Just Culture: Practical Implementation for Radiologist Peer Review

Burns, Judah; Miller, Todd S.; Weiss, Jeffrey M.; Erdfarb, Amichai J.; Silber, David L.; Goldberg-Stein, Shlomit

doi:10.1016/j.jacr.2018.10.021

Cited by 14 publications

(7 citation statements)

References 10 publications

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“…The notion of institutional and individual responsibility for healthcare has been highlighted in the contemporary professional literature [44], especially in the wake of the COVID-19 pandemic [45]. This just culture framework outlines organiza-tions that use errors or lapses as an opportunity to learn how to prevent future errors and to foster continuous quality improvement rather than punishing individuals [46,47]. Veterans in our sample described similar experiences (e.g., being given the wrong medication) and the admission of error as courageous.…”

Section: Discussionmentioning

confidence: 99%

Institutional Courage in Healthcare: An Improvement Project Exploring the Perspectives of Veterans Exposed to Airborne Hazards

Bloeser

McAdams

McCarron

et al. 2023

Behavioral Sciences

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Background: Military environmental exposures and care for subsequent health concerns have been associated with institutional betrayal, or a perception on the part of veterans that the US government has failed to adequately prevent, acknowledge, and treat these conditions and in doing so has betrayed its promise to veterans. Institutional courage is a term developed to describe organizations that proactively protect and care for their members. While institutional courage may be useful in mitigating institutional betrayal, there is a lack of definitions of institutional courage in healthcare from the patient perspective. Methods: Using qualitative methods, we sought to explore the notions of institutional betrayal and institutional courage among veterans exposed to airborne hazards (i.e., airborne particulate matter such as open burn pits; N = 13) to inform and improve clinical practice. We performed initial interviews and follow-up interviews with veterans. Results: Veterans’ depictions of courageous institutions contained key themes of being accountable, proactive, and mindful of unique experiences, supporting advocacy, addressing stigma related to public benefits, and offering safety. Veterans described institutional courage as including both individual-level traits and systems or organizational-level characteristics. Conclusions: Several existing VA initiatives already address many themes identified in describing courageous institutions (e.g., accountability and advocacy). Other themes, especially views of public benefits and being proactive, hold particular value for building trauma-informed healthcare.

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Section: Discussionmentioning

confidence: 99%

Institutional Courage in Healthcare: An Improvement Project Exploring the Perspectives of Veterans Exposed to Airborne Hazards

Bloeser

McAdams

McCarron

et al. 2023

Behavioral Sciences

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“…1,2,10 Just culture tools, which include QI, are promoted as a means to improve PR. 8,11,12 Other studies show PR remains problematic in terms of standardization, incorporation of best practices, redesigning systems of care, or demonstrable improvements to facility safety and care quality. 1,4,6,8 Several publications have described interventions to improve PR.…”

Section: Limitationsmentioning

confidence: 99%

Is There a Relationship Between Facility Peer Review Findings and Quality in the Veterans Health Administration?

Ryder¹

2022

Federal Practitioner

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Background: The aim of clinical peer review (PR) is to improve facility health care quality. However, prior authors have shown that PR may be biased, have rater reliability concerns, or be used for punitive reasons. It is important to determine whether facility PR processes are related to objective facility quality of care. Methods: We collected proportion of PR findings that "most experienced and competent clinicians may have managed the case differently" or "most experienced and competent clinicians would have managed the case differently" as an objective measure of facility PR processes and outcomes. We correlated these with facility quality metrics for 2019. Results: PR findings were not associated with facility quality metrics but were strongly associated with previous year findings. Conclusions: This study describes a potentially new source of bias in PR and demonstrates that objective facility outcomes are not related to individual PR findings.

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“…Just culture supports health care workers in prioritizing patient safety by removing the fear of undue blame from human error, and its ability to encourage errorreporting and learning allows it to act as a feedback mechanism on the construction of reliable system design [27,28,56,[90][91][92][93][94][95][96]. In a just culture environment, medical errors can be discussed and systems weaknesses highlighted without fear of blame or retribution [97,98]. Thus, discussing interprofessional handoff failures becomes a peer learning opportunity, and building a true just culture environment becomes an organizational tool that influences the creation of level 1 and level 2 error prevention strategies [16,27,28,99].…”

Section: Automation the Automation Of Handoff Components In The Electronic Health Record Removes Human Factors At Bothmentioning

confidence: 99%

Handoffs in Radiology: Minimizing Communication Errors and Improving Care Transitions

Burns

Ciccarelli

Mardakhaev

et al. 2021

Journal of the American College of Radiology

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Just Culture: Practical Implementation for Radiologist Peer Review

Cited by 14 publications

References 10 publications

Institutional Courage in Healthcare: An Improvement Project Exploring the Perspectives of Veterans Exposed to Airborne Hazards

Institutional Courage in Healthcare: An Improvement Project Exploring the Perspectives of Veterans Exposed to Airborne Hazards

Is There a Relationship Between Facility Peer Review Findings and Quality in the Veterans Health Administration?

Handoffs in Radiology: Minimizing Communication Errors and Improving Care Transitions

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