Patient Safety and the "Just Culture"

Patient Safetyand the“Just Culture”David Marx, JDPresident, Outcome Engineering, LLC2007Copyright 2007, Outcome Engineering, LLC. All rights reserved.

Agenda• What is Just Culture?• The Safety Task• The Just Culture Model• Statewide InitiativesCopyright 2007, Outcome Engineering, LLC. All rights reserved.

Copyright 2007, Outcome Engineering, LLC. All rights reserved.What is a “Just Culture?”

An Introduction to Just CultureThe single greatest impediment toerror prevention in the medical industry is“that we punish people formaking mistakes.”Dr. Lucian LeapeProfessor, Harvard School of Public HealthTestimony before Congress onHealth Care Quality ImprovementCopyright 2007, Outcome Engineering, LLC. All rights reserved.

An Introduction to Just Culture“There are activities in which the degree ofprofessional skill which must be required is sohigh, and the potential consequences of thesmallest departure from that high standard areso serious, that one failure to perform inaccordance with those standards is enough tojustify dismissal.”Lord DenningEnglish JudgeCopyright 2007, Outcome Engineering, LLC. All rights reserved.

An Introduction to Just Culture“People make errors, which lead to accidents.Accidents lead to deaths. The standard solutionis to blame the people involved. If we find outwho made the errors and punish them, we solvethe problem, right? Wrong. The problem isseldom the fault of an individual; it is the fault ofthe system. Change the people without changingthe system and the problems will continue.”Don NormanAuthor, the Design of Everyday ThingsCopyright 2007, Outcome Engineering, LLC. All rights reserved.

An Introduction to Just Culture“…No person may operate an aircraftin a careless or reckless mannerso as to endangerthe life or property of another.”Federal Aviation Regulations§ 91.13 Careless or Reckless OperationCopyright 2007, Outcome Engineering, LLC. All rights reserved.

An Introduction to Just Culture“As far as I am concerned, when I say “careless” I am not talkingabout any kind of “reckless” operation of an aircraft, but simplythe most basic form of simple human error or omission that theBoard has used in these cases in its definition of“carelessness.” In other words, a simple absence of the duecare required under the circumstances, that is, a simple act ofomission, or simply“ordinary negligence,” a human mistake.”National Transportation Safety BoardAdministrative Law JudgeEngen v. Chambers and LangfordCopyright 2007, Outcome Engineering, LLC. All rights reserved.

The Problem StatementWhat system ofaccountability bestsupports systemsafety?SupportofSystemSafetyAs applied to:• Providers• Managers• Healthcare Institutions• RegulatorsBlame-FreeCulturePunitiveCultureCopyright 2007, Outcome Engineering, LLC. All rights reserved.

Copyright 2007, Outcome Engineering, LLC. All rights reserved.The Safety Task

Managing System ReliabilityDesign forSystem Reliability…100%SystemFailureSystem ReliabilitySuccessfulOperation• Human factors design toreduce the rate of error• Barriers to prevent failure• Recovery to capturefailures before theybecome critical• Redundancy to limit theeffects of failure0%PoorGoodFactors Affecting System Performance… knowing that systems will never be perfectCopyright 2007, Outcome Engineering, LLC. All rights reserved.

Managing Human ReliabilityDesign forHuman Reliability…100%HumanErrorHuman Reliability• Information• Equipment/Tools• Design/Configuration• Job/Task• Qualifications/Skills• Perception of Risk• Individual Factors• Environment/Facilities• Organizational Environment• Supervision• Communication0%PoorSuccessfulOperationFactors Affecting Human PerformanceGood… knowing humans will never be perfectCopyright 2007, Outcome Engineering, LLC. All rights reserved.

Copyright 2007, Outcome Engineering, LLC. All rights reserved.The Just Culture Model

A Model that Focuses on Three Duties balancedagainst Organizational and Individual Values• The Three Duties– The duty to avoid causingunjustified risk or harm– The duty to produce anoutcome– The duty to follow aprocedural rule• Organizational andIndividual Values– Safety– Cost– Effectiveness– Equity– Dignity– etcCopyright 2007, Outcome Engineering, LLC. All rights reserved.

The Behaviors We Can Expect• Human error - inadvertent action; inadvertently doingother that what should have been done; slip, lapse,mistake.• At-risk behavior – behavioral choice that increasesrisk where risk is not recognized or is mistakenlybelieved to be justified.• Reckless behavior - behavioral choice to consciouslydisregard a substantial and unjustifiable risk.Copyright 2007, Outcome Engineering, LLC. All rights reserved.

ExampleA nurse is going to administer a medication to a baby in theneonatal ICU. The ICU has an automated dispensing system.The automated dispensing system opens a drawer with fourbins. As he has always done, he reached into the second binwhere the vial of medication is, confirms the blue cap on the vial,grabs the medication and takes it to deliver the medication. Atno time in the process did the nurse actually confirm themedication label, instead relying on the medication’s location inthe dispensing system and color of the cap to confirm the correctmedication. In this case, pharmacy had dispensed the wrongdose in the dispensing system.Copyright 2007, Outcome Engineering, LLC. All rights reserved.

Accountability for Our BehaviorsHumanErrorAt-RiskBehaviorRecklessBehaviorInadvertent action: slip, lapse,mistakeA choice: risk not recognized orbelieved justifiedConscious disregard ofunreasonable riskManage through changes in:Manage through:Manage through:ProcessesProceduresTrainingemoving incentives for At-Risk Behaviorsreating incentives forhealthy behaviorsRemedial actionPunitive actionDesignncreasing situationalawarenessEnvironmentConsole Coach PunishCopyright 2007, Outcome Engineering, LLC. All rights reserved.

Just Culture is about:AdverseEvents• Creating an open, fair,and just culture• Creating a learningcultureHumanErrors• Designing safe systems• Managing behavioralchoicesSystemDesignManagerialand StaffChoicesLearning Culture / Just CultureCopyright 2007, Outcome Engineering, LLC. All rights reserved.

It’s About a Proactive Learning Culture• It’s not seeing events asthings to be fixed• It’s seeing events asopportunities to improveour understanding of risk– System risk, and– Behavioral riskWhere management decisionsare based upon where our limitedresources can be applied tominimize the risk of harm,knowing our system is comprisedof sometimes faulty equipment,imperfect processes, and falliblehuman beingsCopyright 2007, Outcome Engineering, LLC. All rights reserved.

It’s About Reinforcing the Roles of Risk,Quality, and HR• Risk/Quality– Helping improve theeffectiveness of thelearning process– Providing tools to linemanagers– Helping to redesignsystems• HR– Protecting the learningculture– Helping with managerialcompetencies• Consoling• Coaching• PunishingCopyright 2007, Outcome Engineering, LLC. All rights reserved.

It’s About Changing Managerial Expectations• Knowing my risks– Investigating the source of errors and at-riskbehaviors– Turning events into an understanding of risk• Designing safe systems• Facilitating safe choices– Consoling– Coaching– PunishingCopyright 2007, Outcome Engineering, LLC. All rights reserved.

It’s About Changing Staff Expectations• Looking for the risks around me• Reporting errors and hazards• Helping to design safe systems• Making safe choices– Following procedure– Making choices that align with organizational values– Never signing for something that was not doneCopyright 2007, Outcome Engineering, LLC. All rights reserved.

Copyright 2007, Outcome Engineering, LLC. All rights reserved.Statewide Initiatives

Statewide Initiatives• A willingness of stakeholders to work together– Individual providers– Healthcare organizations– Professional boards– Departments of health• One model of shared accountability– Protecting the learning culture– Safety-supportive accountabilityCopyright 2007, Outcome Engineering, LLC. All rights reserved.

An Algorithm to Follow• One methodthat worksacross allvalues• One methodthat works bothpre and posteventCopyright 2007, Outcome Engineering, LLC. All rights reserved.

Doves and Hawks – Who are we?Copyright 2007, Outcome Engineering, LLC. All rights reserved.

Thank YouDavid Marx, JDdmarx@outcome-eng.comwww.justculture.org972-618-3600Copyright 2007, Outcome Engineering, LLC. All rights reserved.