A Just Culture - NYSPFP · PDF file NYSPFP Culture and Leadership Webconference: Just Culture...
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Transcript of A Just Culture - NYSPFP · PDF file NYSPFP Culture and Leadership Webconference: Just Culture...
A Just Culture It’s Role in Building a Better World
Presented by David Marx CEO, Outcome Engenuity
We Build a Healthcare System
The Principal Ground Rule: Primum non nocere
We Decide its not Working
• 44,000 to 98,000 preventable deaths per year
• 1+ million injuries
…the eighth leading cause of death in the US?
Experts Decide Healthcare Too Punitive!
• AHRQ survey looks at internal organizational culture – Sees punitive culture as a
deterrent to open reporting, patient safety
• We see additional problems: – A general inability to learn from
events – The expectation of system
perfection – The expectation of personal
perfection – No harm, no foul
The single greatest impediment to
error prevention in the medical industry is “that we punish people for making
Dr. Lucian Leape Professor, Harvard School of
We Look for A Different Model:
the 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.
Our Inescapable Fallibility
• Human Error - inadvertent action; inadvertently doing other that what should have been done; slip, lapse, mistake.
• At-Risk Behavior – behavioral choice that increases risk where risk is not recognized or is mistakenly believed to be justified.
• Reckless Behavior - behavioral choice to consciously disregard a substantial and unjustifiable risk.
The Just Culture Model (simplified)
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…
The Just Culture Model
• One method that works across all values • One method that works both pre- and post-event
The Just Culture Algorithm
• It’s About Both Error and Drift • It’s About Both Pre- and Post-Event • It’s About Executive Commitment • It’s About Values and Expectations • It’s About System Design and Behavioral Choices • It’s For All Employees • It’s About Partnership With the Regulator • It’s About Doing the Right Thing • It’s About Producing Better Outcomes Together
Slide Number 1 We Build a Healthcare System We Decide its not Working Experts Decide Healthcare Too Punitive! We Look for A Different Model: Slide Number 6 Our Inescapable Fallibility Slide Number 8 Slide Number 9 The Just Culture Algorithm Slide Number 11