Matsalla – Leader Implementation of Just Culture within AHS 1 Graham Matsalla APRJ-699 Leader ...

66 Pages·2016·1.34 MB·English

Matsalla – Leader Implementation of Just Culture within AHS 1
Graham Matsalla
APRJ-699
Leader implementation of Just Culture within Alberta Health Services (AHS)
teams to improve quality and safe healthcare services
Word Count: 19,583
September 11, 2016
Mr. Tim Carroll
Matsalla – Leader Implementation of Just Culture within AHS 2
Abstract

A challenge in providing safe, quality healthcare is to eliminate errors that can
result in negative outcomes or even mortality. Traditionally, healthcare as an
industry has sought out the individual responsible and punished them. This
method does not acknowledge the responsibility of the system, which typically
holds a corresponding role. Thus, the error is not prevented from repeating. In
order to create an environment where all levels of an organization are held
accountable for an error, a Just Culture needs to be created. A Just Culture is an
environment of open and honest reporting aimed to improve the operations of
safe and quality healthcare outcomes. A Just Culture environment prevents
errors and promotes continuous quality and safety improvement. Instead of a
focus only on errors and outcomes, Just Culture requires a change to the
systemic design and management of healthcare organizations employees’
choices. The purpose of this applied project is to determine how to measure Just
Culture of teams within Alberta Health Services (AHS) in order to make
improvements in Just Culture implementation, improve service quality, and safety
improvement. The goals of the applied project were reached by answering the
primary research question: how can Just Culture be measured and implemented
within AHS teams? This is accomplished through the measurement, identification
of opportunities, identification of actions, and analysis of these actions. Sub-
questions used to answer the primary research question include:
• What are common themes or issues identified in the literature that
healthcare organizations have to consider when improving Just Culture?
• What is the influence of current AHS culture on Just Culture development?
• What changes need to occur within AHS to improve the Just Culture
principles developed by AHS (Appendix B)?
• Based on the fact that AHS makes value-based, evidence-informed
decisions, what forms of measurement are required in order to evaluate
the progress of Just Culture?
• How does AHS ensure that staff are engaged in the process of Just
Culture development?

A literature review is key in developing evidence-based recommendations. The
literature review resulted in a model that can be used to develop a Just Culture in
Alberta Health Services (AHS). Current measures of Just Culture obtained from a
national, organizational, and team levels provide some measurement but specific
measures still must be made. An assessment tool would ensure specific and
accurate measurement of Just Culture. This applied project provided team
change management suggestions to support team change that will inevitably
lead to broader organizational changes in Just Culture. Leadership engagement
demonstrated directions leaders should take to accomplish team improvements
through training and education initiatives. Data collection and analysis
demonstrated communication improvements and measures required for inclusion
in developing Just Culture. Finally, recognition of Just Culture improvements
must occur.
Matsalla – Leader Implementation of Just Culture within AHS 3

The results of this applied project provided evidence-based resources, to serve
as evidence-based improvement recommendations in Just Culture that can then
be made within AHS teams. Best practice and collection of evidence can
contribute to the development of Just Culture as AHS team leaders determine
the strengths and weaknesses of their team ability to apply Just Culture
principles.

Organizational support should be demonstrated within the design of AHS and
with senior leadership adhering to Just Culture principles. Processes within AHS
can be expanded to support improvement of safety in non-punitive ways that
emphasizes systemic improvement while maintaining an individual’s
accountability for their actions. Team capacity must improve through training and
team leadership support. This can occur by walking around units to encourage
discussion, through short huddles, or during longer monthly meetings. Just
Culture must be discussed to demonstrate its importance. Implementation of a
Just Culture model provides a map for leaders and teams to follow to ensure that
Just Culture principles are implemented into the operations of AHS teams.
Organizational culture change is a process that requires a significant amount of
commitment by an organization. AHS must engage leadership, provide
education, improve communications to facilitate knowledge translation, and
measure changes within an environment of trust while emphasizing a patient-
centered approach to healthcare services. A team approach will empower
employees to take an active role in the creation of a Just Culture in AHS. In the
future, quality improvement, expanded data collection, and an accountability
framework should be developed by AHS to continue to improve Just Culture
within the organization.
Matsalla – Leader Implementation of Just Culture within AHS 4

Table of Contents
Introduction .................................................................................................................. 6
Research Purpose and Research Questions .............................................................. 8
Research design ........................................................................................................ 10
Literature Review, Results and Analysis ................................................................... 12
Culture .................................................................................................................... 12
Healthcare Culture. ............................................................................................ 13
Culture of Safety. ................................................................................................ 14
Just Culture. ....................................................................................................... 15
System and Structure ............................................................................................. 16
System. .............................................................................................................. 16
Structure. ............................................................................................................ 18
Organizational Change. ...................................................................................... 19
Trust. .................................................................................................................. 20
Engaged Leadership .............................................................................................. 21
Leading Change. ................................................................................................ 22
Team Approach. ................................................................................................. 24
Education ............................................................................................................... 25
Training. ............................................................................................................. 25
Learning. ............................................................................................................ 25
Data and Analytic ................................................................................................... 26
Communication - Knowledge Translation. .......................................................... 26
Measurement. .................................................................................................... 28
Supports and People .............................................................................................. 31
Results ....................................................................................................................... 36
Matsalla – Leader Implementation of Just Culture within AHS 5
Culture .................................................................................................................... 36
System and Structure ............................................................................................. 37
Engaged Leadership .............................................................................................. 38
Education ............................................................................................................... 41
Data and Analysis .................................................................................................. 42
Supports and People .............................................................................................. 45
Recommendations ..................................................................................................... 46
Measuring Just Culture .......................................................................................... 46
Organizational Support ........................................................................................... 47
Internal Unit or Team Capacity ............................................................................... 49
Implementation of a Just Culture Model ................................................................. 51
Organizational change ........................................................................................... 51
Further efforts ......................................................................................................... 53
Conclusion ................................................................................................................. 54
Appendices ................................................................................................................ 56
Appendix A – AHS Values ...................................................................................... 56
Appendix B – Just Culture Guiding Principles ........................................................ 57
Appendix C – Four Approaches to Effectiveness Values ....................................... 58
Appendix D –Framework to Improve Just Culture within AHS ............................... 59
Appendix E – Alberta Quality Matrix for Health ...................................................... 60
Appendix F – AHS Strengthening Patient Safety Culture Template ...................... 61
References ................................................................................................................ 62
Matsalla – Leader Implementation of Just Culture within AHS 6
Introduction

Culture is an important concept within organizations. An organization’s unique
customs, character, nature, and identity forms a culture within that organization
that creates shared belief and value systems that are demonstrated by
employees. According to the ESLS-669 Study Guide (Athabasca University,
2016, Section 5-2: Organizational Culture), “organizational culture is often
described as ‘the way we do things around here.’ Culture influences every aspect
of the organization (including employee productivity, performance, commitment,
self-confidence, and ethical behaviour)”. An organizations culture can also be
influenced by the sector they work within.

There are many contributing factors that influence culture in the healthcare
sector. The needs of clients, patients, families, organizational providers, and
regulators all have specific outcome expectations. Healthcare is a hierarchical
structure with a matrix form of organizational structure (Athabasca University,
2015). This matrix structure benefits from the use of functional and divisional
parts of the organization to leverage strengths based on the environment the
organization is faced to work within. In order to function, the matrix structure in
healthcare combines the traditional vertical hierarchy with formal horizontal
teams. The challenge is to balance reporting and decision-making in both
directions. Organizational structure influences team decision-making and the
hierarchical structure creates a culture of blame within healthcare organizations.
The major consequence of this type of culture is that individuals will tend to avoid
reporting errors or ‘near misses’ in order to protect themselves from blame. This
prevents process, system improvements, and prevents organizational learning
from occurring. It is important for Alberta Health Services (AHS) to move away
from a culture of blame to a Just Culture. Boysen (2013) explained Just Culture
in that it, “balances the need for an open and honest reporting environment with
the end of a quality learning environment and culture” (p. 400). Healthcare
organizations need to support and respect their employees and patients alike.
Employees need to be held accountable to their choices in providing safe, quality
healthcare. Instead of a focus only on errors and outcomes, Boysen (2013)
stated that Just Culture requires a change to the systemic design and
management of employees’ choices. Promoting a culture of safety and quality
improvement is a challenge without an environment that encourages openness
and shared learning throughout the organization to identify and address
weaknesses.

Alberta Health Services (AHS) is Canada’s first, and largest, provincial
healthcare system (AHS, 2016). With over 100,000 employees in five zones
throughout the province, AHS strives to improve patient experience and quality of
care by applying organizational values. The Triple Aim approach of better quality,
better outcomes, and better value is supported in AHS’s 2015 – 2018 Health
Plan & Business Plan through the organization’s seven values: respect,
accountability, transparency, engagement, safety, learning, and performance
Matsalla – Leader Implementation of Just Culture within AHS 7
(Appendix A). These values guide decisions that employees make while
achieving organizational outcomes. Research has shown that organizational
values are important to influencing organizational culture. Grant (2013) pointed
out that, “to the extent that values are shared among organizational members,
they form a central component of organizational culture” (p. 50). There are many
challenges to changing culture within AHS: building a culture of recognition,
building a culture of innovation, and patient safety culture.

It is important to note that within AHS, quality and performance improvement has
an integrated perspective toward cultural improvement. The principles that AHS
has identified to achieve the goal of creating a core culture to positively influence
quality and performance is called Just Culture. The challenge is to provide
leaders within the organization objective measures to identify their team’s
position in relation to Just Culture principles (Appendix B). It is important to learn
and report errors in order to continually improve healthy environments for
employees and clients, prevent errors, lessen ‘near misses’, and support
continuous quality and safety improvement. AHS highlights that, “a Just Culture
is an environment where everyone feels safe, encouraged, and enabled to
discuss quality and safety concerns” (AHS, 2016). When an error occurs,
employees need to feel that they will be supported and treated fairly. If an
employee feels that they are safe to report errors, leadership will have an
opportunity to prevent the situation from reccuring by dealing with the
precipitating factors, make systemic changes, and share the learning with other
areas of the organization. AHS needs to provide the necessary resources,
supports, and tools to enable staff to become aware of, understand, and apply
the Just Culture guiding principles (Appendix B). Just Culture guiding principles
are integrated into AHS values, therefore, by practicing Just Culture, employees
are also practicing organizational values.
Matsalla – Leader Implementation of Just Culture within AHS 8
Research Purpose and Research Questions

This applied project determines how to measure Just Culture within AHS teams
in order to make improvements in the implementation, service quality, and safety
of Just Culture. The primary research question asks: how can Just Culture be
measured and implemented within AHS teams? This is accomplished through
measurement, identification of opportunities, identification of actions, and
analysis of these actions. Sub-questions used to answer the primary research
question include:
• What are common themes or issues identified in the literature that
healthcare organizations have to consider when improving Just Culture?
• What is the influence of current AHS culture on Just Culture development?
• What changes need to occur within AHS to improve the Just Culture
principles developed by AHS (Appendix B)?
• Based on the fact that AHS makes value-based, evidence-informed
decisions, what forms of measurement are required in order to evaluate
the progress of Just Culture?
• How does AHS ensure that staff are engaged in the process of Just
Culture development?

The management issues that led to the primary question and sub-questions
include:
• strategic leadership,
• organizational strategy analysis,
• organizational theory and design,
• change management and leading change,
• communications, and
• culture change.

Although this research could apply to the entire healthcare sector, the scope of
this applied project will be limited to focus is on AHS. AHS is a large healthcare
organization with over 108,000 employees, 106 acute care hospitals, 2,439
mental health beds, 42 primary care networks, and 650 facilities around the
province where programs and services are offered (AHS, 2016). Just Culture
principles (Appendix B) support current safety culture improvements that are
being made within AHS. Although a culture of safety supports Just Culture
principles actions need to expand to include applications of Just Culture
principles. Assessment of safety culture alone does not identify successful
implementation of Just Culture. A Just Culture assessment tool needs to be used
to create specific measurement and direct change. In using an assessment tool,
validity and reliability of the tool will continue to increase.

An assumption of this applied project assumes that the accurate data is provided
(organizational and national surveys) and is accessible by all levels of leadership.
A second assumption is that AHS is committed to implementing a Just Culture
plan within AHS. Finally, increasing a safety culture will have the greatest
Matsalla – Leader Implementation of Just Culture within AHS 9
positive influence on Just Culture improvements. The literature review was
guided by a framework, which in turn guided the research to improve Just Culture
within AHS (Appendix E).
Matsalla – Leader Implementation of Just Culture within AHS 10
Research design

This applied project used a literature and organizational resource review, which
was analyzed to create a framework and to obtain best practices in order to
develop conclusions and recommendations. Through a qualitative analysis the
proposition was that in order to create Just Culture within AHS teams tools need
to be developed in order to measure and assess current levels of Just Culture
principles and make changes to team culture to improve Just Culture principles
where needed. The governing theory is that an appropriately led Just Culture that
is measured and supported will improve outcomes in quality and optimize safe
healthcare. This literature review followed a framework (appendix D). This
framework provided structure and scope to the literature review.

Using the Athabasca University online library peer-reviewed articles were
collected for review. This search began looking for articles directly related to Just
Culture in healthcare and culture issues within healthcare in general. Historically,
Just Culture began in the aviation industry but has an abundance of literature
relating to healthcare. Healthcare culture is unique to teams and organizations
but a few specific issues are worthy of mention. A culture of blame with punitive
actions to individuals created a culture of avoidance of addressing systemic
issues. Although this requires change, individuals still need to be held
accountable to their actions and a culture of safety still must be maintained. The
literature indicated that healthcare system and structure change needs to occur
consistently and trust needs to be established between organizational leadership
and staff. Therefore, it was determined that leadership needed to engage in
change management and support of a team approach. In order to reach this
state, training is required by staff and leadership. In order to ensure that changes
are occurring toward a Just Culture data needs to be collected and
communicated to staff.

Measurements to identify the demonstration of Just Culture principles are results
from nation, organizational, and team data. The literature search identified
various evidence-based tools and best practices that provide indicators of
demonstrated Just Culture principles (Appendix B), which in turns creates a
significant focus on patient safety. Opportunities for improvement in Just Culture
principles are identified through the measures that can be applied to AHS as an
organization and specifically, to health units or teams. The result of this literature
review and analysis included the development of a framework (Table 1.a & b),
measurement tool, and implementation recommendations for leaders attempting
to improve Just Culture within AHS teams. Measurement of Just Culture
principles must be achieved at national, organizational, and team levels in order
to determine where principle improvements can be made and to evaluate the
progress resulting from these changes. Problems identified by these measures
provide opportunities to make improvements and allows for action-oriented plans
to correct deficiencies in Just Culture principles. These actions should be
measured to determine if they are effectively improving Just Culture in the