can you describe your process for handling near misses?

6. Reviewing Past 30 Days

7. Group Discussion on Action Item Hands On Practice - JC Algorithm Use the algorithm to walk through a recent employee discipline scenario Share what insights you discovered as a result

8. Managing Human Error and Consoling Employees

10. Human Error • Inadvertent action; inadvertently doing other that what should have been done; slip, lapse, mistake Just Culture Model • Console the person who has made the error • Address the system design

11. Consoling Conversation Is one that acknowledges... • The event • The employee’s emotions It also… • Provides an appropriate, comforting response • Helps to understand why the human error occurred • Identifies how it can be managed in the future.

12. Scenario One Group Discussion

13. A lab tech is running a complete blood count for an emergency department patient. When entering the values into the computer she transposes the red blood cell count value and the white blood cell count value. The emergency department physician reads the incorrect white blood cell count and orders a large dose of broad spectrum antibiotics.

14. Scenario One Questions • What would you need to know from the event investigation? • Were any duties breached in this scenario? If yes, which? Now walk this scenario through the Just Culture Algorithm • What is you assessment using the algorithm? • What action would you take based on your assessment?

15. Scenario Two Group Discussion

16. An accountant working for a hospital is asked to give the lab manager a sense of how much budget they have left over at the end of the fiscal year. This extra budget would be transferred to the mobile medical office – an under-funded service to support homeless people in the city. When year-end spending was announced, the lab had overspent roughly $25,000, base in part on the accountant who incorrectly failed to account for some supply purchases made by the lab. The lab manager was told in his performance review that he needed to maintain better control of his budget.

17. Scenario Two Questions • What would you need to know from the event investigation? • Were any duties breached in this scenario? If yes, which? Now walk this scenario through the Just Culture Algorithm • What is you assessment using the algorithm? • What action would you take based on your assessment?

18. Scenario Three Group Discussion

19. The nurse goes to the medication room to retrieve Demerol for her patient. She reaches into the bin and grabs the vial in the bottom right corner of the drawer. Next, she draws up the medication and administers it to the patient. The pharmacy had made a change and placed Morphine in the slot where the Demerol used to be kept. The nurse actually gave the patient Morphine. The patient had an allergic reaction and coded. Although they were able to revive him, he suffered anoxic injuries that resulted in right-sided paralysis.

20. Scenario Three Questions • What would you need to know from the event investigation? • Were any duties breached in this scenario? If yes, which? Now walk this scenario through the Just Culture Algorithm • What is you assessment using the algorithm? • What action would you take based on your assessment?

21. The Next 30 Days

22. Thank You! Questions? July 3rd Just Culture Webinar 10-11 am Case Studies – High Risk Clinical Processes