Fair and Just Culture, Team Behavior, and Leadership Engagement: The Tools to Achieve High Reliability

Abstract

Background. Disparate health care provider attitudes about autonomy, teamwork, and administrative operations have added to the complexity of health care delivery and are a central factor in medicine's unacceptably high rate of errors. Other industries have improved their reliability by applying innovative concepts to interpersonal relationships and administrative hierarchical structures (Chandler 1962). In the last 10 years the science of patient safety has become more sophisticated, with practical concepts identified and tested to improve the safety and reliability of care. Objective. Three initiatives stand out as worthy regarding interpersonal relationships and the application of provider concerns to shape operational change: The development and implementation of Fair and Just Culture principles, the broad use of Teamwork Training and Communication, and tools like WalkRounds that promote the alignment of leadership and frontline provider perspectives through effective use of adverse event data and provider comments. Methods. Fair and Just Culture, Teamwork Training, and WalkRounds are described, and implementation examples provided. The argument is made that they must be systematically and consistently implemented in an integrated fashion. Conclusions. There are excellent examples of institutions applying Just Culture principles, Teamwork Training, and Leadership WalkRounds—but to date, they have not been comprehensively instituted in health care organizations in a cohesive and interdependent manner. To achieve reliability, organizations need to begin thinking about the relationship between these efforts and linking them conceptually.

Confronting Safety Gaps Across Labor and Delivery Teams

“…Create opportunities for people to speak up and discuss their concerns. 51 These discussions have to occur, but need a safe time and safe space." They cannot interrupt or derail the labor and delivery process itself.…”

Nonbeneficial Treatment and Conflict Resolution: Building Consensus

“…This required a great investment in teamwork and communication. 8 This meant that the teamwork required for consensus building needed to emphasize tools and behaviors easily incorporated into the treatment-planning workflow. We recognized that physicians were the de facto champions that must commit to embracing the nonbeneficial treatment and conflict resolution process and must be supported in its use by the health care team that works with them.…”

Medications and the Culture of Safety

“…Developing such a culture is essential to improve both the safety and the quality of care delivery [2,3]. A culture of safety is comprised of several elements, some of which are discussed below in greater detail.…”

“…However, this culture has no tolerance for behaviors that repeatedly or purposefully violates the policies/procedures put in place to maintain the safety of patients [4]. When an error, close call, or adverse event occurs, rather than asking Bwho does blame lie with,^a Just Culture asks Bwhy or how did this happen.Ĥ uman error can be viewed in one of two ways: (1) it is the fault of the people working in the system (disregard for procedure or policy, carelessness of people) or (2) it is a symptom of a system that has latent vulnerabilities dispersed throughout. Latent vulnerabilities are faults created by policies, directives, equipment, and/or decisions, many of which may be far removed from immediate patient care setting where the actual error plays out.…”

“…Frontline staff will only believe that safety is important to the organization's senior leadership if those leaders visit the departments where the work occurs and engage directly with the staff about what they see and where their concerns are. This allows for cyclical flow of information [2], from staff to leaders and back. Leaders must make clear their expectation that the safety of patients is the highest priority and show support for directives and policies that enhance safety (time outs, checklists, follow through on actions from root cause analysis, daily safety huddles, etc.).…”