a regulatory model/decision tree for collaboration and practice accountability
DESCRIPTION
A Regulatory Model/Decision Tree for Collaboration and Practice Accountability Maryann Alexander, PhD, RN Nancy Spector, PhD, RN Maureen Cahill, MS, RN Kathy Russell, JD, RN. The Just Culture Model (simplified). Human Error. At-Risk Behavior. Reckless Behavior. - PowerPoint PPT PresentationTRANSCRIPT
A Regulatory Model/Decision Tree for Collaboration and Practice Accountability
Maryann Alexander, PhD, RNNancy Spector, PhD, RNMaureen Cahill, MS, RNKathy Russell, JD, RN
© 2012
The Just Culture Model (simplified)
RecklessBehavior
Conscious Disregard of Substantial and
Unjustifiable Risk
Manage through: • Remedial action• Punitive action
At-RiskBehavior
A Choice: Risk Believed Insignificant or Justified
Manage through:
• Removing incentives for at-risk behaviors
• Creating incentives for healthy behaviors
• Increasing situational awareness
HumanError
Product of Our Current System Design and Behavioral Choices
Manage through changes in:
• Choices• Processes• Procedures• Training• Design• Environment
Console Coach Punish
A Single Event Repetitive Events
• Repetitive errors – yes, there is a process
• Repetitive at-risk behaviors – yes, there is a process
• Both may lead to disciplinary action…
The Just Culture Model
Just Culture
Examines the fallibility of the system as well as inevitable human error and flawed behavioral choices
• System• Human Error• Flawed decisions
Regulation
• Public Protection• Holding systems and individuals accountable
for their actions• Safer care for Patients
Regulatory Model
– Encourage reporting of errors so that systems, processes and behaviors can be improved
– Collaborative/Partnership (Facility and BON and Nurse and Facility)
– Centers around the patient– Focus is on ethical behavior– Encourages remediation– Employs discipline where needed
Accountability of Nurse Recognize Contributions of System Errors Patient Outcome Not Primary to BON Decision Boards and Employers Collaborate Use Reliable Tools to Evaluate Behaviors and
Systems
Regulatory Decision Model
Next Steps
• Volunteers• Try out the decision tree• Send us your feedback/comments• Feedback from Outcomengenuity• Develop a resource kit• Pilot the model/algorithm once completed
Our Goal
Help BONs make consistent decisions that protect the public and lead to safer systems and competent practitioners.