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...

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    A Just Culture It’s Role in Building a Better World

    Presented by David Marx CEO, Outcome Engenuity

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    We Build a Healthcare System

    The Principal Ground Rule: Primum non nocere

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    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?

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    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

    mistakes.”

    Dr. Lucian Leape Professor, Harvard School of

    Public Health

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    We Look for A Different Model:

    the Just Culture

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    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.

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    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.

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    The Just Culture Model (simplified)

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    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

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    • One method that works across all values • One method that works both pre- and post-event

    The Just Culture Algorithm

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    • 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