Browsing "Just Culture"

Just Culture – Entry 3

Dear Diary:

Today I listened to a webinar on “just culture” and I realized that this is something that I have put on the back burner for quite some time. Since working with the staff on not looking for someone to blame, like the nursing assistant who they pointed fingers at when Hattie fell last year, I realized that we haven’t made any significant changes in our culture to make it more fair and just. We did a great root cause analysis (RCA) on what was the real cause of that fall. And, sure enough, Sherry, the nursing assistant, was not to blame. Hattie had been in the middle of transferring herself, so Sherry didn’t have time to assist her with a transfer belt. We used that incident to help us change our focus when we are doing RCAs. Instead of assuming that education or training of an individual is the problem, we focus on what was going on at the time that allowed the problem to occur and then look for opportunities to change the process in order to minimize the chance of the problem happening again.

I think we are doing a pretty good job at focusing on systems rather than individual behavior. However, the webinar made me think more about how we need to work on establishing a culture in which caregivers do not fear retaliation for reporting quality concerns. To do this, we must hold everyone accountable for their performance, but not punish for unintentional errors.

As I review the QAPI self assessment, I see that our organization does not have a process in place to distinguish between unintentional errors and intentional reckless behavior. I am overwhelmed –changing a culture is hard! The webinar speaker referred to the Minnesota Alliance for Patient Safety (MAPS) Road Map to a Safety Culture. I checked out the audit questions under the Justice Domain and found specific actions that will help our home. Looks like the first step is having a chat with our administrator, Dan, since we need to start by educating our senior leadership. I know I can’t do this alone!

I wonder what other efforts will help result in a safer environment for our residents and a fair and just culture for our staff?

Signed, Donna


  • At our last QAPI it was noted that the majority of our Vulnerable Adult reports are related to staff not following a residents care plan. Current practice has been to bring staff in for education asking them to sign a performance discussion tool. Documenting that they have received the information and understand the importance of following residents care plans.
    At our QAPI meeting we determined that we needed to focus on systems and find out what barriers are keeping staff from following the care plan. We have always asked the question and looked at the why’s to implement changes. We are taking this one step further and looking at the system to determine if process changes are necessary.

  • We have have worked on just process by “blame the system not the people” unless it is obvious reckless behavior. We involve staff from all departments to look at the system to look at changes that could occur thru root cause analysis to improve quality and decrease recurrence of incident.
    Staff are encouraged to speak up and be an active part of the change.
    For example at one of our QAPI meetings we did a root cause analysis of how to ensure “anti roll backs on w/c’s are working properly and started a “maintenance prevention audit”.

  • We are moving in that direction…we use the term adaptive culture. The biggest piece is for every worker to understand they do have “power”. I still hear the verbiage of management versus “us”. This is were we are focusing our attention, in the power we all have to make change and recognizing those that use their power respectfully and wisely.

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Just Culture – Entry 2

Dear Diary:

I brought Anna (RN) and Sherry (NA) together to talk about what happened and to share their feelings about Hattie’s fall. They were able to clear the air by really listening to each other and sharing what happened. I then brought the rest of the team together to discuss the events that took place. I reinforced the concept of “just culture” and how important it is for us to work together to create a non-blaming, non-punitive culture here at River View.

I feel like the team better understands that when an event happens, rather than just blaming someone, it’s important to talk about and determine the root cause of the event. In this case, Sherry didn’t have time to put a transfer belt on Hattie since our resident was in the middle of transferring herself when Sherry entered the room. We could have had a number of other reasons such as a transfer belt was unavailable, it wasn’t communicated that Hattie needs to be transferred with a transfer belt, or Hattie may have refused to use a transfer belt. There is a reason for everything. Working as a team to understand the reason, we can hopefully prevent it from happening again.

We talked about the three behaviors of a just culture: human error, at-risk behavior, and reckless behavior. I certainly don’t think Sherry was using reckless behavior since she did not intentionally choose to not use a transfer belt. The team seemed to understand. Anna needs to do a better job of coaching her nursing aides to work together to prevent future occurrences rather than jumping right away to the “blame game”.

We’ve still got some work to do, but I think we’re making some strides in creating a just culture around here.

Signed, Donna

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Just Culture – Entry 1

Dear Diary:

Well, today was a tough day. I think one of my challenges at River View Rehabilitation and Care Center is going to be trying to get everyone to work together as a team. Everyone is so quick to point fingers when something goes wrong. Take today, for example.

Sweet Hattie who’s 92, came to us from her home after being treated for pneumonia and dehydration in the hospital and she has been really weak. I imagine her psychotropic meds contribute to this weakness. Hattie was in bed and needed to go to the bathroom, so she called for the nurse. When Sherry, one of our nursing aides, went into her room, Hattie was already trying to get out of the bed herself so Sherry went to help her. For some reason the NA didn’t use a transfer belt. Hattie’s legs gave out when the NA tried to help and she ended up falling on the floor.

At that point, Sherry pulled the call button for assistance and a nurse came in. They assessed Hattie and determined that she had possibly fractured her hip. They called our doctor who said to call 911 and now she’s back in the hospital.

Evidently, the nurse scolded Sherry, which of course made her feel bad and start crying. The incident report said the reason for the fall was because a nursing aide didn’t use a transfer belt. Technically, that may have been the case, but I want the nursing staff to think more deeply than that.

How do I convince everyone that rather than blaming someone else, what could have been done to prevent this?

How can we work more as a team rather than blaming one another?

Signed, Donna


  • I love this idea. When will you be publishing more of these.

    • We plan to publish more entries before the end of June. Once the nursing homes participating in the ATTAX campaign select the topic areas they plan to work on, Stratis Health will be developing more frequent diary entries to tied to those areas to support nursing home learning and quality improvement.

  • Well, we had another fall with injury. Hattie, a fairly new resident, fell and broke her hip. Her daughter, Carol stopped by to talk with me. Naturally, she was upset. I told her that we’d investigate the details and get back to her. I’ve got Donna doing some follow-up. We’ll meet later today to talk about what she found and together call Carol. Building trust with families is so important. I also have to talk with Donna about our fall rates and what we can do to decrease those rates. Probably should be on the agenda of our next manager meeting also. It’ll take everyone to bring those rates down. I also heard that Sherry was upset. She was the nursing assistant involved with the fall. I think I’ll go talk with her and see what she has to say about the incident.

  • I walked into Hattie’s room as she was trying to get out of bed. I rushed to her and grabbed her arm but she fell before I got a good hold of her. It looks like she broke her hip. I feel so bad. Hattie was confused, looking for her husband and I know she’s been a widow for a long time. I pulled the call light and hollered for help. Anna came quickly, thank goodness, and told me to stay with Hattie while she called the doctor and 911. After Hattie was transferred, Anna yelled at me for not using a transfer belt. I know she was upset, but she didn’t listen to me. I told the other nursing assistants. They suggested I go talk with Anna when she’s not so busy. Maybe I will.

  • Hattie, a new resident fell and broke her hip. I heard a yell from her room. Sherry was standing over her. She said Hattie was trying to transfer and fell. It was obvious her hip was broken. I called the doctor and 911. After Hattie was transferred, I was so angry. It looks like Sherry didn’t even grab a transfer belt before moving her. I told Sherry it was her fault Hattie fell. I know she was upset, but so was I. Why can’t the nursing assistants think ahead to what might happen?

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