Discussion: Group Management for Culture

Discussion: Group Management for Culture

Discussion: Group Management for Culture

Discussion: Group Management for Just Culture

The concept of a fair and just culture refers to the way an organization handles safety issues. Humans are fallible; they make mistakes. In a just culture, ‘hazardous’ human behavior such as staff errors, near–misses and risky actions are identified and discussed openly in hopes of finding ways to improve processes and systems—not to identify and punish the individual.
—Pepe & Caltado, 2011

This Discussion examines the opportunities of managers in working with groups to promote change that facilitates the delivery of safe, high–quality care.

To Prepare

Review the information on just culture presented in the Learning Resources.
For this discussion, you will use the Regulatory Decision Pathway found in Russell, K. A. & Radtke, B. K. (2014).
Examine an adverse event at the unit level in your organization or one with which you are familiar and apply the Regulatory Decision Pathway.
Compare the findings of the Regulatory Decision Pathway to what actually happened at the unit in your organization. Was the event deemed: bad intent, reckless, at risk, or human error? According to the pathway, do you now think it was the correct action?
Think about how a nurse leader–manager may use just culture as a framework to create or maintain a focus on accountability and outcomes throughout a group. What actions could be taken if a systems–related error was made or if an error resulted from risky behavior?
How might role conflict and/or ambiguity have contributed to the situation?

Post a description of an adverse event in your organization and your analysis of the issue using the Regulatory Decision Pathway. Explain how role conflict or ambiguity might have influenced this situation. Apply the principles of just culture as you explain how you, as the group’s manager, would handle the situation.

http://sidneydekker.com/wp-content/uploads/2013/01/JustCultureCritique.pdf

http://www.outcome-eng.com/wp-content/uploads/2012/01/manage-risk.pdf

**************Below is a paper to use as reference!!!!!!!!!

PLEASE USE THIS AS A REFERENCE ONLY.

Adverse Event

Adverse events are a part of the healthcare environment and how an event is dealt with can affect patient safety. The regulatory pathway and just culture are a means of improving the quality of care and safety culture (Russell & Radtke, 2014). Health care employees need to trust in their organization that an adverse event can be reported so that the organization and employee can learn from the event, and that it is not just a means to place blame.

An adverse event that took place in the cardiac catheterization lab was a procedure was done on the wrong patient. A patient that was to have a pacemaker instead ended up having a diagnostic catheterization. This event involved a patient identification issue by the nurse. The hospital’s patient identification policy and time out policy were not adhered to by the nurse and then the catheterization team. The incident was reported to the state, and there were several event meetings with the nurse and physician. As a result of the investigation, all staff in the catheterization lab were re-educated to the patient identification and time out policy. All staff had to sign an individual affidavit that they understood the policy. The nurse was given a written warning. This event would not have happened if the nurse and catheterization team had adhered to policy.

Regulatory Decision Pathway

Using the regulatory decision pathway, the nurse did not intend to harm the patient deliberately. The nurse asked the patient if she was Ms. X and the patient said yes. The identification policy is to check the patient’s identification band for name and medical record number against a second identifier. This was not done. There were no significant circumstances involving the system that led to the error. The nurse did not conceal the error or falsify the record. The nurse did not disregard or consciously take a substantial risk. She thought she had the correct patient. There were no similar or serious errors by this nurse. A reasonably prudent nurse would not have done the same in similar circumstances as the patient identification policy would have been adhered to. According to the regulatory decision pathway, this was at-risk behavior by the nurse (Russell & Radtke, 2014).

The catheterization team which included the physician, nurse, physician assistant, and technician contributed to this adverse event. The team did not follow the time out process policy where everything stops, and patient identification is reconfirmed with other parameters. Again, following the regulatory decision pathway, the catheterization team demonstrated at-risk behavior. At-risk behavior involves unsafe practice and carelessness which is shown by the nurse and catheterization team not adhering to policy (Russell & Radtke, 2014).

Discussion: Group Management for Culture

Discussion: Group Management for Culture

Role Conflict

The cardiac catheterization lab is very fast-paced, and the nurses can feel the stress of the workload. The procedure area and recovery room was very busy and crowded that day. Role conflict could have contributed to the situation as there is constant pressure to keep moving. Role conflict could have contributed in the time-out process not taking place in the procedure room. Nurses have to initiate the time out process when the physician arrives, and some physicians are not very cooperative in the process. Since the adverse event, patient identification and the time out policy are strictly adhered to.

Just Culture

Quality improvement and work environment improvement are a part of just culture (Lockhart, 2015). Just culture is safety issues, improving processes, and not about punishing individuals (Pepe & Cataldo, 2011). As the group’s manager using the principles of culture, I would have done firm counseling stressing the significance of the incident, but as this was the nurse’s first risky behavior, I would not have done a formal written warning with the threat of being fired if it happens again. Doing a staff meeting and re-educating the policies was appropriate. Patient identification and the time out process are now part of the cardiac catheterization lab’s monthly quality assurance surveys. All new employees are well educated in the two policies and must sign an attestation that they understand by the end of orientation. This adverse event led to improved processes in the cardiac catheterization lab which is the goal of just culture (Pepe & Cataldo, 2011).

References

Lockhart, L. (2015). Does your organization have a just culture? Retrieved from http://www.NursingMadeIncrediblyEasy.com doi-10.1097/01.NME.0000457286.16594.92

Pepe, J., & Cataldo, P. J. (2011). Manage risk, build a just culture. Health Progress. Retrieved from http://www.outcome-eng.com/wp-content/uploads/2012/01/manage-risk.pdf

Russell, K. A. & Radtke, B. K. (2014). An evidence-based tool for regulatory decision-making: regulatory decision pathway. Journal of Nursing Regulation, 5(2), 5-9. https://class.waldenu.edu/bbcswebdav/institution/USW1/201810_27/MS_NURS/NURS_6201/readings/USW1_NURS_6201_Russell.pdf

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ADDITIONAL INSTRUCTIONS FOR THE CLASS

Discussion Questions (DQ)

Initial responses to the DQ should address all components of the questions asked, include a minimum of one scholarly source, and be at least 250 words.
Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source.
One or two sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words.
I encourage you to incorporate the readings from the week (as applicable) into your responses.
Weekly Participation

Your initial responses to the mandatory DQ do not count toward participation and are graded separately.
In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies.
Participation posts do not require a scholarly source/citation (unless you cite someone else’s work).
Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.
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Familiarize yourself with APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required).
Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation.
I highly recommend using the APA Publication Manual, 6th edition.
Use of Direct Quotes

I discourage overutilization of direct quotes in DQs and assignments at the Masters’ level and deduct points accordingly.
As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content.
It is best to paraphrase content and cite your source.
LopesWrite Policy

For assignments that need to be submitted to LopesWrite, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me.
Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes.
Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own?
Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for tips on improving your paper and SI score.
Late Policy

The university’s policy on late assignments is 10% penalty PER DAY LATE. This also applies to late DQ replies.
Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances.
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Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class.
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