{"id":2182,"date":"2012-08-17T00:15:36","date_gmt":"2012-08-17T07:15:36","guid":{"rendered":"http:\/\/www.wapatientsafety.org\/?p=2112"},"modified":"2019-08-02T22:34:38","modified_gmt":"2019-08-02T22:34:38","slug":"a-just-culture-environment-is-critical-to-safety-and-quality-improvement-and-deserves-the-boards-full-attention","status":"publish","type":"post","link":"https:\/\/www.qualityhealth.org\/wpsc\/2012\/08\/17\/a-just-culture-environment-is-critical-to-safety-and-quality-improvement-and-deserves-the-boards-full-attention\/","title":{"rendered":"A \u201cJust Culture\u201d environment is critical to safety and quality improvement and deserves the board\u2019s full attention."},"content":{"rendered":"

[two_third]<\/p>\n

Patient safety and quality is ultimately the responsibility of our governance boards.\u00a0 In the past, it was thought to be a clinical issue for the clinicians to figure out.\u00a0 Today, with the increased recognition that preventable harm causes 200,000 patient deaths a year, it is clear that the \u2018buck stops\u2019 at the highest level of authority in the organization and that the board must work closely with the CEO to oversee, support and demand safety and quality excellence.<\/p>\n

The ability to see our risks, hazards and errors in order that we can fix the systems, processes and practices that lead to the majority of preventable harm events, is a significant component of safety and quality improvement work.\u00a0 In the past, we thought that by simply empowering our caregivers to raise issues of concern, information would flow freely.\u00a0 Today, we better understand that a \u201cJust Culture\u201d environment that fairly and appropriately supports caregivers when mistakes occur is critical to priming and sustaining the flow of information.<\/p>\n

A \u201cJust Culture\u201d environment deserves the board\u2019s full attention. So what should the board do? Here are several governance best practices:<\/p>\n

    \n
  1. Provide the board with the most current \u201cJust Culture 101\u201d education materials.\u00a0 David Marx, the Institute for Healthcare Improvement, the Governance Institute and the Canadian Patient Safety Institute are all excellent resources.<\/li>\n
  2. Routinely review the organization\u2019s \u201cJust Culture\u201d plan, policies and procedures.\u00a0 Ensure the plan is well documented, thoroughly communicated and continually assessed. Compare the components of sample plans provided by the organizations above to your current plan, and identify and discuss the gaps.<\/li>\n
  3. Review and discuss your formal culture of safety survey feedback information, to assess the willingness of caregivers to raise issues of concern, and their input on the effectiveness of the organization\u2019s \u201cJust Culture\u201d policies and procedures.\u00a0 Compare your survey results with the experiences of best performers to challenge your current position.<\/li>\n
  4. Review and discuss a recent incident where \u201cJust Culture\u201d policies were utilized.\u00a0 What went well?\u00a0 What could be improved?<\/li>\n
  5. Ask caregivers and management about the \u201cJust Culture\u201d environment during trustee rounding.\u00a0 Survey data is very helpful.\u00a0 Direct feedback is invaluable.<\/li>\n
  6. Consider bolder, more aggressive goals and objectives for instilling a \u201cJust Culture\u201d based upon organization-wide feedback and assessment findings.<\/li>\n
  7. Be very clear about the board\u2019s commitment to open disclosure and a \u201cJust Culture.\u201d\u00a0 Trustees should \u2018be seen\u2019 by the organization to be knowledgeable, interested and supportive.<\/li>\n<\/ol>\n

    – Tom VanDawark, Orca Partners<\/em>[\/two_third]<\/p>\n

    [one_third_last]<\/p>\n

    Thoughts to share with\u00a0Tom?<\/h4>\n

    [button link=”mailto:tom@orcapartnersllc.com”] Mail Tom[\/button]<\/p>\n

    [\/one_third_last]<\/p>\n","protected":false},"excerpt":{"rendered":"[two_third] Patient safety and quality is ultimately the responsibility of our governance boards.\u00a0 In the past, it was thought to be a clinical issue for the clinicians to figure out.\u00a0…","protected":false},"author":3,"featured_media":6708,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_topic_count_hidden":0,"_bbp_reply_count_hidden":0,"_bbp_forum_subforum_count":0,"footnotes":""},"categories":[8],"tags":[],"class_list":["post-2182","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-the-safety-blog"],"aioseo_notices":[],"jetpack_featured_media_url":"https:\/\/www.qualityhealth.org\/wpsc\/wp-content\/uploads\/sites\/3\/2015\/12\/safety_blog.jpg","_links":{"self":[{"href":"https:\/\/www.qualityhealth.org\/wpsc\/wp-json\/wp\/v2\/posts\/2182","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.qualityhealth.org\/wpsc\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.qualityhealth.org\/wpsc\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.qualityhealth.org\/wpsc\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/www.qualityhealth.org\/wpsc\/wp-json\/wp\/v2\/comments?post=2182"}],"version-history":[{"count":1,"href":"https:\/\/www.qualityhealth.org\/wpsc\/wp-json\/wp\/v2\/posts\/2182\/revisions"}],"predecessor-version":[{"id":6742,"href":"https:\/\/www.qualityhealth.org\/wpsc\/wp-json\/wp\/v2\/posts\/2182\/revisions\/6742"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.qualityhealth.org\/wpsc\/wp-json\/wp\/v2\/media\/6708"}],"wp:attachment":[{"href":"https:\/\/www.qualityhealth.org\/wpsc\/wp-json\/wp\/v2\/media?parent=2182"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.qualityhealth.org\/wpsc\/wp-json\/wp\/v2\/categories?post=2182"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.qualityhealth.org\/wpsc\/wp-json\/wp\/v2\/tags?post=2182"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}