Quality Rounds: How Does Personal Responsibility Fit in a Just Culture?
In a Just Culture, staff are encouraged to report mistakes and near misses so that system-based issues can be corrected, resulting in improved quality and safety. But this system of shared accountability does not absolve us of personal responsibility as health care professionals, said Ron M. Walls, MD, executive vice president and chief operating officer at Brigham Health.
When we promise unerring safety to our patients, it must be a personal commitment, said Walls, who spoke about the topic at Quality Rounds on March 22. Most importantly, that means taking ownership of decisions and outcomes, he added.
“Just Culture is an important part of our safety and quality culture, but it has, to a degree, sidetracked us from the notion of personal responsibility,” Walls said.
To illustrate his point, Walls shared examples of how this has unfolded. He noted that one area where there is a greater need for personal accountability at the Brigham is hand hygiene compliance, specifically when working with patients at risk for clostridium difficile (C. diff) infection, a bacterium that causes diarrhea and can be fatal. When caring for patients who are at high risk for developing C. diff, health care workers can unintentionally spread the bacteria by not properly following the compliance measures of wearing a gown and gloves and washing their hands with soap and water before entering the patient’s room.
Following a four-month observation period, the hospital found that staff practiced those compliance measures 58 percent of the time when caring for patients at high risk for C. diff.
“Acquiring an infection in the hospital where you came to get well is a terrible outcome,” Walls said.
Hand hygiene is one of many areas where greater personal accountability will lead to tangible improvements in care quality and safety.
An individual’s failure to follow safety protocols properly aren’t malicious, Walls explained. Often, staff attribute noncompliance to external factors, such as time constraints or inconvenience. But Walls contended that this is where the need for greater personal accountability comes into play.
When patient safety is on the line, “I don’t have time to walk to the sink” is not an acceptable reason to sidestep hand hygiene, he said. Instead, he suggested staff adopt a solution-oriented outlook: “I have to find a sink” or, “It’s my responsibility to ensure that my patient leaves the hospital having received appropriate care.”
Promoting Secondary Responsibility
In addition to personal responsibility, Walls noted another area for improvement at the Brigham is strengthening our commitment to secondary responsibility – holding not only ourselves accountable but also our colleagues. In the coming months, BWH plans to unveil a new policy that will articulate expectations and processes for upholding this.
Returning to the hand hygiene example, Walls explored how secondary accountability could be practiced if a BWHer notices his or her colleague does not wash their hands before entering a patient’s room. If the noncompliant colleague – after being confronted and reminded about the importance of hand hygiene – deflects or becomes angry, the BWHer who approached their colleague would be personally responsible for filing a safety report about the incident.
Walls said this change in policy is needed because hospital leadership and the Quality and Safety team have tried everything they can to get people to exercise responsibility when an error, mistake or adverse event occurs.
“Had you walked into this hospital at any point over the past 10 years, our hand hygiene compliance rate would have probably been close to the same as today,” he said. “But I assure you that you’re not going to walk in next year and see that our rate is still that low.”
View the Quality Rounds webcast here (accessible only on the Partners network).