Embedding Just culture in healthcare quality assurance reviews

4 Dedication . 5 Acknowledgements . 6 List of Figures . 10 List of Tables . 11 Chapter One: Focus and Framing . 12 Significance of the Inquiry . 15 Organizational Context . 17 Systems Analysis of the Inquiry . 19 Chapter Summary . 22 Overview of Thesis . 23 Chapter Two: Literature Review . 24 Just Culture in Healthcare . 24 Second Victim . 29 Leading Organizational Culture Change . 37 Chapter Summary . 42 Chapter Three: Inquiry Project Approach . 43 Inquiry Project Methodology . 43 Inquiry Team . 45 Project Participants . 45 EMBEDDING JUST CULTURE 8 Inquiry Project Methods . 48 Ethical Issues . 54 Chapter Summary . 58 Chapter Four: Inquiry Project Findings and Conclusions . 59 Study Findings . 59 Study Conclusions . 71 Scope and Limitations of the Inquiry . 78 Chapter Summary . 79 Chapter Five: Inquiry Implications . 80 Study Recommendations . 80 Organizational Implications . 90 Implications for Future Inquiry . 93 Thesis Summary . 94 References . 98 Appendix A: Evolution of Safety Culture to High-Reliability Organizations . 108 Appendix B: Action Research Engagement Model . 109 Appendix C: Inquiry Team Member Letter of Agreement . 110 Appendix D: Research Information Letter for Leadership QAR Participants: . 111 Appendix E: Email Invitation . 114 Appendix F: Survey Questions . 115 Appendix G: Interview Session Questions . 116 Appendix H: Focus Group Session Questions . 117 EMBEDDING JUST CULTURE 9 Appendix I: Interview Consent Form . 118 Appendix J: Focus Group Research Consent Form . 119 Appendix K: Presentation to CancerControl Alberta Quality Assurance Committee . 120 EMBEDDING JUST CULTURE 10 List of Figures Figure 1. Management of CSAEs systems map. 20 Figure 2. Outline of project participants. 46 EMBEDDING JUST CULTURE 11 List of Tables Table 1 Supportive Behaviours for Just Culture Identified by Survey Participants . 62 Table 2 Survey Responses Relating to Support . 70 Table 3 Conclusions Linked to Subquestions . 72 Table 4 Conclusions and Recommendations Aligned with Subquestions . 81 EMBEDDING JUST CULTURE 12 Chapter One: Focus and Framing Patient safety is a top priority at Alberta Health Services (AHS), which is the largest publicly funded healthcare organization in Canada. The AHS (2013b) Patient Safety Strategic Plan outlined the mission as “working together to eliminate preventable harm” (p. 6), realizing that one of the best ways to ensure the safety of patients is to learn from staff members’ close calls and mistakes. AHS strives to be a high-reliability organization, which means that “constraints are in place to review errors without defensiveness” (AHS, 2017a, p. 11; see Appendix A). AHS aims to respond to risks and mitigate them prior to any patients being harmed. In order to do this, the staff need to report when close calls or clinically serious adverse events (CSAEs) happen so they can be managed, then staff can learn from them and, finally, share the learnings. As several research studies have shown, patients are at risk when medical errors, close calls, or hazards are not reported because these errors are likely to reoccur (Kohn, Corrigan, & Donaldson, 2000; Morris, 2011). As a healthcare practitioner in Alberta for 25 years, I have witnessed exemplary practice as well as inappropriate patient care. Throughout my career, I have been passionate about ensuring my own best practice and have taken steps to safeguard it; I continue to teach advanced clinical courses in paramedic and nursing programs, take advantage of learning opportunities when possible, and learn from those around me. In past years as a frontline primary care paramedic and registered nurse, I ensured my own practice was appropriate, but had a small sphere of influence. When I began work with the corporate Provincial Patient Safety team in early 2015 with AHS, my scope of influence and the opportunity to create changes for the larger organization grew. My role as a senior provincial patient safety specialist on the team is EMBEDDING JUST CULTURE 13 coordinating project work and conducting quality assurance reviews (QARs) for complex CSAEs. The QARs are completed after serious CSAEs happen and are focused on “identifying system deficiencies and generating recommendations to make care safer” (AHS, 2017c, p. 2). I have seen firsthand when system issues led to substantial recommendations through QARs and the staff have felt supported. Unfortunately, I have also witnessed staff lose their jobs over system issues in which they had little control. I have learned healthcare providers have a long way to go in the quest for reliable safe patient care; AHS members have an appetite for improvement; and, due to the size of the organization, change takes time, but it could happen with the right approach. In order to build trust and support staff in reporting and learning from mistakes, AHS has adopted the philosophy of just culture, which strives for an environment in which everyone feels safe, encouraged, and enabled to discuss quality and safety concerns (AHS, 2013b, p. 7). Within the healthcare setting, a just culture is defined as an environment supportive of open dialogue to facilitate continual improvement and safer practices for patients, staff, and physicians without forgoing appropriate accountability (Frankel, Leonard, & Denham, 2006, pp. 1692–1693). This is especially important after a CSAE. If staff members report the errors, oper