A Regulatory Model/Decision Tree for Collaboration
and Practice Accountability
Maryann Alexander, PhD, RN
Nancy Spector, PhD, RN
Maureen Cahill, MS, RN
Kathy Russell, JD, RN
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:
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Choices
Processes
Procedures
Training
Design
Environment
Console
© 2012
Manage through:
• Removing incentives
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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…
Just Culture
Examines the fallibility of the system as well as
inevitable human error and flawed behavioral
choices
• System
• Human Error
• Flawed decisions
Regulation
• Public Protection
• Holding systems and individuals accountable
for their actions
• Safer care for Patients
Regulatory Model
– Encourage reporting of errors so that systems,
processes and behaviors can be improved
– Collaborative/Partnership (Facility and BON and
Nurse and Facility)
– Centers around the patient
– Focus is on ethical behavior
– Encourages remediation
– Employs discipline where needed
 Accountability of Nurse
 Recognize Contributions of System Errors
 Patient Outcome Not Primary to BON Decision
 Boards and Employers Collaborate
 Use Reliable Tools to Evaluate Behaviors and
Systems
Regulatory Decision Model
Next Steps
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Volunteers
Try out the decision tree
Send us your feedback/comments
Feedback from Outcomengenuity
Develop a resource kit
Pilot the model/algorithm once completed
Our Goal
Help BONs make consistent decisions that
protect the public and lead to safer systems
and competent practitioners.