Creating a Just Decision-Making Culture for Clinicians Involved in Errors, by Dr. Patricia
Folcarelli.
In collaboration with the Institute for Professionalism and Ethical Practice.
Hello, I'm Pat Folcarelli.
I'm the Senior Director for Patient Safety at Beth Israel Deaconess Medical Center in
Boston.
Following an adverse event, many of you have systems to support the patient and family,
to communicate with patients and families, and then systems to understand exactly what
did happen during that adverse event.
You may have even heard about the term "no blame culture" in follow-up to events like
this, where you consider the nurses, the physicians, the technicians involved in the event.
Today, we're going to talk a little bit about a culture of accountability and how you consider
clinicians in a fair and just manner.
The first thing that we like to do when we're looking at what happened during an event is
to ask ourselves was there anyone involved in this event that was impaired?
Or was there anybody that came to work that day with an intentional, willful disregard
of a policy?
Or did they make a conscious decision to disregard a policy or practice and put a patient in
a state where there was an unjustifiable risk?
When you're in this territory, you're really talking about something where you are going
down a disciplinary path.
The next thing to do is to do something we call a substitution test.
A substitution test is when you consider the people who are involved in the event and you
substitute in people who have the same amount of experience, the same amount of education--
and you can do this by actually thinking about this in your mind, but also by interviewing
people who work in that practice and see whether the decisions that were made in that situation
would be the same that these clinicians will have made.
What you can find out when you do something like this-- this substitution test-- is that
there's been a drift in the entire practice.
So everyone has developed a workaround around something that should have been done another
way.
Or you might even find that there's a larger organizational issue, which is something where
maybe you've rolled out a new policy or a new practice and people just don't know about
it.
This substitution test is extremely helpful, because when you're developing corrective
action plans, you actually can know that there's been drift or that you need to do more work
around education and training.
So the first thing is to substitute in the clinicians.
When people pass the substitution test, it usually means that you're not in a disciplinary
mode with these employees or these clinicians.
You're more in the mode of consoling them and really trying to figure out how you can
prevent this from happening to other patients or families.
The other thing, though, to consider is to consider the people involved in the event
and whether or not they have a history of unsafe acts.
Is this a person who has had multiple episodes of at-risk behavior?
For example, is the third time that somebody has given the wrong medication?
When you're in that territory, you might be in the territory with the clinicians or the
staff of more of a counseling or disciplinary action territory.
In general, though, what I would like to say by closing is that the fair and just approach
is a core component of a safety culture, that the substitution test and the assessment of
past behavior is extremely important, but that this whole thing should be applied in
a context where there are human resources policies, and medical staff policies that
support this kind of decision making that's fair and just.
But-- and the two, I think, very important parts about this-- is that there needs to
be consistent application for physicians, for non-physicians, and for employees and
other clinicians in the institution.
But that-- and this is the hardest part of it-- is that it needs to be consistently applied
despite the outcome of the patient.
So in other words, you make fair and just decisions about clinicians involved in events--
whether there's a serious harm event with the patient or whether the event leads to
something that's fairly minor.
And you steel yourself against making judgments about performance just based on the outcome
with the patient.
Reflective Exercise.
Please post your responses on the comments board for this video so that others may learn
from them.