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Transcript of JUST CULTURE



Arthur Holly, Jr. Patient Safety & Just culture

The single greatest impediment to error prevention in the medical industry is :that we punish people for making mistakes.

Dr. Lucian LeapeProfessor, Harvard School of Public HealthTestimony before Congress on Health Quality Improvement

An introduction to just culture

What is Just Culture?The acknowledgement that all humans are destined to make mistakes, and destined to drift into at-risk behavioral choices, regardless of how well the system is designedShift of focus: from errors and outcomes to system design and behavioral choices.The Just culture community

Traditionally, health cares culture has held individuals accountable for all errors or mishaps that befall patients under their care A just culture recognizes that individual practitioners should not be held accountable for system failings over which they have no control. A just culture also recognizes many errors represent predictable interactions between human operators and the systems in which they work. Recognizes that competent professionals make mistakes. Acknowledges that even competent professionals will develop unhealthy norms (shortcuts, routine rule violations). A just culture has zero tolerance for reckless behavior.What do we mean by Just Culture?

Create a learning cultureRecognize risk at individual and organizational levelRisk is seen through events, near misses, and observations of system design and behavioral choices.Utilize FEEDBACK at an organizational levelDebrief after team events

Learning culture

Move away from overly punitive cultureStrike a middle ground between punitive and blame free cultures.AccountabilityProvide mutual supportUtilize CUS, (concerned, uncomfortable, safety issue)

Create an open and fair culture

Manage behavioral choicesDesign safe systemsApply situation awareness and provide mutual supportOn an individual level utilize STEP, Im SAFE, and hold yourself accountableEliminate No harm, No foul mentalityRecognize human fallibility

Human error: an inadvertent action. Slip, lapse, or mistake.At-Risk behavior: behavioral choice that increases risk where risk is not recognized or is mistakely believed to be justified.Reckless behavior: a behavioral choice to consciously disregard a substantial and unjustifiable riskManage behavioral Choices

Human Error is a social label. It may be characterized as follows

Human error is a term that we use to describe our everyday behavior-missing a turnoff on the freeway, or picking up strawberry ice cream instead of chocolate. The threshold for labeling behavior human error is very low- we make errors every day with generally minimal consequences. In the health care profession, we make similar types of errors- perhaps not at the frequency of those in our off-work hours, but often with much more potential for dire consequences. We use terms like mistake, slip and lapse to basically tell the same story-that someone did other than what they should have done, and inadvertently caused an undesirable outcome. When a physician prescribes the wrong dosage, we will likely label her actions a human error. We understand that the physician did not intend her error or its undesirable outcome even though the consequences are potentially life threatening.

Human Error

Negligence, at least in our social dialogue, is conduct subjectively more culpable than human error. Negligence, as a legal term, arises from both the civil (tort) and criminal liability systems. Negligence is the term generally used when an individual has been harmed by the healthcare system. A basic tenant of common law is that he who is negligent must pay for the resulting damages. In most states, negligence is defined as failure to exercise the skill, care, and learning expected of a reasonably prudent health care provider. Criminal negligence, as defined by the model penal code, involves objective determination that a person should have been aware that they were taking a substantial and unjustifiable risk toward causing an undesirable outcome.Negligent Conduct

Reckless conduct, alternatively referred to as gross negligence, involves a higher degree of culpability than negligence. Reckless conduct in both the civil liability and criminal systems involves conscious disregard of risk.5 Reckless conduct differs from negligent conduct in intent; negligence is the failure to recognize a risk that should have been recognized, while recklessness is a conscious disregard of a visible, significant risk. Consider the term reckless driving. For most of us, it connotes a much higher degree of culpability than mere human error.Reckless Conduct

Most rules, procedures, and duties will require or prohibit a specific behavior. The intentional rule violation occurs when an individual chooses to knowingly violate a rule while he is performing a task. This concept is not necessarily related to risk taking, but merely shows that an individual knew of or intended to violate a rule, procedure, or duty in the course of performing a task.Intentional Rule Violations

Human error: ConsoleAT Risk: Listen and coach supportive discussion with the employee on the need to engage in safe behavioral choices.Reckless: Discipline actions beyond remedial, up to and including punitive action or termination.How do we react?

To err is humanTo drift is humanRisk is everywhereWe must manage in support of our valuesWe are all accountableRisk management


In many organizations, values reflect desired behavior but are not reflected in observed behavior.What are your values?

SBARSituation what is going on?Background- what is the clinical background or context?Assessment- what do you think the problem is?Recommendation-What would I do to correct it?

CheckBackClose the loop as receiver accepts a message, sender double-checks to ensure message was received.What can we do?

What can we do? (cont.)

Use as a safety toolUse to evaluate events, near misses or risky behaviorUse to evaluate conduct when the behavior of the employee does not match the values of the organizationUse to assess system contributions and accountability

Just Culture Algorithm

Risk/QualityHelping improve the effectiveness of the learning processProviding tools to line managersHelping to redesign systems

HRProtecting the learning cultureHelping with managerial competenciesConsolingCoachingPunishing

Its about Reinforcing the Roles of Risk, Quality, and HR

Takes focus off of errors and outcomes And puts focus on the quality of system designand the quality behavioral choices puts it onsystems and behavioral choices Systematic and uniform process designedto support practiceA More Just Culture for Providers