Describe whether the ethical theory of Just Culture
If culture drives quality in a health care organization, can it be assumed that a just culture drives equity? Health care is provided one person at a time, often through silos that keep different professions away from each other. One way to respond to errors made by those we work with is to blame and shame them, saying they should have paid more attention or been aware something bad would happen. Dr. Donald Berwick used to talk about the “culture of bad apples,” where the health care organization is compared to a pristine bushel of apples. An error is made, and the organization quickly moves to get rid of the bad apple in the bushel—without considering how systems and processes may have “set up” that person to err. How do we provide responses to errors made by those we work with? How do we hold ourselves and others accountable?
This week, you will evaluate different models that an organization might use to improve the culture of quality and the validity of a “Just Culture” as it relates to improving quality.
Learning Objectives
Students will:
Evaluate models health care organizations might use to improve the culture of quality
Evaluate whether a Just Culture might improve quality
Photo Credit: [Yuri_Arcurs]/[DigitalVision]/Getty Images
Learning Resources
Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.
Required Readings
Joshi, M. S., Ransom, E. R., Nash, D. B., & Ransom, S. B. (Eds.). (2014). The healthcare quality book: Vision, strategy, and tools (3rd ed.). Chicago, IL: Health Administration Press.
Chapter 8, “The Culture Connection: Hardwiring Consistent Quality Delivery” (pp. 193–206)
Chapter 11, “Patient Safety and Medical Errors” (pp. 269–294)
Chapter 12, “Creating a Culture of Safety and High Reliability” (pp. 297–324)
Detsky, A. S., Baerlocher, M. O., & Wu, A. W. (2013). Admitting mistakes: Ethics says yes, instinct says no. Canadian Medical Association Journal, 185(5), 448.
Note: Retrieved from the Walden Library databases.
MacLeod, L. (2014). “Second Victim” casualties and how physician leaders can help. Physician Executive, 40(1), 8–12.
Note: Retrieved from the Walden Library databases.
Nelson, W. A. (2013). Addressing the second victims of medical error. Healthcare Executive, 28(2), 56–59.
Note: Retrieved from the Walden Library databases.
Stempniak, M. (2014). The other victim. When a patient is harmed, staff often suffer in silence. Hospitals & Health Networks, 88(7), 18.
Note: Retrieved from the Walden Library databases.
Centers for Disease Control and Prevention. (2016). Chronic disease prevention and health promotion: Statistics and tracking. Retrieved from http://www.cdc.gov/chronicdisease/stats/index.htm
Hospital Consumer Assessment of Healthcare Providers and Systems. (n.d.). CAHPS hospital survey. Retrieved from http://www.hcahpsonline.org/home.aspx
Healthy People 2020. (2016a). 2020 topics and objectives: Objectives A–Z. Retrieved from http://www.healthypeople.gov/2020/topics-objectives
Healthy People 2020. (2016b). Access to health services. Retrieved from http://www.healthypeople.gov/2020/topics-objectives/topic/Access-to-Health-Services
Healthy People 2020. (2016c). How to use DATA 2020. Retrieved from http://www.healthypeople.gov/2020/How-to-Use-DATA2020
Required Media
Institute for Healthcare Improvement Open School. (2014d). Josie King [Video file]. Retrieved from http://www.ihi.org/education/ihiopenschool/resources/Pages/CourseraVideo1.aspx
Note: The approximate length of this media piece is 6 minutes.
Institute for Safe Medication Practices (Producer). (n.d.). Beyond blame documentary [Video file]. Horsham, PA: ISMP.
Note: The approximate length of this media piece is 10 minutes.
Accessible player
Discussion: Culture Connections and Patient Safety
Culture drives quality—if an organization does not have a culture in which they hold themselves and others accountable, it is probable that it will not achieve and sustain high-level quality outcomes. Patient safety is defined as freedom from accidental injury; you have seen how medical errors are harmful, and that there are second victims that suffer as well. Remember quality can be defined as “the cumulative impact of all that happens to a patient while in an organization’s care” (Porter, 2012, p. 193).
A Just Culture gives organizations a template to uniformly address the shortcomings or errors of those who fail. It addresses failures in four different areas, which include 1) human errors and mistakes, meaning unintentional harm; 2) carelessness or at-risk behavior—or not paying attention that results in an error; 3) recklessness or a flagrant disregard for norms where an error occurs unintentionally, but because of recklessness; and 4) those who just do not pay attention and have no regard for authority.
In this Discussion, you will identify a model that a health care organization might use to improve their culture of quality and describe whether the ethical theory of Just Culture would improve the quality and why.
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