Protecting the Public
through Disciplinary
Action
Maryann Alexander, PhD, RN, FAAN
Kathleen Russell, JD, RN
The Board’s Duty Is To
Protect The Public
Not
Punish The Licensee
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.
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
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)
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.
Punishment
 People tend to hide errors
 Prevents fixing the system
 Risk to patient
 Focus is on punishment
 Effective when used in the right way.
Questions
 When do we take no action?
 When do we counsel, remediate and
supervise?
 When do we punish/remove from practice?
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.
The Just Culture Model (simplified)
Human
Error
At-Risk
Behavior
Product of Our Current
System Design and
Behavioral Choices
A Choice: Risk Believed
Insignificant or Justified
Manage through
changes in:
•
•
•
•
•
•
Choices
Processes
Procedures
Training
Design
Environment
Console
© 2012
Manage through:
• Removing incentives
•
•
for at-risk behaviors
Creating incentives
for healthy behaviors
Increasing situational
awareness
Coach
Reckless
Behavior
Conscious Disregard of
Substantial and
Unjustifiable Risk
Manage through:
• Remedial action
• Punitive action
Punish
System versus Individual Errors
© 2012
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
Human Error
Human Error
 Can happen to high performers with no
history of past error
 Discipline may not prevent
 Remediation may not be needed
Risk-Taking Behavior
“Justifiable Risk”
Risk-Taking Behavior
 May need remediation/counseling
 May need discipline/supervision
Reckless
the police.
Reckless
 Discipline
 Remediation/supervision/counseling/job
transfer
The Just Culture Model (simplified)
Human
Error
At-Risk
Behavior
Product of Our Current
System Design and
Behavioral Choices
A Choice: Risk Believed
Insignificant or Justified
Manage through
changes in:
•
•
•
•
•
•
Choices
Processes
Procedures
Training
Design
Environment
Console
© 2012
Manage through:
• Removing incentives
•
•
for at-risk behaviors
Creating incentives
for healthy behaviors
Increasing situational
awareness
Coach
Reckless
Behavior
Conscious Disregard of
Substantial and
Unjustifiable Risk
Manage through:
• Remedial action
• Punitive action
Punish
The Just Culture Model
A Single Event
Repetitive Events
 Repetitive errors – yes,
there is a process
 Repetitive at-risk
behaviors – yes, there is
a process
 Both may lead to
disciplinary action…
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.
Deliberate Behavior
 Discipline
 May warrant permanent revocation of
license
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
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.
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