1. Creating a Just Culture of Safety
Colleen K. Snydeman RN, MSN, PhD(c), NE-BC
Director , Patient Care Services
Office of Quality & Safety
Massachusetts General Hospital

2. Objectives
At the conclusion of the presentation the participant will be
able to :
1. Describe the influences in advancing the safety culture
in healthcare.
2. Describe characteristics of a just culture of safety.
3. Identify examples of a just culture of safety.

3. Overview
1.
Quality & Safety
a) Definitions
b) Adverse events
2.
Professional Accountability
3.
Just culture
a) Influences
b) Characteristics
c) Examples
1.
MGH
a) Just culture in action
b) Innovation initiatives

4. Quality (IOM, 2001)
Quality- the degree to which health services for individuals
and populations increase the likelihood of desired
outcomes and are consistent with professional
knowledge.
Quality/Cost = Value
Measures – Structure, Process & Outcomes (Donabedian, 1988)

5. IOM 6 Aims of Quality Care (2001)
Efficient
Equitable
Effective
Safe
Timely
Quality
Care
Patient
Centered

6. Safety (IOM,2000)
• Safety
– “Freedom from accidental or preventable injury”
– the first domain of quality
• Patient Safety
– prevention of harm to patients
– critical subset of quality patient care
– Includes:
1. safe care
2. practice that is consistent with current
evidence/knowledge
3. customization
• Measures - difficult to measure due to dependence on selfreporting.

7. Safety Culture Influences

8. Professional Accountability
• There is a social contract between society and a profession.
• Professions are the property of society and are responsible to
society.
• Professions acquire recognition and relevance from society.
• It is society that determines what professional skills and knowledge
are most needed and desired of a profession.
• Society grants professions authority over functions vital to itself
and allows for autonomy in the conduct of their own affairs.

9. Nursing Accountability
• Nursing is a profession and therefore responsible to society.
• Nursing must be perceived as serving the interests of society.
• Professions are therefore expected to act responsibly and mindful
of the public’s trust.
• Self-regulation assures high quality performance and is the
hallmark of a mature profession.

10. Nursing is:
The protection, promotion, and optimization of health and abilities,
prevention of illness and injury, alleviation of suffering through the
diagnosis and treatment of human response, and advocacy in the care
of individuals, families, communities, and populations.
American Nurses Association

11. Errors and Adverse Events
•
•
•
•
98,000/year deaths estimated from medical errors (IOM, 2000)
210,000 deaths/year associated with preventable harm in hospitals (James, 2013:
J Pt Safety).
Error - (process) an act of commission ( doing something wrong) or omission
(failing to do the right thing) leading to an undesirable outcome or significant
potential for such an outcome (AHRQ, 2013).
– Not all errors lead to adverse events.
Adverse Event – (outcome) Unintended physical injury resulting from or
contributing to by medical care (including the absence of indicated medical
treatment) that requires additional monitoring, treatment, or hospitalization, or
that results in death (IHI, 2013).
– Not due to an underlying disease
– Unpreventable
– Preventable
• Negligent – care falling below a professional standard
– Side effects – may not be preventable or a medical error

12. Moving toward a safer culture
James Reason
•
•
Goal: to create a safer culture consisting of:
• Reporting
• Learning
• Flexibility
• Just Culture
Swiss Cheese Model
David Marx
•
•
Just culture algorithm – systems, behavioral choices, injury severity & not
blame-free but just
Core principles:
• To err is human –human errors, systems
• To drift is human – well intentioned, cut corners, fast paced, creates risk
• Risk is everywhere
• We are all accountable

13. Reason’s Swiss Cheese Model
(emeraldinsight.com)

14. Just Culture – Human Error
The single greatest impediment to error prevention
in the medical industry is
“that we punish people for making mistakes.”
Dr. Lucian Leape
Professor, Harvard Medical School of Public Health
Testimony before Congress on Health Care Quality Improvement

15. Just Culture – Systems thinking
“People make errors, which lead to accidents.
Accidents lead to deaths. The problem is seldom the fault
of the individual; it is the fault of the system.
Change the people without changing the system
and the problem will continue.”
Don Norman
Author, the Design of Everyday Things

16. Just Culture – Reckless behavior
“…No person may operate an aircraft
in a careless or reckless manner so as to
endanger the life or property of another.”
Federal Aviation Regulations 91.13 Careless or reckless operation

17. Just Culture
1. Emphasizes quality and safety over blame and punishment.
2. Promotes a process where mistakes/errors do not result in
automatic punishment but a process to uncover the root cause of
the error.
3. Human errors that are not deliberate or malicious result in
coaching, counseling, and education to decrease the likelihood of a
repeated error.
4. Promotes increase error reporting that leads to system
improvements to create safer environments for patients and staff.

18. Proactive Learning Culture
• Not seeing events as things to
be fixed
• Seeing events as opportunities
to improve our understanding
of risk
– System risk
– Behavior risk

19. Blame vs. Accountability
1. Was the individual impaired?
2. Did the individual consciously decide to engage in an unsafe act?
3. Did the caregiver make a mistake that other similar individuals
would make in similar circumstances?
4. Does the individual have a history of unsafe acts?

20. Fair evaluation & response (Frankel &
Leonard

21. Allen Frankel’s Algorithm (2010)

22. Examples
• Unintentional Error
– RN draws blood, gown slips over tourniquet, finds arm
swollen
• At-Risk Behavior
– RN draws blood, patient complains of noise, takes blood
out of room and labels at desk with wrong label, without
checking 2 identifiers at bedside
• Reckless Behavior
– During medication administration, bar code scanning
alerts nurse to wrong medication, nurse ignores alert and
administers wrong medication without re-checking

23. Evidence- Based Patient Safety Improvements
(2012, Gosbee, J.)
Weak
•
•
•
•
Double checks
Warnings
Training
New procedures
Intermediate
•
•
•
•
Redundancy
Increase staffing
Checklists
Standardize
communication
tools
• Education
Strong
• Simplify processes
• Standardize
equipment and
processes
• Force functions
• New devices with
usability testing
• Physical plant
changes
• Tangible
involvement of
leadership

24. Adverse Drug Events
$3.5 Billion
in costs
(CDC, 2012)
700,000 ED
visits
120,000
admissions
Yellow- no error
Purple- Error, no harm
Blue- Error, Harm
Orange- Error, Death

25. MGH Culture of Safety
• Edward P. Lawrence Center for Quality and
•
•
•
•
•
•
•
Safety
Just Culture embraced
Robust safety reporting – over 19,000 reports
filed in 2012
Safety Culture Perception Survey
Model to address professional conduct issues
Root Cause Analysis
Communication and Apology
Executive Leadership Safety Rounds

27. Patient Care Services Quality and Safety
• Office of Quality and Safety
• Safety reporting notification structure and follow up
– Root cause analysis
• Data driven
– Nurse-sensitive indicators
– Hospital-acquired conditions
– Patient satisfaction
– Nurse satisfaction
• Regulatory requirements
• Practice alerts- red flag
– SBAR

29. MGH Sentinel Event
Event
•
•
•
•
•
•
90 year old male surgical patient
with complete heart block sent to
CICU
Plan for pacemaker in a few days
Transferred back to surgical unit on
a cardiac monitor
Found in cardiac arrest
Code Blue activated
Patient expired
Post-event
•
•
•
•
•
•
•
•
RNs discovered monitor alarms were off
– Filed safety report
– Alerted leadership
Monitors, pumps etc… investigated
Root cause analysis initiated
Conversations with family begin
Reported to Department of Public Health
Boston Globe report
MGH launches Interdisciplinary
Physiologic Monitoring Tiger Team
– Physiologic Monitoring Criteria
– Physiologic Monitoring Assessment
– Physiologic Monitoring Practice
Standards
Clinical Technology Oversight Committee

30. Professional Practice Model

31. Magnet Recognition: External Evaluation

32. Staff Perceptions of the Professional Practice
Environment Survey: Internal Evaluation
• Evaluate the effectiveness of the Professional Practice Model based
on eight professional practice environment (PPE) characteristics:
- autonomy
- control over practice
- clinician-physician relationships
- communication
- teamwork
- conflict management
- internal work motivation
- cultural sensitivity
• Identify opportunities for improvement
• Trend data over time
• Provide report card for reflection and future direction

34. Guiding Principles
•
Care delivery should always be: patient and family-focused, evidence-based,
accountable and autonomous, coordinated and continuous.
•
It’s important to know the patient.
•
Inpatient and family care is provided by a designated nurse and physician
who are accountable and responsible for continuity of care.
•
Continuity of the team is a basic precept.
•
Every novice team member deserves mentoring from an experienced
clinician.
•
Every patient deserves the opportunity to participate in the planning of
his/her care.
•
Advancements in technology create opportunity for improved provider
communication and efficiency.

35. “Patient Journey” Framework
Before
Preadmission
Care
During
Admission
Process: ED,
Direct Admits,
Transfers
Patient Stay;
Direct Patient
Care, Tests, Treatments, Procedu
res,
Clinical Support,
Operational Support
Post
Discharge
Process
Support Functions: Finance, Information Systems, HR
Goal: High-performing interdisciplinary teams that deliver safe, effective, timely,
efficient and equitable care that is patient and family centered.
Where Are There Opportunities to Reduce Costs Across These Processes of Care?
Post
Discharge
Care

36. Innovations in Care Delivery
Patient Journey Framework
Discharge
process
Intervention
Patient stay; direct patient care;
tests; treatments; procedures;
clinical support;
operational support
After
Intervention
Admission
process: ED,
direct admits,
transfers
Intervention
Preadmission
care
During
Intervention
Before
Postdischarge
care
Goal: High-performing, inter-disciplinary teams that deliver safe, effective, timely,
efficient, and equitable care that is patient- and family-centered
The Interventions
•Enhance clinical datacollection before admission
•Create Innovation Unit
Welcome Packet
•Engage Patients and
families in redesign
•Revise Domains of Practice
•Implement inter-disciplinary team rounds
•Install unit census and in room whiteboards
•Utilize communication devices
•Utilize wireless laptop computers
•Business cards
•Hourly rounding
•Quiet hours
•Implement Discharge
Follow-up Call Program
Relationship-based care
Increased accountability through the attending nurse role
Utilization of Evidence Based staffing and care delivery;
Utilization of the Hand-Over Rounding Checklist

37. Relationship Based Care
• Mary Koloroutis: a model for transforming practice
• 3 Crucial relationships
– Care provider’s relationship with patients and families
– Care provider’s relationship with self
– Care provider’s relationship with colleagues
• Incorporates a formula for leading change with:
– Inspiration
– Infrastructure
– Education
– Evidence
– Bolstered by 5 Cs – clarity, competence, confidence,
collaboration, commitment

38. Relationship-Based Care
Patient safety is most effectively safe guarded when an advocate (most often
the nurse) in the health care system knows the patient, family, and what matters
most to them.

39. Attending Nurse Role
Responsible Nurse/Attending Nurse 
Expand staff nurse role.
•
Accountable for patient/family continuity and progression along the
developed overall plan of care from admission to discharge
•
Ensures, along with the Attending MD, that patient care meets the unit’s clinical
standards and vision of patient- and family-centered care
•
Develops and revises the patient care goals with the clinical care team daily
•
Coordinates meetings with clinicians for timely decision making and connects
nurses to optimize handoffs across the continuum
•
Is the primary bedside communicator with the patient and family, discussing
plan of the day, care progress, potential discharge, and answers
questions/teaches/coaches

40. Evaluation
•
•
•
•
•
•
•
•
Dashboards - outcomes
Nurse Director walk rounds
Patient & Family Advisory Councils (PFAC)
Patient interviews – follow up phone calls, on-site
interviews
Focus groups
Audits
Retreats
Weekly meetings with Attending RNs

41. Innovation Unit Dashboard
Throughput and Efficiency
 LOS
 TSI bud/flex
 Wait time for bed to be ready
 Admits
 Medication turnaround time
Patient & Staff Satisfaction
 MD & RN Communication
 Responsiveness
 Cleanliness
 Noise reduction
 Staff perception of support
 Equitable care
Massachusetts General Hospital - PCS Innovation Units Dashboard
Measures
Pediatrics
Ortho Oncology Medicine NICU
Surgery
White 6 Lunder 9 Ellison 16 Blake 10 Ellison 17 Ellison 18 White 7
CICU
ICU Obstetrics Psych Vascular
Ellison 9 Blake 12 Blake 13 Blake 11 Bigelow 14
QUALITY AND SAFETY
Patient-Centered Outcome Measures
Falls per 1,000 Patient Days
Total Fall Rate
Observed (N)
Falls with Injury per 1,000 Patient Days
Falls with Injury Rate
Observed (N)
4.50
11
1.46
3
4.95
13
0.77
1
1.92
2
1.32
2
2.16
5
1.79
2
TBD
0.65
2
4.85
10
0.45
1
0.41
1
0.49
1
1.52
4
0.00
0
0.96
1
0.00
0
0.00
0
0.89
1
TBD
0.00
0
1.45
3
0.45
1
0.0%
0
6.9%
2
0.0%
0
0.0%
0
0.0%
0
0.0%
0
7.7%
1
TBD
NA
4.8%
1
4.2%
1
0.0%
0
0.0%
0
0.0%
0
0.0%
0
0.0%
0
0.0%
0
7.7%
1
TBD
NA
4.8%
1
4.2%
1
0.0%
0
0.0%
0
0.0%
0
0.0%
0
0.0%
0
0.0%
0
7.7%
1
TBD
NA
0.0%
0
0.0%
0
NA
NA
0.0%
0
0.0%
0
0.0%
0
NA
NA
NA
NA
NA
NA
2.90
1
4.76
1
0.00
0
1.10
1
1.70
2
TBD
NA
0.00
0
0.00
0
Hospital Acquired (HA) Pressure Ulcers
Total HA Pressure Ulcer Prevalence Rate
0.0%
Observed (N)
0
Hospital Acquired (HA) Pressure Ulcers Type II or Greater
Total HA Pressure Ulcer Type II or Greater Prevalence Rate
0.0%
Observed (N)
0
Restraints
Total Restraint Prevalence Rate
Observed (N)
0.0%
0
Peripheral Intravenous (PIV) Infiltrations - Pediatric/Neonatal
Total PIV Infiltration Prevalence
NA
Observed (N)
Central Line-associated Bloodstream Infections per 1,000 Line Days (CLABSI)
Total CLABSI Rate
6.54
NA
1.36
Observed (N)
1
1
Quality and Safety
Note: metrics to be reported beginning FY 2012
Color Shading relative to Benchmark:
 Unplanned Return to OR
Rate is worse (higher) than benchmark.
Catheter-associated Urinary Tract Infections per 1,000 Device Days
 Readmission Rate
Rate is better (lower) than benchmark.
Ventilator-associated Pneumonia per 1,000 Vent Days
 Restraint Free Rate
 Falls/Pressure Ulcer Reduction
Innovation Unit Dashboard
 Foley Catheter Days
July – September 2011
 Hard-stop Time Out Performance

42. A Strong Safety Culture
1. Creates a learning culture
• Foundation of patient safety
2. Creates an open, fair and just culture
• Encourage reporting
• Reinforce accountability for safety at all levels
3. Designs safe systems
• Systems have the greatest influence on patient safety
4. Manages behavioral choices
• Critical thinking and decision making emphasizes the
continuous evaluation of risk
• Choices lead to desired safety outcomes

43. References
•
•
•
•
•
•
•
•
•
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Agency for Healthcare Research and Quality. Available at: http://webmm.ahrq.gov/glossary.aspx
Committee on Health Care in America, Institute of Medicine (2001). Crossing the Quality Chasm: A
New Health System for the 21st Century. Washington D.C.: National Academies Press.
Committee on Quality of Health Care in America, Institute of Medicine (2000). To Err is Human:
Building a Safer Health System. Washington D.C.: National Academies Press.
Donabedian, A. (1988). The quality of care. How can it be assessed? JAMA 1988;260:1743-1748.
Gosbee, J. (2012). Assessing the strength of healthcare facility improvement actions. Massachusetts
Board of Registration in Medicine Quality and Patient Safety. Retrieved from:
www.patientsafety.gov
Institute for Healthcare Improvement, Available at: http://www.IHI.org
James, J. (2013). A new, evidence-based estimate of patient harms associated with hospital care.
Journal of Patient Safety 9(3) 122-128.
Koloroutis, M. (Ed.) (2004). Relationship-based Care: A model for transformational practice. Minneapolis,
MN: Creative Healthcare Management Inc.
Leonard, M.W. & Frankel, A. (2010). The path to safe and reliable healthcare. Patient Education and
Counseling 80: 288-292.
Wachter, R.M. (2012). Understanding Patient Safety 2nd ed. New York, NY: McGraw Hill|LANGE.