Just Culture and Culture of safety Comprehensive Nursing Paper Example

Just Culture and Culture of safety Comprehensive Nursing Paper Example

A just culture is a critical component of a culture of safety. Just culture learns and improves by recognizing and evaluating its weaknesses openly. This culture is transparent, and those identifying with it are open and willing to expose weaknesses and areas of excellence. Employees in a just culture feel safe and protected when voicing their perspectives and concerns about health care and environmental safety. They feel free to discuss their actions and those of others in the environment regarding actual and potential adverse events or human errors (Paradiso & Sweeney, 2019). In a just culture, human is not perceived as the cause of adverse events but rather a consequence or symptom of a troubled or imperfect system. Therefore, leaders are not quick to judge or punish staff involved in errors but first assess the care delivery system for hidden failures and vulnerabilities. Kaiser Permanente strives to improve patient safety by creating a just culture and a culture of safety. (Just Culture and Culture of safety Comprehensive Nursing Paper Example)

Healthcare Organization Description

Kaiser Permanente is a US integrated managed care consortium located in Oakland, California. The organization was founded in 1945 by Henry J. Kaiser and Sidney Garfield (Kaiser Permanente, n.d.). The organization has three districts and interdependent entity groups: the Kaiser Foundation Health Plan, Inc. (KFHP) and its regional operating subsidiaries; Kaiser Foundation Hospitals; and the regional Permanente Medical Groups. Its operations are available in eight states, including Hawaii, Washington, Oregon, California, Colorado, Maryland, Virginia, Georgia, and the District of Columbia. It is among the largest nonprofit healthcare plans in the US, having over 12 million members. The organization operates 39 hospitals and over 700 medical offices, with approximately 300,000 personnel, including over 80,000 physicians and nurses. However, each medical group functions as a separate for-profit partnership or professional corporation, funded by reimbursements. Kaiser Permanente’s quality of care is highly rated because it focuses on preventative care. The organization emphasizes quality of care by creating a culture of safety and fairness. It focuses on minimizing the time patients spend in the hospital through careful planning.(Just Culture and Culture of safety Comprehensive Nursing Paper Example)

Analysis of Factors that Create a Just Culture and Culture of Safety within the Organization

In Kaiser Permanente, patient safety comes first, patient safety is all patients’ right, and patient safety is everyone’s responsibility. Kaiser Permanente maintains Fair accounting principles that help create a just culture and a culture of safety. The principles require leaders to visibly articulate the vision and commit to safe, reliable and high-quality care delivery. Leaders working in Kaiser Permanente are required to develop a sense of urgency around risk management, create a transparent environment, a learning culture, an open and fair culture, develop safe systems, and manage errors and violations (Bonacum et al., 2020). They should also demonstrate orientation to staff training and education, ensure workflows are reliably designed, develop teamwork and sound communication practice across all levels, and create and sustain a psychologically safe climate. Leaders should also address at-risk behaviors and conditions that can lead to harm, investigate adverse outcomes, practice caution, and take steps to reduce risk occurrence. Staff members, including physicians and nurses, are required to report fit for duty, maintain knowledge, clinical reasoning, and technical skills required to operate efficiently and effectively, and ask for help if they are uncomfortable performing a task. Staff members in Kaiser Permanente are required to report activities and conditions that lead to patient harm or affect worker safety, ensure communications are clear, ask for performance feedback, make it safe for others to express themselves if they engage in unsafe actions, and speak up when they observe or hear someone, worker or patient, is unsafe. These principles are fundamental in creating a just culture and a culture of safety within the organization.(Just Culture and Culture of safety Comprehensive Nursing Paper Example)

Kaiser Permanente’s elements of a culture of safety include assessing medical errors, human factors, and system conditions, identifying and prioritizing hazards proactively, observing and coaching, and analyzing incidents and proofing errors. Additional elements include teamwork and communication, health literacy, and reliable design (OPM.gov, n.d.). Kaiser Permanente’s system interventions that improve its culture of safety and create a just culture include a focus on a culture of safety that facilitates adverse events reporting by providers and front line staff, bolstered by a just culture that identifies system and process failures while fostering individual accountability. (Just Culture and Culture of safety Comprehensive Nursing Paper Example)The organization also focuses on High Reliability, integrating elements of The Institute for Healthcare Improvement to enhance the quality and safety of patient care. The organization undertakes advancements in health information technology such as secured email messaging between clients and providers and implementing state of the art technology, including Telestroke technology, Robotic surgeries, Telemedicine, 122 interactive monitors in patient rooms (OPM.gov, n.d.). It has a region-wide medication safety program that includes medication reconciliation via its Transition of Care and High Alert Medication Safety Program, recognizing particular high-risk medications that can cause harmful effects. The medication safety program ensures safe medication management, including proper patient-medication matching and medication adherence.(Just Culture and Culture of safety Comprehensive Nursing Paper Example)

Kaiser Permanente implements surgical interventions that ensure reliability in surgical practices in the operating rooms, ambulatory surgical centers, dental operators, and invasive procedure areas. Interventions include an active steering committee that supports and oversees perinatal and surgical safety, pre-procedure verification and team communication, basic patient safety training, utilization of surgical or procedural checklists, simulation training, and continuous improvement to minimize surgical-procedure-acquired infections (OPM.gov, n.d.). The organization also adopts a team approach to patient safety and ensures adherence to the Joint Commission National Patient Safety Goals. It has multiple clinical improvement projects that include chronic disease management and cancer screening. The adopted interventions have helped the organization create a just culture and a culture of safety. (Just Culture and Culture of safety Comprehensive Nursing Paper Example)

Evaluation of Mission and Vision

Kaiser Permanente’s mission is “to provide high-quality, affordable health care services and to improve the health of our members and the communities we serve.” Its vision is “to be a leader in total health by making lives better” (Kaiser Permanente, n.d.).(Just Culture and Culture of safety Comprehensive Nursing Paper Example)The mission and vision statements integrate elements of a just culture and a culture of safety, including high-quality care, affordable health services, and total health, which is a state of complete physical, mental, and social well-being. For instance, focusing on High Reliability and integrating elements of The Institute for Healthcare Improvement to enhance the quality and safety of patient care is one factor that creates a just culture and a culture of safety at the organization. The organization’s mission to provide high-quality care to improve the health of community members aligns with this factor. The mission also aligns with the company’s focus on a culture of safety that facilitate adverse events reporting by providers and front line staff, bolstered by a just culture that identifies system and process failures while fostering individual accountability. Developing fair practice principles for leaders and staff, addressing system and individual failures, enhancing accountability, and implementing interventions like state of the art technology, Kaiser Permanente gets closer to ensuring total health, which is its vision. The organization’s factors of a just culture and a culture of safety align with its mission and vision.    (Just Culture and Culture of safety Comprehensive Nursing Paper Example)

Conclusion

A just culture focuses on system errors as the underlying causes of human errors. A culture of safety includes shared beliefs, attitudes, and values that combine to establish a commitment to safe care and a working environment and minimize harm. Kaiser Permanente joins other healthcare institutions to ensure patient and worker safety by creating a just culture and a culture of safety. Numerous factors within the organization, including fair practice principles for leaders and staff, teamwork and collaboration, continued learning, error reporting, implementing state of the art technology, implementing surgical interventions, and focusing on High Reliability contribute to creating a just culture and a culture of safety. The organization’s mission and vision align with the factors that help create a just culture and a culture of safety.(Just Culture and Culture of safety Comprehensive Nursing Paper Example)

References

Bonacum, D., Convissar, J., & Graham, S. (2020). Educating leaders, middle managers, physician chiefs, frontline clinicians and staff. Kaiser Permanente.(Just Culture and Culture of safety Comprehensive Nursing Paper Example)

Kaiser Permanente. (n.d.). About: Our history. https://about.kaiserpermanente.org/our-story/our-history(Just Culture and Culture of safety Comprehensive Nursing Paper Example)

Kaiser Permanente. (n.d.). About: Who we are. https://about.kaiserpermanente.org/who-we-are/(Just Culture and Culture of safety Comprehensive Nursing Paper Example)

OPM.gov. (n.d.). Kaiser Foundation Health Plan of the Northwest (Kaiser Permanente) Patient Safety. https://www.opm.gov/healthcare-insurance/healthcare/plan-information/plan-codes/safety/57.asp(Just Culture and Culture of safety Comprehensive Nursing Paper Example)

Paradiso, L., & Sweeney, N. (2019). Just culture: It’s more than policy. Nursing management, 50(6), 38–45. https://doi.org/10.1097/01.NUMA.0000558482.07815.ae(Just Culture and Culture of safety Comprehensive Nursing Paper Example)

https://www.ncbi.nlm.nih.gov/