Applying the Just Culture Algorithm to Suspected Diversion with Becky Doerhoff, MSN, RN, CNL Director Patient Safety & Clinical PI, Barens Jewish Hospital, and Amanda Hays, PharmD, MHA, BCPS, CPHQ, FASHP , Director, Medical Affairs at BD
A great discussion with Becky Doerhoff and Amanda Hays on how to utilize the Just Culture algorithm for suspected diversion. We give an overview of the Just Culture approach for those of you who are not familiar with it, and we talk about when it may or may not apply to an impaired healthcare professional or one who is suspected of diversion. They give some things to consider that many of you may not have contemplated previously.
Transcript:
Terri
Welcome back, everybody. Our sponsor today is IMI. IMI offers a comprehensive line of products to increase pharmacy efficiency and safety. All IMI products are manufactured in the United States at their FDA registered ISO certified facility under the strictest quality standards. My guests today are Amanda Hayes and Becky Deerhoff. Amanda is a pharmacist and currently working for BD as the director of medical affairs. Becky is a nurse and the director of patient safety, risk management and compliance at Barnes Jewish Hospital. Today we’re going to be discussing “Just Culture” and how it can be applied to suspected diversion. Now, for those of you listening that maybe aren’t familiar with Just Culture, I’m just going to give you a quick overview, and I’m sure Becky and Amanda will interject and correct me if I misspeak on anything. So I’m certainly not the expert, but I have used it.
It is an excellent algorithm to assist with evaluating an event and then narrowing down the event to one of three types of behaviors. And I would use it routinely when I was in my role of medication safety officer. So for medication errors is when I would whip out that algorithm. In the case of medication errors, action taken toward the healthcare professional that made the error should be based on the behavior behind the error and not the outcome. So it doesn’t matter if there’s patient harm or not patient harm. It’s based on the behavior. The three behavior choices are number one, “human error”, which is made because we’re all humans and we make mistakes. There was no intention to make the error, but it was made because we’re fallible. The second behavior is “at-risk behavior”, and that is when a person chooses to do something because maybe they’ve lost the discernment of the risk associated with the action, or they believe the risk to be insignificant. Culture becomes tolerant to certain at risk behaviors, and they move toward being the norm instead of being risky. So an example might be scanning a medication after administration rather than before. We all know the only way to prevent a med error with scanning is to scan it before you give it right. But if you scanned it after a few times and there’s no negative consequences, then we kind of begin to lose that discernment of the risk associated. And maybe the culture of the unit has been one that really matter. We just need to get our 100% barcode planning. As long as we do it, nothing bad has ever happened in those cases with at risk behavior, coaching and a system redesign are typically recommended actions. Now, the third type of behavior is “reckless behavior”, and that is one where there’s a conscious disregard of the substantial and unjustifiable risk. In a 2020 article by ISMP, they actually list drug diversion as reckless behavior. Reckless behavior is blameworthy, and disciplinary actions need to be considered.
I heard Amanda and Becky speak on the Just Culture as it relates to diversion. So that’s the discussion that we’re going to have today. And I will tell you that I’ve spoken with them a couple of times, and I’ve asked a lot of questions because it was kind of hard for me to wrap my brain around some of what they said. And so that’s what we’re going to try to do today, is clarify some of that and give you some of those answers. So I’m going to welcome to you both. Becky, I’m going to start with you. And I know you work with Just Culture on a regular basis throughout your day, and I know the two of you used to work together, and that’s where the connection is. So, Becky, share with us some of your thoughts on Just Culture principles. And is there ever a time that we would use that algorithm and not consider suspected diversion as reckless behavior? Let’s talk about that.
Becky
All right, so thank you for having us and continuing this conversation. I think that what we are trying to propose and change the dialogue around is kind of the basic assumptions. The most algorithms or the typical algorithms you see that are referenced in literature are what you’ve described, right? We have an unexpected unwanted outcome, and we are trying to investigate and understand and appreciate human error versus the quality of our choices. And I would say the assumption is that the individual that’s being looked into or the group of individuals, there’s an assumption of competency, of I’m competent to make a choice. I’m acting on the best interests of my organization while I’m at work. I think when you look at the algorithm and you look and appreciate the questions that they ask, those are the baseline assumptions. So when they say, was the duty to follow this rule known to the employee? And typically in these types of investigations, the answer is what? Yes, you did know that these medications are intended, prescribed and intended to be given to patients. Was it possible to follow the rule? And that’s where we look into system design or the risky behaviors.
I think that what we want to look at is a different version of the algorithm. And the one that we mentioned during our presentation was an adaptation made by Al Frankel and Michael Leonard, who are both anesthesiologists by training, and they’re both IHI faculty. They’ve been doing patient safety work for decades. And they published a modified version of the Just Culture algorithm, which first and foremost asks the question if there’s impairment and if there is impairment. So if the person is making a choice without being impaired and is competent, then you follow the Just Culture algorithm. If they know that they’re stealing and are selling or whatever they’re doing, and they’re not it’s not under a substance use disorder, then you follow that algorithm.
I think what we want to highlight and have the conversation is that people assume that because individuals who have chronic substance use disorder appear to be fully functioning. You can drive, you can get dressed, you can arrive at work on time then therefore you’re competent. Your decisions and the quality of your choices can be evaluated by the traditional sense. And I think Amanda, would you want to expand on those assumptions?
Amanda
Yeah, I mean, I think just taking a step back, we know that 10% to 15% of healthcare workers at some point have a dependency or excessive use of either drugs or alcohol. And with that we don’t really know the exact number that go on to divert and we also understand the subsequent patient safety risk. So please remember that nothing that Becky and I are talking about is to negate any of those issues that exist in the baseline workforce nor the potential risk to patients. But I think when you think of especially what’s happened over the last three years in the healthcare workforce, they’ve had extreme amounts of stress beyond what has ever been seen in the healthcare workforce. COVID-19 the impact of that subsequent burnout of healthcare professionals who were seeking to either leave the profession altogether or seek new opportunities outside of what they were normally doing on top of labor shortages.
It all adds to an increased stressful work environment with very sick patients. And then we also know from looking at the literature and from national guidelines that addiction is described as a chronic and relapsing disorder and not a moral failing. And that’s according to the National Institute of Drug Addiction. And so knowing that it is kind of a chronic disease, it is a chronic treatable disease, I think it’s important to keep that in context as we talk about this. The other thing I would say is that for individuals who do have substance use disorder the chemical changes that happen in their brain directly impact their ability to make conscious decisions. So as an example, the pleasure center in the brain or the basal ganglia is impacted where such that anything but the medication or drugs that they are seeking as a part of their use is actually impacted dramatically. The decision centers are also impacted and it increases stress over time for these individuals, increases anxiety and then as I mentioned, the prefrontal cortex which powers your decision making, conscious decision making, self control, again all dramatically impacted by substance use disorder. So while you see with the disease of addiction and substance use disorder that it may be an initial choice to try a medication, subsequent use leads to self control challenges more of that reward from using the substance and then over time as it goes into habitual use, the expected behavioral norms lessen the risk of drug diversion potentially increases. And at that point in time it’s difficult to say based on the science that we know today that these individuals are really capable of making an appropriate conscious decision. We’ve also seen professional organizations come out and speak about this because of the fact that for many years we lived in a punitive environment.
So now, today’s contemporary thinking from both the American Society of Health System Pharmacy, the American Nurse Association, as well as the American Society of Addiction Medicine, which talks specifically about healthcare workers who are impaired, fundamentally talks about that. They have a relapsing chronic condition, but that the punitive actions taken should be considered based on some of the other it’s not to say that they can’t have punitive action, but to kind of be more empathetic about the disease that these individuals are facing. And so I think all that’s important to keep in the context as we talk about Just Culture. Because again, if we start the algorithm discussion with is the individual impaired, it will quickly be apparent that maybe they’re not making a conscious decision because they are under the influences of substances.
Terri
Yeah, that all makes sense. I think something that Becky said is maybe part of what throws us off and that is they’re coming to work and they’re working and you’re working right alongside them. And in many cases sometimes just because peers don’t know what to look for or we try to justify it with other things going on in their life that we know are going on. But the fact remains is many times you will hear from a manager or a peer or something, no, they’re one of the best nurses that we have. So if they can make the appropriate, shall we say, decisions to get them there, to do their charting to work, then how can we argue that they aren’t in control of some of the actions that they take? And so I think that is something that does kind of throw us off a little bit in terms of accountability.
Amanda
Yeah, I think if you think about an individual who had maybe a workplace injury and is coming or openly disclosed upon hire that they had a medication that they were taking daily, that was a controlled substance, they were not going to pass their higher drug screen. Right. I think it’s important to think of how you address those situations. As you also think about this, many organizations do allow for individuals who have a valid prescription for certain medications to be allowed to continue to work so long as their performance is meeting expectations with appropriate safeguards in place. We also have seen a lot more openness around individuals who are in recovery and on chronic treatment for medication assistance for those with opioid use disorder. And those individuals may even be allowed to continue gainful employment while being actively treated for that in many organizations. So in those cases, those individuals are also being treated with a medication.
I think the one difference is that looking at the desired craving and the desired need for the medication, which in these individuals may be outweighing some of their other needs. Right. So they are maybe not making decisions because the primary craving is that medication that they’re desiring, which often may be the reason that they tip into drug diversion. Opportunity plus access, plus that unfortunate state of illness. And seeking the medication over other appropriate social norms is something that I think we do see as the disease progresses.
Terri
Yeah, I guess that is the difference, right? I mean, there’s the working impaired. So why are you impaired? Is it your prescription med that you’re not abusing but the dose is too high, perhaps, or the way you’re responding to it, maybe it’s a new treatment plan. Or alcohol. Of course there’s that too. And then there’s the I am on something, but I do function, and then there’s the craving. So all three of those are somebody who is taking something while they’re working. But the difference is, I guess a lot of it is the craving piece of it.
Okay, so with this different algorithm in terms of, I guess, how do you go about it? So if you think that there is an issue, you have to do a little differentiating before you decide which path to go. So do you know that how far into the investigation? What is your process? If you think there might be some sort of controlled substance involved, this wouldn’t apply to diversion of non controls. Right. That would be more of a theft, probably for money. Or it could be self treatment, but not a craving. Like they know what they’re doing, right? So how do you go about you’ve got someone, you think something may be going on. You’re not sure yet, you’re just starting. What is the process?
Amanda
Becky, do you want to take a shot at that at first?
Becky
Well, I would say that I think the first step is having some policies in place. And I think this is timely because I think on the listserve somebody was asking about impairment policy. So I think that the first thing is to have a process and policies to address. What do you do for employees who are found to be impaired? And then it should back up and support if there’s discrepancies and a diversion concern. And in the absence of those, which many of us have, don’t have those policies in place, we’re left with prior decisions as precedent and therefore there’s nothing to really prevent us from working our way backward from the algorithm. If we want to say, well, stealing is stealing or every choice is going to be evaluated regardless of impairment, then we will end up with reckless as a deciding point.
Becky
And maybe some of our policies, which I think we’ve talked about before, actually support termination. So if our policies support punitive action, then that’s what you’re going to get out of this process. And I think that it’s really about looking at the state that you’re practicing in and then looking and really taking a look at your local policies to start there.
Amanda
One other thing I would add is over my years as being a medication safety officer, I often found myself wanting to jump straight into the algorithm the second I identified a problem. And that’s really not the best way to approach it, you really need to have completed your investigation, darn near completed it, at least so that you can then appropriately go through it because you really don’t know all the facts until you’ve completed interviews, collected the data, maybe even had a conversation with the individual. Personally, when I’ve done some of these interviews with individuals who were suspected or identified as individuals that we should have a conversation with about potential for drug diversion, if they just close in that moment, I think then it may change how you approach your application of the algorithm.
Amanda
So I think I would say, like most things, wait until you have all the facts before you try to determine final outcome or approach that you’re going to take to address the issues. So whether that be a medication error or in this case, a drug diversion case.
Terri
Yeah, that’s a good point. I think that is something that you start to learn with experience when you’re first starting in any of this diversion or med safety or anywhere where a conclusion, I mean, actually life too, I guess, is we can be really quick to like, well, that’s it, that’s so obvious. And the more we do it, the more we get little curveballs and surprises and then we start to realize and actually then it becomes more natural to just, well wait, we’re not done yet, let’s finish. Even when somebody else is saying, well, what could be the possible excuse for that? It’s like, well, you would be surprised what may happen, what you may uncover. So that makes sense now, is the approach the same? Let’s say that you don’t think that there’s diversion involved at all, but it looks like there’s impairment.
Terri
Is there a difference there? You’ve concluded your investigation. Now, there was clear impairment, somebody was exhibiting it, but from what you can see, and they have not admitted to diverting at all. Is there a different pathway for that?
Amanda
I guess I would think of that one more as what is your organization’s policy as it relates to on the workplace impairment? Right. And how you approach that oftentimes, again, if it hadn’t been for initial suspected diversion that they would be kicked out of the algorithm, essentially, I think in those cases they may be treated differently based on your organization’s policies. I know having spoken with many folks across the country, though, we’re starting to see more of that kind of gentler. EAP offered approach for folks. So employee assistance programs as a first step of that intervention, perhaps they’re placed on a probationary period, your analysis is performed and at that time they’re offered EAP and encouraged to try to address whatever issues, provide prescription validation if it’s in fact an illicit substance that’s been prescribed for them. So I think in those cases, again, many factors can go into how those individuals are treated, but I’m seeing a little bit more of a supportive culture even for those individuals.
Amanda
And perhaps in my past 20 years, I’d say I’ve seen a big shift from immediate termination of those individuals as well.
Terri
Yeah, because I don’t know, I’m trying to think, like, if you have diversion, are you going to have impairment? I would say yes. Right. Do you think or you think you could have one without the other? You think you could have one without the other?
Amanda
I have seen diversion with absolutely no self use of the medication.
Terri
Well, that’s true. Okay, so I’m going to take that off the table. Let’s say it is because you have a substance use disorder and you have diverted. It’s possible, of course, you’re just taking it home with you and it’s like weekend use maybe. So I guess from that perspective, it’s possible. And then you have your people that don’t seem to be acting impaired, but it must be influencing something if that craving is so high that you can’t resist the need to take it. Right. So if you have an impaired person, whether it’s alcohol or drugs, that is working, and you can clearly see it, you have a person who has a substance use disorder, and they cannot stop themselves from taking it. So you kind of go with the assumption that they are impaired in some way, whether it’s withdrawals, trying to offend something is not right.
Do you think that hospitals should have different policies, the process should be different in each of those circumstances? Or do they really come together? Because either way, you’ve got patients that are in danger, facilities that are in danger, with a liability, and you’ve got a healthcare professional who is in danger and needs help. So would you suggest that the policies handle them differently or really one and the same? It doesn’t matter. The only difference in this case is whether they stole something.
Amanda
Yeah, I think it’s up to organizational values and what level of comfort they have with supporting those individuals that are seeking recovery or interested in recovery. Right. And so, again, having kind of seen that shift over the past 20 years of my career, I think, and from my personal experiences right. My early days in my career, I worked with several individuals that were diverting controlled substances, and some of them being really close individuals to me. And I think that shaped a lot of my belief system in the potential for recovery. I’m proud to say that a couple of those folks are well over 20 years into recovery. I know others that are ten to 15 years into recovery still actively participating in AA and NA meetings, and some of those are even sponsors now for other healthcare workers. And so my value system may be different than an organization’s value system as it relates to belief in the possibility of recovery for these individuals.
So I do think it is an organizational discussion that has to happen from all angles because Becky and I are both very passionate about this side of it. But you may have conversations with your legal counsel who may have a different view or media right. That your individuals who support customer external optics around what your organization would go through, should there be a diversion, right. They may have different value statements and value beliefs than you that may shape your organizational policies.
Terri
Yeah all very true. And that’s one of the reasons I have these podcasts, because to try to get the more we hear about real life cases and situations and recovery and successful reintegration programs and stuff, the more people start to hear that it’s possible. These are people and hopefully there’s a shift in the way they start to look at things too. Okay, so you’ve determined that there is substance use disorder, there’s some diversion. What does this different algorithm say, aside from these three behaviors that I went through? What does this other process tell you to do at that point direct you to do?
Becky
Basically suggest that you work with risk HR your own policy kind of to be determined. I think that we’ve just been talking about kind of what that could look like. They don’t define it. Again, it’s really based on elevating the conversation and kind of challenging the more traditional approaches to this.
Amanda
I think the interesting thing is, as Becky’s answering that really makes me pause for a second is remembering that the individuals who developed this draft of an algorithm are anesthesiologists historically they have been recognized as a group that has a higher potential. Whether or not that’s validated fully in the literature with real data, I think remains to be seen broadly. But I think at the same time, healthcare professionals that work in certain areas have not always been treated consistently. Right. So you may see a different approach for nursing and pharmacy versus physicians, where physician reintegration into the workforce is often a primary goal depending on their commitment to recovery versus nursing and pharmacy, which may have a different path. And so I think kind of thinking that through it makes a little bit more sense of why there’s been some advocacy around. Hey, think of this differently, because recognizing that they are again under the influence of a substance at the time that subsequent actions occurred, I think it’s important to think of that as how your organization would approach it.
Because if you’re going to segment out disciplines, does that really make the most sense at the end of the day when fundamentally you’re either committed to a value system that allows reintegration or your firm on reckless behavior and subsequent consequences therein?
Terri
Yeah agreed. It shouldn’t matter. I guess the whole point is that they no longer fall in the standard. Just Culture and that’s what we need to remember. It’s not the reckless or at risk behavior because it just doesn’t fall under that anymore. And then that’s where our policies and procedures and our risk and legal and knowing ahead of time how you’re going to handle it, as opposed to just on the fly, then figuring it out.
Becky
And then have it fair and equitable across all roles.
Terri
Yes. Which also makes a big difference ahead of time is that this is how you have defined it. Yeah, that makes perfect sense. Okay. All right. Anything else you guys want to cover?
Amanda
I’d say one of the questions I’ve had and interested in really just having a discussion with Becky about this is what happens when there’s potential tampering that could directly lead to patient safety risks, potentially bloodborne pathogen. Right. I know in my past experiences that leads to some what I would call outcome bias. Right? You’ve directly done harm to a patient or potentially done harm to a patient. And should that still follow the same algorithm that we just discussed? And I personally feel that one is complicated. Right. It adds a layer of complexity to what we just discussed that I think it kind of goes back to where does your organization’s values lie? Do they continue to believe more in the support for individuals who are under the influence or do they value the patient’s values? And I think it is really complicated and I don’t know that there’s a right answer. Becky, I’m interested in your random thoughts on this.
Becky
That’s a good one, yeah. I think whenever you insert any outcome bias that we have a tendency to treat the individuals differently. And that’s part of when you’re learning Just Culture, to be aware of the biases that we all have and again, to have a consistent team that’s working on this. So I work with teams of individuals who we keep ourselves accountable so that we don’t allow ourselves just to go down a pathway because we’re all emotionally tied or we have individuals that are potentially demanding different outcomes because it involves patient and disclosure in those conversations. So I think that’s in my mind, it’s critical to have the consistency and a team that is diverse and committed to one, knowing that they might be falling down a hindsight outcome bias pathway and to really mitigate that. And I think we actually acknowledge when there is a potentially bad outcome involving patients, that we have to acknowledge that this is a factor in this investigation and we need to address that just as humans, like we are upset, we might be grieving and have empathy with the patient and the family or families that were involved.
Becky
Right. And the impact of the reputation and all that goes with that dynamic.
Terri
Yeah, that was a good question, Amanda. Thanks for asking that. I think, too, just because we are advocating for some compassion and some empathy doesn’t mean we are saying there shouldn’t be accountability and consequences. Right. So you can still try to get that person help and be empathetic for the fact that they do have a substance use disorder. They were not in control necessarily of what they were doing. It got very out of control that it got to the point where it was tampering and they may have to face those legal consequences, but that doesn’t have to take away the empathy piece of that interaction and working to try to get them some help as well. But you’re right, it’s hard to just like, oh, how could you do that?
Becky
I think I’ll add the importance of speaking to the individuals involved because I will say that you might have individuals who put patients harm away intentionally and that’s not what we see in these investigations. You see people with substance use disorders who are not wanting to cause harm. Right. It was a byproduct of the impact of their quality decisions. But you have to engage them. You can’t assume that what their intent was. I think that’s a critical piece to this process as well. You don’t get to answer all those questions on the algorithm. That’s not how it was intended and that’s not how it was designed. You have to actually talk to the individual involved to appreciate where they were coming from when they made those decisions.
Terri
And that goes back to don’t jump to any conclusions until you have gone through the entire thing because sometimes we’re surprised. Really surprised. Yeah. All right, this is great. Well, I want to thank you both for the discussion today. I think it was a great discussion. Thank you everybody for listening. Please hit that subscribe button. And I do want to thank our sponsor whose product line is an active deterrent to diversion to see IMI’s complete line of innovative tamper evident products and how they work. Check them out@imiweb.com you. Thank you, Amanda and Becky, for your time today.
