PRACTICE OPERATIONS
Implementing Just Culture to Improve Patient Safety
ABSTRACT: This literature-review study focused on publications from 2017 through 2022 to find and study the most current evidence describing the principles and practices of “just culture” in healthcare organizations. “Just culture” is a concept that has been used for some time by industries with obviously high stakes in risk management. Industries such as aviation, train transportation, and nuclear power have used principles of just culture to shift how organizations respond to adverse events.
In the absence of just culture, there is strong evidence of underreporting of errors and failures by health professionals driven by fear of consequences and repercussions. On the other hand, in a just culture, there is a clear shift away from blaming individuals involved. It is acknowledged that errors do not occur simply as a result of individual behavioral choices — they can also occur as a result of system failures. In a just culture, individuals feel that when they, or colleagues, report errors, they will be treated fairly.
In a just culture, the organization treats human behavior categorically in three types, with appropriate responses for each:
Human error: (unintentional errors, lapses in judgment, and forgetfulness)
Console the involved individual and explore improvements to prevent similar errors in the future
At-risk behavior: (decreased awareness of risk and belief that the risk is insignificant or justified)
Coach the involved individual to help them recognize that their behavioral choice carried greater risk than they may have recognized at the time
Reckless behavior: (actions that are knowingly counter to established standards and a conscious disregard of unjustified risks)
Discipline the involved individual according to organization policies and procedures
To implement sweeping culture changes like this requires engaged and committed leaders from the top down. Engagement means leaders being visible, accessible, approachable, and actively engaged with staff to understand any questions related to the culture change. They must build a foundation that rests on clear statements and understanding of expectations. Each employee must become aware that they each play an important role in maintaining patient safety.
Once policies and procedures to assure accountability are rolled out and implemented consistently, the leadership will have to monitor staff perceptions and attitudes as they evaluate the success of creating a just culture.
EXPERT COMMENTARY: Since psychologist James Reason more-or-less introduced the concept of “just culture” back in 1997, high-risk industries have picked up on his principles of identifying and differentiating between “blameworthy acts” and “honest mistakes.” Looked at from a systemic point of view, the organization applies appropriate accountability and consequences differently.
How do you handle errors in your organization? Historically, dysfunctional organizations spend more time trying to fix the blame on someone than the time spent on fixing the problem and its cause. If there is a general atmosphere characterized by the question, “who’s at fault here?” you will have a fearful staff that will avoid self-reporting, and often will help teammates cover up their failings, too.
Of course, there are going to be instances of negligence, even egregious negligence. More rarely, there will be malicious intentions, too. Such failures must be addressed even-handedly and consistently — no matter how painful. But if you do not face every failure openly and head-on, you will never come close to the quality-improvement that will result in excellence.
Most healthcare professionals think about failures in terms of bad patient outcomes, but think about your entire operation: Where else do processes and policies break down? What does “failure” and “error” look like at the front desk, in an ancillary department, in your billing department, and so forth? Why not develop a “quality-control” team for each department?
Source: John S Murray, PhD, MPH, MSGH, RN, CPNP-PC, CS, FAAN, USAF, NC (Ret.), Joan Clifford, DNP, RN, FACHE, NEA-BC, Stacey Larson, PsyD, JD, Jonathan K Lee, PhD, and Gary L Sculli, MSN, ATP, AMSUS Military Medicine, May 18, 2022; https://academic.oup.com/milmed/article/188/7-8/1596/6589441 .
PHYSICIAN ISSUES
Should Alcohol Be a Part of Medical School Events?
ABSTRACT: Emergency room physician Alexis Cordone, MD, remembers her surprise at how alcohol drinking was a significant part of the opportunities for students to socialize with each other, including at school events. Privately, she noted a number of students who turned to binge drinking to unwind together after particularly stressful experiences. Much like the general population, it is estimated that up to one third of medical students abuse alcohol.
The connection between suicide and intoxication has been well established, and when you consider that medical students are three times more likely to take their own lives than the general population of similar age, it would only make sense for school administrators to address these risks. Students who wish to abstain for reasons ranging from religious convictions to medical contraindications say they often feel stigmatized at social events as they have to explain and defend their decisions to peers.
In light of the mounting evidence, medical schools need to revisit these issues and develop better ways to connect socially through events that do not revolve around alcohol.
EXPERT COMMENTARY: We know more than ever about the effects of alcohol, the components of abuse and addiction, and recovery strategies. Multiple studies have revealed alcoholism slowly trending downward in the U.S. over the past couple of years. Still, it remains a significant problem for people in high-risk professions where sobriety requirements are a matter of life and death. Medicine is, of course, no exception. Substance-abuse disorder rates among doctors are actually comparable to the general population — somewhere around 15%. (Some studies indicate that rates for female physicians may exceed those among their male peers.)
Medical students learn massive technical information and critical clinical skills in their training programs, but that is not all they learn. In addition to learning how to do medicine, they also learn how to be doctors. That is a socialization process. As interns, residents, and fellows watch, listen to, and take instruction from teachers and attendings, they naturally pick up behaviors and expectations. Teaching physicians need to appreciate the total influence they have on each successive generation of new doctors.
With that in mind, this article’s call to revisit the issues related to alcohol use (and abuse) in and around our medical education programs is warranted.
If you would like a little help starting some productive conversations, consider resources like the quick, poster-style summary of key data from the Surgeon General’s advisory on the HHS website (https://www.hhs.gov/surgeongeneral/reports-and-publications/alcohol-cancer/index.html ).
Source: Alexis Cordone, MD, MPH, MHS-MEd, MedPage Today, January 15, 2025; https://www.medpagetoday.com/opinion/second-opinions/113790
MARKETING
Toward Hospitable Healthcare
ABSTRACT: Customer satisfaction data confirms what most of us already knew: Service experiences with most hospitals, clinics, physicians, and other providers fall well short of their experiences with most hotels, resorts, restaurants, and similar hospitality service providers. Healthcare providers need to understand there may be much to learn from the hospitality industry — and that need is accelerated by the convergence of the following trends:
The “information everywhere” environment is resulting in more patient-directed provider selection.
The demand for more transparent health services pricing has engendered greater competition and more informed consumer choice.
Most healthcare providers must now engage in direct-to-consumer marketing to attract new patients.
This article is based on original research that began with a survey of 1200 adults with experiences in both clinical settings and in the hospitality service industry. It restricted its inquiry to pre-COVID encounters and focused questions on what the researchers identified as 24 “touchpoints” that hospitality and healthcare have in common.
Significant gaps in customer/patient satisfaction exist in almost every area. Notably, healthcare lags behind in service innovation and improvement. Problem-resolution is far less satisfying in healthcare. Recovery from service failures demonstrates a guest-centric culture in the hospitality industry.
EXPERT COMMENTARY: Healthcare has lagged behind other industries in the arena of “customer satisfaction” for decades. Whether you want to talk about inefficient appointment scheduling, waiting-room nightmares, weak tech tools, frustrating automated phone systems, opaque billing processes or what have you, we must acknowledge our culpability in creating a non-patient-centric system of delays, unreturned messages, and bad attitudes.
Over 30 years ago, we began hearing about doctors and their administrators attending a new training center for leaders and managers to improve customer experiences. The Disney Institute used its expertise and experience as world leaders in amazing service to share insights, best practices, and systems developed in its famous theme parks. The Institute focuses on three primary domains: leadership, engagement, and service. And many health systems and hospitals testify that the principles learned in Orlando have revolutionized their organizations.
Of course, it is expensive — but it can be an investment with a handsome return.
Do not misconstrue these remarks as a commercial ad for Disney. Rather, recognize that you may find excellent resources in unlikely places. After all, what can Mickey Mouse teach a hospital CEO? What do service staff at the Happiest Place on Earth know about healthcare? You might be surprised.
Source: Peter C. Yesawich and Stowe Shoemaker, ScienceDirect International Journal of Hospitality Management, July 2023; https://www.sciencedirect.com/science/article/abs/pii/S027843192200278X
LEGAL/MED MAL
Smartphones, Texts, and HIPAA: Strategies to Protect Patient Privacy
ABSTRACT: For obvious reasons, medical practitioners have embraced smartphone technology that brings instant communications, mobile convenience, and access to vast libraries of information at the touch of your finger. Of course, your patients have similar patterns, and the tech is certainly not limited to peer-to-peer use. Patients want to access physicians, and most physicians have become accustomed to some level of accessing (or responding to) their patients. On top of that, the rapid development of patient remote monitoring adds a whole new layer.
But with increased convenience comes potentially decreased security. To use pocket devices for communication, physicians and staff must strictly follow rules to avoid running afoul of HIPAA privacy regulations.
Prohibit personal-platform messaging. The organization must have a robust, secure platform for all communications about patients and their PHI. This goes beyond communicating with patients. Doctor-to-doctor texts need end-to-end encryption and all the proper security measures must be in place.
Ensure accuracy in messaging. Avoid shortcuts, shorthand, and informal abbreviations in your text communications — even between peers. Remember that text messages are legally discoverable if a complaint or suit is launched.
Go beyond texting. Do not rely on a quick text exchange when verbal dialogue is needed for clarity and collaboration.
Word your texts appropriately to become chart entries. Text messages should be imported verbatim into the affected patient’s chart — for all to see. And that could include the patient’s lawyer, a judge, and a jury at some point.
Here are methodical steps you can take to help protect your practice:
Conduct a risk assessment
Acquire and use a HIPAA-compliant text-messaging platform
Enable encryption on your mobile devices (personal and work)
Set screens that might display PHI to lock automatically with password requirements for reopening
Make sure you have reliable user identification in place (strong passwords, biometrics, etc.)
Include examples of acceptable and unacceptable messages in your policies and procedures
Minimize details about the patient’s identity in any text messages
Maintain control of your personal (and practice-owned) devices
Report any possible infraction or breach immediately to your organization’s designated privacy officer
EXPERT COMMENTARY: It is human nature to relax our standards when we feel safe and secure. Our familiarity with our personal data devices breeds a natural contempt for inconvenient rules. Data-management professionals often talk about the “security-convenience” tradeoff. Increasing data security typically involves adding more layers of authentication, encryption, and restrictions, usually making access less convenient. Conversely, prioritizing convenience often means reducing security measures, increasing the risk of breaches or unauthorized access.
It is tough enough to design a balanced system that lowers risk without making it unbearable to stick to the rules. And it is even harder to establish and maintain a culture of security that prioritizes conscientious habits regarding processes and standard operating procedures — especially when “no one is looking.” Safeguarding our practice data and our patients’ PHI must become an ingrained value on par with clinical patient safety. The goal is for everyone to have an internal “default setting” that strictly adheres to security rules.
There is a principle in social settings that says: “Reputation is what others think and say about you; character is what you think and know you are.” Character is revealed in those times when nobody is looking. Corporate culture is the collection of values and behaviors that are considered “the right things” by members of the culture.
It is quite possible that your organization does not need new rules — perhaps you need new values.
Source: Richard F. Cahill, JD, The Doctors Company, December 2024; https://www.thedoctors.com/articles/smartphones-texts-and-hipaa-strategies-to-protect-patient-privacy/