Healthcare organizations are finding that the “just culture” concept can be applied to the physician peer review process. The belief is that individuals should not be blamed for performance errors when the real fault may lie with flawed organizational processes.
Just culture is a philosophy centered on the idea that accountability should not always be about the individual at the center of the medical error or other issue under investigation because organizational failures may be the true root cause.
One research paper described it this way: “A just culture balances the need for an open and honest reporting environment with the end of a quality learning environment and culture. While the organization has a duty and responsibility to employees (and ultimately to patients), all employees are held responsible for the quality of their choices. Just culture requires a change in focus from errors and outcomes to system design and management of the behavioral choices of all employees.” (The paper is available online at: https://bit.ly/2efYVB7.)
Necessary to Focus on Quality
A just-culture approach is necessary if the overall purpose of the peer review process is to improve quality of care and safety rather than placing blame, says Mary Ellen Glasgow, PhD, RN, ANEF, FAAN, dean and professor of nursing at Duquesne University in Pittsburgh.
“You need to have a culture that is open to improving quality and not one of blame if there is an error,” Glasgow says. “A just culture is one in which people are encouraged to report errors for the patient’s sake, one where people are comfortable enough to say ‘we need to do this better’ or ‘we had a near mistake because there’s distraction in this area.’ Everyone can report a safety violation — the janitor, the CEO, the nurse, physician — because your rank doesn’t matter.”
The peer review process will benefit from members who have a clear understanding of and commitment to just culture, Glasgow says. Errors should be assessed with an eye toward detecting process and structural failings that allowed them to happen, such as medication labels that were too similar, as well as at-risk behavior and reckless behavior from individuals.
“At-risk behavior can include physicians or nurses who think they are doing the right thing by not following the rules. An example is how hospitals are putting emphasis now on letting patients sleep in the ICU, which is a big movement now and based on legitimate goals,” Glasgow says. “But then you have a clinician who doesn’t check the patient’s identification band because it might wake the patient. That is at-risk behavior in which the person was well-intended, but they misunderstood the rules.”
That would require remediation, after which a change in behavior should be expected.
And then there’s reckless behavior, such as willful disregard of rules, bullying, and intoxication on duty. Reckless behavior requires discipline even with a just culture.
“People think of just culture as being easy on misbehavior, but it isn’t. It’s about analyzing different errors and safety issues, putting them in categories based on the context,” Glasgow says. “When a medical professional is participating in peer review and has a good understanding of just culture, not supporting hierarchies and being true to the just-culture principles, it should make them more effective in ensuring patients receive the highest quality of care.”
Discipline Still Required
Applying just culture is not always easy because it requires individuals to overcome the natural desire to blame someone for an error, Glasgow says. In many cases, the just-culture approach will require acknowledging that the physician in question did commit an error, but that the error was made possible or even encouraged by a poorly designed system. In such cases, the peer review committee should take that into account when determining the appropriate response.
But on the other hand, the just-culture concept also calls for discipline of reckless behavior without regard to the organizational hierarchy and the individual’s status. That might be the stated goal of all peer review, but just culture requires that it be carried out uniformly, Glasgow notes.
“You need senior executive buy-in for this concept to work because if the person is reckless — whether it’s a surgeon bringing in millions of dollars a year or a janitor — they both need discipline. In the past, you would see different punishments based on someone’s rank or value to the system,” Glasgow says. “That can’t be allowed to happen in a just culture, and that kind of change will require buy-in from the highest levels of the organization.”
Banner Health Adopts Just Culture
Incorporating just culture into the peer review process is still a relatively new concept even among healthcare organizations that adopted it more broadly, Glasgow says.
Banner Health is forging ahead with the idea. The just-culture approach is an important part of the health system’s peer review process, says Michael O’Connor, MD, chief medical officer of risk management with Banner Health, based in Phoenix. With more than 50,000 employees, it is one of the largest healthcare systems in the country.
Banner Health formed a peer review council in 2009 to improve the process and standardize some elements across the organization, including the scoring of physicians. At the same time, Banner Health was working to adopt just culture.
“The peer review council was looking for ways to improve the quality of peer review and the accuracy of the assessment, and at the same time recognize the role and impact of systems of care on events,” O’Connor says. “We worked to incorporate just culture into the event investigation, the assessment of the event, why it happened, and then looking at how we would attribute that to choice, systems design, or both.”
Just Culture Training for Peer Reviewers
The council first settled on the definition of just culture it would use and designed the peer review workflow, which was worked into a software program that walks the reviewer through the algorithms in the decision-making process.
Peer review committee members at Banner Health now must complete training in just-culture methodology and use it when scoring cases. They focus on these key requirements for a just-culture environment:
- create a learning environment;
- create an open and fair environment;
- design safe systems;
- manage behavior choices.
(Banner Health described the process in more detail with a post about peer review in an ambulatory care environment for the American Association for Physician Leadership. That article is available online at: https://bit.ly/2S7cLIR.)
The initial work was done at the facility level and then the final design was approved by the peer review council. Once the council approved the final version, the plan was implemented throughout Banner Health in 2014.
The health system provided physician and leader training in just culture, and physician reviewers were trained in how to use the software for peer review.
New System Takes Longer
O’Connor and the other council members learned that the new system requires more time than the previous peer review processes used in Banner Health facilities. They determined that some issues coming to the peer review process for individual reviews were rule-based indicators, such as compliance with core measures, or rate indicators, such as deviation from standard metrics. Rather than taking those issues through the full peer review process, the council found better avenues for addressing some of those issues.
“We’re still refining our rules indicators and rate indicators so that we only have the most important events come through the full just-culture review process, which helps us gain the most from that process,” O’Connor says. “Standardizing the scoring system has been a big challenge because with 20 hospitals and each one having an independent medical staff, establishing uniformity in something as close to the medical staff as peer review was the most difficult part of what we did.”
Banner Health also uses clinical consensus groups that define processes. When the peer review process identifies process and workflow problems, they are sent to those groups for review and improvement. Issues also can be sent to the operations teams that work within the health system. Informatics also is sometimes called on for assistance.
Physicians Welcome Fair Approach
O’Connor cautions that any significant change to the peer review process will rattle physicians. Start with explaining why the change is necessary, he says, and acknowledge that the just-culture concept will require additional training. Also note that the process will be more time-consuming, but the tradeoff is that the reviews will be much more meaningful, he says.
There was initial skepticism from Banner Health physicians when the plan was first introduced, but the medical staff embraced the concepts of just culture once the new process was in place and they saw how it worked.
“Peer review traditionally has been a blame game, and this was a process where we really looked at the entire event and addressed accountability in a different way, recognizing that errors are not a choice and can happen to the best of us,” O’Connor says. “Our systems and processes can influence the outcomes as much as the physicians themselves. It was seen as a very fair way to approach these reviews.”
- Mary Ellen Glasgow, PhD, RN, ANEF, FAAN, Dean and Professor of Nursing, Duquesne University, Pittsburgh. Phone: (412) 396-6554. Email: [email protected].
- Michael O’Connor, MD, Chief Medical Officer of Risk Management, Banner Health, Phoenix. Email: [email protected].
