What makes CAPSAC's approach to increasing patient safety different from others?

 

Many institutions assume medical errors are caused by negligent individuals and organizations, and, as such, can and should be prevented by assigning blame and punishment. This creates a culture in which health care providers are afraid to report errors and near misses. In contrast, CAPSAC members believe that a strictly punitive approach to the handling of medical errors can actually make things more unsafe by creating an incentive to not report possible safety concerns and errors. The CAPSAC approach to protecting the public from medical errors is to focus on making systems better and not on punishing individuals.

 

CAPSAC Mission Statement: To enhance patient safety and increase reporting of near misses and medical errors through promoting a fair and just culture across the continuum of healthcare in California.

 

Additional Information

Goals of CAPSAC

About a Fair and Just Culture

 

Goals and Objectives

 

1.  Facilitate the adoption of a fair and just culture across health care organizations in California.

 

Train 1,000 Senior Healthcare Leaders in concepts of Just Culture by December 1, 2008

By December 2010, 90% of CAPSAC member organizations will sign and return the California Statement of Support for a Statewide Culture of Learning, Justice and Accountability

 

Obtain support of CAPSAC from Healthcare Providers, Labor Unions, Boards of Medicine, Nursing and Pharmacy, as well as Department of Health, and Consumer Advocacy groups by June 2009

 

Attendance at Just Culture training and adoption

 

Membership at CAPSACSigned letters of support

 

2.  Monitor, evaluate, and discuss patient safety initiatives and progress in other states.

 

Convene senior administrators at a statewide meeting to learn about other states’ efforts by July 31, 2008

 

Establish governance and financial structure that will sustain membership, and learning by December 2008

 

3.  Provide opportunities for health care organizations to share best practices; and establish a mechanism for shared learning across organizations to minimize the same errors from occurring again.

 

By June 2009, establish a mechanism for California healthcare organizations to share safety culture survey results from the Safety Attitudes Questionnaire (SAQ), the Agency for Healthcare Research and Quality (AHRQ) Hospital Survey, and the Patient Safety Climate in Healthcare Organizations (PSCHO)

 

Collaborate with California Healthcare Patient Safety Organization (CHPSO) to identify opportunities for sharing errors and best practices in a protected environment by Dec. 08

 

Disseminate the information presented by Kathy Billingsley, Assistant Deputy Director, Center for Health Care Quality, Department of Public Health, California on July 11th to all member organizations by September 1, 2008.

 

Beginning in 2009, at least one member organization will present a best practice at all CAPSAC meetings.

 

4.  Monitor, evaluate, disseminate, and inform charter members of legislative and regulatory activities related to patient safety

 

Semi-annual updates to the CAPSAC members on upcoming legislation as well as a summary from the Department of Public Health on reported events, and administrative fines

 

5.  Develop strategies to educate and inform consumers and the media in the principles of a fair and just culture

 

By December 2008, design public outreach and educational materialsObtain funding for a public and media conference on concepts of Just Culture and CAPSAC by December 2008.

 

Fair and Just Culture

 

CAPSAC promotes a "fair and just culture." What does this mean?

 

The "fair and just culture" principle that CAPSAC advocates is an approach to medical event reporting that emphasizes learning and accountability over blame and punishment. It is built on the recognition that simply forbidding errors cannot prevent them from occurring. However, by learning from errors through better event reporting, health care providers can improve safeguards and reduce the chance of future errors.

 

Where does the idea of a "fair and just culture" come from?

 

The principles of a fair and just culture are based on research by human behavior and management experts such as James Reason, Ph.D., and David Marx, JM.D. Their work has shown that how an organization responds to errors can make a critical difference in preventing future errors from occurring. The most effective way of preventing errors, they find, is to accept that humans will act in unpredictable ways that may lead to mistakes. By understanding how each error occurred, the system can make changes in the work place to prevent errors or mitigate their effects.

 

Will non-punitive reporting lead to a loss of individual accountability?

 

It seems counterintuitive that reducing blame would reduce errors, but blame and accountability are not necessarily connected. Adopting a fair and just culture does not mean throwing out an organization's disciplinary system. Instead, it means changing that system to focus on future error prevention rather than individual punishment. Dr. Reason's work, in particular, addresses how to do this. He developed an "unsafe acts algorithm" for deciding when an individual's error should be managed through a system change - like a change in staff training, the work environment or a process - or a traditional disciplinary action, like such as firing the employee. In a fair and just culture, an individual is accountable to the system, and the greatest error is to not report a mistake, and thereby, prevent the system and others from learning.

 

 

How do we know this approach works?

 

Other safety-conscious industries, such as the airline industry, and health care providers in other states have been able to reduce system problems that lead to errors by adopting the principles of a fair and just culture. When these principles are adopted, health care organizations and regulatory agencies investigate all reports to identify and correct the systems and processes of care that contributed to the medical error or near miss; the do not assign blame. By feeling protected by this non-punitive culture of medical error reporting, health care organizations and providers report more errors and near misses, which further allows the health care industry to improve patient safety improvements.

 

Why is it important to focus on a "fair and just culture" now?

 

In recent years, health care providers, consumers, regulators and legislators have become increasingly focused on reducing medical errors. However, there has not been an advocacy organization in place to help all these parties learn about best practices from other systems. Through promoting a fair and just culture in medical event reporting, we can make current efforts to improve patient safety more effective and prevent potential problems associated with punitive regulatory and legislative changes.