Protecting the Public through Disciplinary Action

1. Protecting the Public through Disciplinary Action Maryann Alexander, PhD, RN, FAAN Kathleen Russell, JD, RN

2. The Board’s Duty Is To Protect The Public Not Punish The Licensee

3. Criminal Justice System • Punishment does not improve behavior • Emphasis is needed on examining what happened and how can we prevent you from doing this again. • Support and resources lessen the chance of recidivating.

4. TERCAP Data Individuals disciplined by their employer have a much higher chance of being disciplined by the board of nursing at sometime in the future

5. 2012 • 200,000 people die from medical errors a year (Andel, et al, 2012) • More than 130,000 Medicare beneficiaries experienced one or more adverse events in hospitals in a single month. (HHS, OIG, 2012). • When quality life adjusted years (QALYs) are applied to patients that die, the errors committed on an annual basis translates into $1 trillion dollars a year (Andel, et al, 2012)

6. What does all this mean? • Regulation and health care facilities need to work together. • We need to effectively prevent errors. • Examine system as well as individual errors. • Punishment may not be the best option for preventing future errors or poor performance. • Remediation, counseling, supervision are tools that need to be considered as part of disciplinary action.

7. Punishment • People tend to hide errors • Prevents fixing the system • Risk to patient • Focus is on punishment • Effective when used in the right way.

8. Questions • When do we take no action? • When do we counsel, remediate and supervise? • When do we punish/remove from practice?

9. Just Culture a system of justice (disciplinary and enforcement action) that reflects what we now know of socio-technical system design, human free will and our inescapable human fallibility.

10. The Just Culture Model (simplified) Human Error At-Risk Behavior Reckless Behavior A Choice: Risk Believed Insignificant or Justified Conscious Disregard of Substantial and Unjustifiable Risk Product of Our Current System Design and Behavioral Choices • Manage through changes in: • Choices • Processes • Procedures • Training • Design • Environment • Manage through: • Removing incentives for at-risk behaviors • Creating incentives for healthy behaviors • Increasing situational awareness • Manage through: • Remedial action • Punitive action Console Coach Punish

11. System versus Individual Errors

12. System Errors • May be due to a deficit in the institution’s policies and/or procedures • May be due to other providers in the health care system • Often a combination of factors

13. Human Error

14. Human Error • Can happen to high performers with no history of past error • Discipline may not prevent • Remediation may not be needed

15. Risk-Taking Behavior“Justifiable Risk”

16. Risk-Taking Behavior • May need remediation/counseling • May need discipline/supervision

17. Reckless the police.

18. Reckless • Discipline • Remediation/supervision/counseling/job transfer

19. The Just Culture Model (simplified) Human Error At-Risk Behavior Reckless Behavior A Choice: Risk Believed Insignificant or Justified Conscious Disregard of Substantial and Unjustifiable Risk Product of Our Current System Design and Behavioral Choices • Manage through changes in: • Choices • Processes • Procedures • Training • Design • Environment • Manage through: • Removing incentives for at-risk behaviors • Creating incentives for healthy behaviors • Increasing situational awareness • Manage through: • Remedial action • Punitive action Console Coach Punish

20. The Just Culture Model • Repetitive errors – yes, there is a process • Repetitive at-risk behaviors – yes, there is a process • Both may lead to disciplinary action… Repetitive Events A Single Event

21. Remediation • Alternative to Discipline Programs • Only effective if the remediation is truly directed towards preventing future occurrence. • Monitoring and mentoring. • Institution must be aware and involved.

22. Deliberate Behavior • Discipline • May warrant permanent revocation of license

23. Regulatory Action Pathway • Consistent way of evaluating BON cases • Based on principles of James Reason, Just Culture, patient safety movement • Transparent • Patient centered • Relies on remediation • Partnership with hospitals

24. Regulatory Action Pathway • Encourage good choices beginning with reporting and identification of errors that might lead to better systems • Identify the difference between errors that are caused by human fallibility, risk-taking behaviors and recklessness • Direct discipline according to the type of error.

25. Regulatory Action Pathway • Patient centered • Examines intention and distinguishes between types of errors • Encourages reporting of errors • Encourages partnership between BON and institution • Emphasis on corrective activities • Accounts for system related issues • Looks at repeated occurrences • Discipline when needed