Black River Memorial Hospital in Wisconsin has dramatically improved error reporting by promoting a non-punitive approach among its managers. Its award-winning risk manager Sue Pearson told HRMR how this was achieved.
In May this year Sue Pearson, the quality and risk manager of Black River Memorial Hospital in Wisconsin, received the first annual John S. Coldiron, MD, Performance Improvement Innovation Award for her work in encouraging staff to be open about errors. She achieved this by training managers to deal with errors in a constructive, largely non-punitive way.
Crucial to this approach was the use of Just Culture tools (see below) to ensure that employees can expect the same treatment for the same incident no matter who is the manager.
“This is essential to the open reporting of errors, which is critical to performance improvement,” says Pearson.
She also included a question about the use of Just Culture tools in almost every incident review and created reports to track completion time of incident reviews. The flexibility of the hospital’s Occurrence Insight incident reporting system allowed the easy addition of questions to reviews as needed.
As a result of these changes, Pearson was able to measure impressive improvements in staff’s reporting of events, communication openness and non-punitive responses to errors.
Innovative Change
Her innovations were part of a larger strategy to make positive culture and operational changes at Black River, a rural critical access hospital employing around 300 staff, that began in 2008 when the hospital became a Studer Group partner (Studer Group is an organization that works with healthcare organizations to help them achieve exceptional outcomes and build a culture of accountability). Around the same time the hospital started achieving the top workforce climate awards from the Jackson Group.
In 2010, Pearson reorganized the patient safety committee and began to look for improvement opportunities that would mesh with the Studer Group concepts. This led her to share the hospital’s Agency for Healthcare Research and Quality (AHRQ) Culture of Patient Safety Survey results for 2006 and 2008 with the team.
“We decided to address the ‘non-punitive response to error’ composite from the survey for our first major performance improvement project,” she says. “We felt the Just Culture concepts and ideas would enable us to further improve how our staff perceived occurrence reporting and follow-up.”
During the first half of 2010, the patient safety team rolled out these plans by developing educational programming for senior leaders, managers and staff in the use of the Just Culture flowcharts, which help managers unpick an event to decide what behaviors caused it.
Several cycles of learning have occurred since then: Pearson has added the education materials and the flowcharts to the Quality page on the hospital’s intranet so that all staff can access the information about Just Culture and can bring copies of flowcharts with them should they need to review an error with their manager. She has worked with Kim Collyer at Insight Health Solutions to incorporate Just Culture flowchart use questions into nearly all of the various manager review screens, and she has developed a monthly detail report showing managers which type of Just Culture flowchart was used for a given occurrence.
Comprehensive Analysis
Pearson went on to analyse every occurrence review completed by the managers or their designees, evaluated the Just Culture flowchart choices made by managers and offered suggestions as to which flowchart was the most appropriate for the situation.
She then worked with Insight Health Solutions to develop a rolling 12-month report that displays flowchart uses by each department over time.
“My next steps in the process will include re-review of the personnel policy manual to make sure that our wording matches our process and we incorporate the Just Culture concepts into that document,” she says. She also intends to develop additional questions in the managers’ occurrence review screens to ensure that when they state ‘monitoring in progress’ that a plan is actually in place and what the plan is.
Pearson offers the following tips for replicating Black River’s success:
“Senior leader and manager buy-in, support, and role-modelling are essential. Without this combination, success is likely to be elusive. Do your research well, create a good proposal, and build a good work team—not only managers but get staff in there too.
“I would recommend doing things in stages, biting off one bit of the project at a time. Our journey to excellence is just that—it’s a journey and not just a trip. We’re not going from point A to point B, we’re heading out and we just keep going.”
What is Just Culture?
Just Culture is a system for implementing organizational improvement, designed to help change an organization’s culture by placing less focus on events, errors and outcomes, and more focus on risk, system design and the management of behavioral choices. This is done by defining three manageable behaviors: human error, at-risk behavior and reckless behaviour, and promoting an environment of free and open reporting of errors.
This helps to build a culture which encourages coaching and honesty at all levels, in order to bring about the best possible outcomes.
The Just Culture flowchart is a tool for understanding and categorizing the choices made by those in an organization. With it an event can be evaluated in order to determine which of the three behaviors was most likely in play, enabling the event and the people involved to be addressed in a constructive way rather than simply reacting to the outcome.
Studer Group
Studer Group works with more than 850 healthcare organizations in the US and beyond, teaching them how to achieve, sustain, and accelerate exceptional clinical, operational, and financial outcomes. It works to bring structure and focus to organizations through the creation of cultures of accountability and helps set them up to be able to execute quickly.
Studer Group helps organizations install an execution framework called Evidence-Based Leadership (EBL) that aligns their goals, actions, and processes. This framework creates the foundation that enables them to transform the way they provide care in this era of rapid change.
The Jackson Group
The Jackson Group commits its resources to “helping organizations manage well, serve well and communicate well”. Through a growing array of solutions for organizations—including employee surveys, customer satisfaction surveys, exit surveys, Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), and community perceptions assessments—the group helps healthcare providers understand and respond to their work environment and better serve their community.
Meet Sue Pearson
Before becoming quality and risk manager in 2008 Pearson was the laboratory manager at Black River for many years. She was very active in a wide variety of committees and work teams and was well versed in quality concepts, managerial functions and the use of various software programs.
One of the biggest challenges of the job was not taking customer and patient concerns or complaints personally. “We didn’t get many complaints in the laboratory so expanding my involvement in this aspect of quality and risk management hospital-wide was a challenge.
“I had to learn how to listen in a different way and think more globally,” she says. “As a result, I’ve learned a great deal more about this aspect of customer service.”
Wisconsin, Sue Pearson, Just Culture, Black River, flowcharts
