Just Culture

Right at Home Belmont has adopted a “Just Culture” which promotes a learning culture that supports client safety while assigning accountability for behavioral choices. The Safety Committee headed by the President uses “Just Culture” concepts when reviewing practice events or errors and when identifying appropriate resolutions that promote practice enhancement and client safety.

The Just Culture Concepts:

• Focus on evaluating the behavioral choices made by an individual, not on the outcome of the event;
• Require leadership commitment and modeling;
• Distinguish among normal human error, unintentional risk-taking behavior, intentional risk-taking behavior, and reckless behavior;
• Foster a learning environment that encourages reporting (including self-reports) of all near misses, mistakes, errors, adverse events, and system weaknesses;
• Lends itself to continuous improvement of work processes and systems to ensure the highest level of client and staff safety;
• Encourage the use of non-disciplinary actions whenever appropriate (including coaching, counseling, training, and education);
• Hold individuals accountable for their own performance in accordance with their job responsibilities; and,
• Does not expect individuals to assume accountability for system flaws over which they had no control

Just Culture Terms, Definitions and Examples

Human Error

(Not reportable to appropriate authorities)

Definition:

• Caregiver inadvertently, unintentionally did something other than intended or other than what should have been done;
• A slip;
• A lapse; or
• An honest mistake.
• Isolated event, not a pattern of behavior.

(Repetitive human error or pattern of behavior requires further evaluation)

Examples:

• Single medication event/error (wrong dose, wrong route, wrong client, or wrong time) (RN ONLY)
• Failure to implement a Caregiver Task due to oversight

Responses to Behavior:

• Consoling or Coaching

At-Risk Behavior:

Administrative decision based on individual circumstances

Definition:

• Behavioral choice that increases risk where risk may not be recognized or is mistakenly believed to be justified;
• Caregiver does not appreciate risk;
• Unintentional risk taking; and
• Caregivers performance or conduct does not pose a continuing practice risk to clients or others.

(Repetitive at-risk behavior or pattern of behavior requires further evaluation)

Examples:

• Exceeding scope of practice
• False Documentation
• Major Deviations from Careplan without Administration approval
• Caregiver knowingly deviates from a standard due to a lack of understanding of risk to client, organization, self, or others

Responses to Behavior:

Coaching or Counseling

• If behavior not a pattern of practice) to raise awareness of accepted procedures and potential risks for failure to comply
• Remedial actions taken may include education, training, and assignment of activities appropriate to knowledge and skill
• Caregiver may be informed failure to change is not an option
• If caregiver does not accept coaching, may result in disciplinary action

Administrative Action:

• Non-disciplinary Remediation
• Disciplinary Action if Indicated

Reckless Behavior:

(Mandatory report to Administrator)

Definition:

• Caregiver consciously disregards a substantial and unjustifiable risk;
• Caregiver's action or inaction is intentional and purposeful; or
• Caregiver puts own self/personal interest above that of client, organization or others

Examples:

• Caregiver abandons clients by leaving workplace before reporting to another appropriately licensed Caregiver. Caregiver leaves workplace before completing all assigned patient/client care (including documentation) for a non-urgent reason.
• Caregiver does not intervene to protect a client because Caregiver is not assigned to client
• Caregiver makes serious medication error, when realized tells no one, and when questioned denies any knowledge of reason for change in client condition
• Caregiver falsifies documentation to conceal an error

Response to Behavior:

• Report to Administrator for Investigation
• Contact appropriate authorities

Additional Definitions:

Consoling – affording comfort or solace; restoring confidence and relieving anxiety.

Coaching – supportive discussion with an employee on the need to engage in safe behavioral choices.

Counseling – a first step in disciplinary action; putting an employee on notice that performance is unacceptable.