Jones & Bartlett Learning Health Blog

    Just Culture and Speaking Up

    Posted by sharonb on Nov 2, 2014 9:53:45 PM

    Many years ago in the late 1970's when I was an intravenous (IV) therapist at an upstate New York academic health center, a patient who worked with rabies virus in the New York State Laboratory across the street was admitted through the Emergency Department. The admitting resident physician, who was a friend, told us the patient presented with seizures, photophobia, and "foaming at the mouth." However, because the patient had been vaccinated against rabies, the physician felt there was "no way" the patient could have the disease. I disagreed.

    The patient was admitted to a four bed Intensive Care Unit room. When I went to start an IV on him, I gowned, gloved, and masked. As I entered the room, the infectious disease team rounded and confronted me, asking me why I was "dressed up." I told them the patient had rabies. They ridiculed me and my concerns, because he'd been vaccinated.  I responded I was taking precautions, regardless of their opinions.

    About a week later, the patient's antibody tests returned from the Centers for Disease Control and Prevention (CDC). Much to everyone's shock (except mine) he had rabies. Nurses, physicians, technicians, housekeepers, dietary aides, family members and other patients had been exposed to this patient. The hospital had to provide weeks of in-service education and training and identify and vaccinate each and every person who had direct contact with the patient.

    I recounted this story to a guest speaker who was talking about "Just Culture" during our most recent residency weekend for our MS in Healthcare Management program. She marveled that I had the nerve to speak up and act on my concerns about these risky behaviors. In those days, physicians were not to be contradicted. Why did I feel confident enough to speak up when others didn't? Looking back, I was secure in my education. I have an undergraduate degree in Psychology, with a minor in Biology, plus a graduate degree in Psychology, specifically Neuropsychology. In addition, I was the supervisor of the IV service, so I felt empowered to speak up as a manager in that organization.

    Even now, despite extensive research that demonstrates the importance of teamwork and safety, nurses and other healthcare professionals are reluctant to speak up and confront physicians when they are concerned about risky behaviors.  How can educators coach students to become resilient graduates who will contribute to the organizational goal of focusing on "what went wrong, not who caused the problem" (Barnsteiner, 2011, Para 6)?

    We can start by anchoring them in a solid educational base and have a curriculum that addresses and assesses interpersonal, professional, teamwork, quality management/improvement, systems thinking, patient safety and leadership competencies, among other things. In addition to these competencies, we can encourage awareness of the importance of their role in patient safety. What are our tools for developing this awareness? Here is a partial list of actions we can take.

    • Educate students about "Just Culture" using AHRQ and other resources available to us.
    • Invite quality management practitioners into our classrooms to speak about their experiences with learning organizations and "Just Culture."
    • Provide case studies and simulations, asking students to analyze the case through the lens of identifying the error in the system, not just the error of a character in the case.
    • Task them to identify when they observe people drift into at risk behavioral choices during capstone or internship experiences and encourage them to discuss their observations with their organizational mentors and their faculty supervisors.
    • Debrief and provide feedback to students about their observations and whether their concerns were founded.
    • Encourage students to use these events as an opportunity to help design safe systems and facilitate safe choices within the organization.

    It is our job to educate the next generation of health care managers to be the ones who not only talk "Just Culture," but also walk "Just Culture."  By building opportunities to learn from errors in healthcare into our curriculum, we can instill confidence and courage into our students to speak up.

    Sharon B. Buchbinder, RN, PhD

    Sharon Buchbinder is Professor and Program Coordinator for the MS in Healthcare Management at Stevenson University in the Graduate and Professional School and former chair of the Association of University Programs in Health Administration (AUPHA). She is also the author of three books from Jones & Bartlett: Introduction to Health Care Management, Cases in Health Care Management, and Career Opportunities in Health Care Management.

    Here are some references if you are interested in this topic:

    Barnsteiner, J., (September 30, 2011) "Teaching the Culture of Safety" OJIN: The Online Journal of Issues in Nursing Vol. 16, No. 3, Manuscript 5.

    FOJP Service Corporation. (2012, Summer). The future of training for patient safety and quality. infocus: The Quarterly Journal for Healthcare Practice and Risk Management. 19: 1-23.

    Frankel, A.S., Leonard, M.W., & Denham, C. R. (2006). Fair and just culture, team behavior, and leadership engagement: The tools to achieve high reliability. Health Serv Res. Aug 2006; 41(4 Pt 2): 1690–1709. doi:  10.1111/j.1475-6773.2006.00572.x

    Jackson, A.C., Warrell, M.J., Rupprecht, C.E., Ertl, H.C.J., Dietzschold, B., O'Reilly, M., Leach, R.P, Fu, Z.F., Wunner, W.H., Bleck, T.P., & Wilde, H. (2003). Management of rabies in humans Clin Infect Dis. (2003) 36 (1): 60-63 doi:10.1086/344905

    Marx, D. (2001, April 17). Patient safety and the “Just Culture”: A primer For health care executives.

    Teamstepps National Implementation. (2014).

    Topics: administration, health administration, quality improvement, Sharon B. Buchbinder, Just Culture, Sharon Buchbinder Blog

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