Just CultureJust Culture

Alison H. Page, MHA, MSNAlison H. Page, MHA, MSN

Chief Safety OfficerChief Safety Officer

Fairview Health ServicesFairview Health Services

We’ve all been there……We’ve all been there……

Medication errrorMedication errror

Failure to check Failure to check patient identificationpatient identification

Why did these accidents Why did these accidents happen?happen?

How what can we do to prevent How what can we do to prevent them from happening again? them from happening again?

How do we judge the How do we judge the clinicians involved?clinicians involved?

NONO harmful harmful outcomeoutcome

- 19% of staff19% of staff- 0% of managers0% of managers - 11% of executives11% of executives - 0% of physicians0% of physicians

Harmful Harmful outcomeoutcome

- 29% of staff29% of staff - 50% of managers50% of managers - 14% of executives14% of executives - 45% of physicians45% of physicians

How would you organization deal with a surgeon who used an unauthorized piece of equipment?

Percentage of those who believe Fairview would discipline the surgeon….if:

We can do two things:We can do two things:

1. Design systems to 1. Design systems to accommodate human accommodate human

beingsbeings

2. Manage human behavior 2. Manage human behavior within the systemswithin the systems

NAVAL AVIATION MISHAP RATE

776 aircraftdestroyed in

1954FY 50-96FY 50-96

Fiscal Year

2.39

39 aircraftdestroyed in

1996

0

10

20

30

40

50

60

50 65 80 96

Angled Carrier Decks

Naval Aviation Safety Center

NAMP est. 1959

RAG concept initiated

NATOPS initiated 1961

Squadron Safety program

System Safety Designated Aircraft

ACT

HFC’s

Cla

ss A

Mis

hap

s/10

0,00

0 F

ligh

t H

ours

Managing SystemsManaging Systems

““Systems produce Systems produce precisely the outcomes precisely the outcomes they are designed for.”they are designed for.”

Don BerwickDon Berwick

EpinephrineEpinephrineEphedrineEphedrine

DopamineDopamineDobutamineDobutamine

EPInephrineEPInephrineEPHEDrineEPHEDrine DOPamine DOPamine

DoBUTamineDoBUTamine

Seven Design Strategies Important to Managing Risk

• Knowledge• Skill• Performance Shaping Factors• Barriers• Redundancy• Recovery• Perception of High Risk

Managing human Managing human behavior is behavior is a bit harder.a bit harder.

Why?Why?

Because – to error is humanBecause – to error is human

Parisin the

the spring

Nominal Human Error RatesNominal Human Error Rates

0.25General error in high stress when dangerous activities occurring rapidly

0.1Personnel on different shifts fail to check hardware unless required by checklist

0.1Monitor or inspector fails to detect error

0.03Simple math error with self-checking

0.003Error of omission when items imbedded in a procedure

0.01Error of omission without reminders

0.003Error of commission (misreading a label)

ProbabilityActivity

Salvendy G. Handbook of human factors & ergonomics 1997.

Aoccdrnig to rscheearch at Aoccdrnig to rscheearch at Cmabrigde Uinervtisy, Cmabrigde Uinervtisy,

it deosn't mttaer inwaht oredr the ltteers in it deosn't mttaer inwaht oredr the ltteers in a wrod are, the olny iprmoetnt tihng is thata wrod are, the olny iprmoetnt tihng is that

the frist and lsat ltteer be at the rghit the frist and lsat ltteer be at the rghit pclae. The rset can be a totalpclae. The rset can be a totalmses and you can sitll raed it mses and you can sitll raed it

wouthit porbelm. Tihs is bcuseae the wouthit porbelm. Tihs is bcuseae the huamn mnid deos not raed ervey lteter by huamn mnid deos not raed ervey lteter by

istlef, but the wrod as awlohe.istlef, but the wrod as awlohe.

The human brain cannot The human brain cannot have multiple simultaneous have multiple simultaneous foci of interest. This lack of foci of interest. This lack of

cognitive resource is the cognitive resource is the single limiting factor of single limiting factor of

human activity.human activity.

Francois ClergueFrancois Clergue

Lessons from Human Factors Lessons from Human Factors ResearchResearch

Errors are commonErrors are common The causes of errors are knownThe causes of errors are known Errors are byproducts of useful Errors are byproducts of useful

cognitive functionscognitive functions

Lessons from Human Factors Lessons from Human Factors ResearchResearch

Many errors are caused by activities Many errors are caused by activities that rely on weak aspects of that rely on weak aspects of cognitioncognition short-term memoryshort-term memory attention spanattention span

Errors can be prevented by designing Errors can be prevented by designing tasks and processes that minimize tasks and processes that minimize dependency on weak cognitive dependency on weak cognitive functionsfunctions

Human Factors Principles & Human Factors Principles & Systems DesignSystems Design

Avoid reliance on memory and Avoid reliance on memory and vigilancevigilance Use protocols and checklistsUse protocols and checklists

SimplifySimplify StandardizeStandardize Use constraints and forcing Use constraints and forcing

functionsfunctions

Human Factors Principles & Human Factors Principles & Systems DesignSystems Design

Improve access to informationImprove access to information Make potential errors obvious Make potential errors obvious Increase feedbackIncrease feedback

Reduce hand-offsReduce hand-offs Decrease look-alikesDecrease look-alikes

Automate very carefullyAutomate very carefully

““We can’t change the human We can’t change the human condition, but we can change condition, but we can change

the conditions under which the conditions under which humans work”humans work”

James ReasonJames Reason

However….However….

Humans Humans areare accountable accountable for their behavioral choicesfor their behavioral choices

Just CultureJust Culture

www.justculture.orgwww.justculture.org

Just Culture is about:Just Culture is about:

Creating an open, Creating an open, fair, and just culturefair, and just culture

Creating a learning Creating a learning cultureculture

Designing safe Designing safe systemssystems

Managing Managing behavioral choicesbehavioral choices

AdverseEvents

HumanErrors

Managerialand Staff

Behaviors

SystemDesign

Learning Culture / Just Culture

outcome engineeringdallas, txwww.outcome-eng.comcopyright 2005

In its 1999 report, “To Err is Human,” the Institute of Medicine reported that 44,000 to 98,000 individuals lose their lives to medical error in our nation’s hospitals every year.

Now, in addition to creating a healthcare delivery system that is more patient-centered, timely, efficient, equitable, and effective, we have been challenged to improve the safety of our nation’s healthcare system.

It has been said that every system is designed to achieve exactly the results it gets. In other words, we are getting the rate of accidental (iatrogenic) injury commensurate with the system we have built. To make a substantial step in patient safety, we must change the healthcare system.

This worksheet illustrates one critical element of that fundamental change - the creation of a more open, fair, and just culture. It is through a just culture that we will begin to see, understand, and mitigate the risks within the healthcare system.

Create a Learning Culture…A learning culture is the foundation of patient safety. It is a culture that is hungry for knowledge - in the case of patient safety it is a culture that is hungry to see risk, both at the

individual and organizational level. Risk can be seen through events, near misses, or merely by observing the

design of the systems in which we work, our own behaviors, and the behaviors of those around us.

Adverse Events

HumanErrors

Managerial and Staff Behaviors

System Design

Learning Culture / Just Culture

Create an Open, Fair and Just Culture…

To create a learning environment, organizations must move away from an overly-punitive reaction to events and

errors. We must instead recognize our own fallibility - that we will make errors

and that we will drift away from what we have been taught.

Design Safe Systems…The first cornerstone of patient safety is the

design of safe systems. It is the system in which we work that has the greatest overall influence on

the safety of the patient. We must design systems that anticipate human error, capture errors before they become critical, and permit recovery when errors do reach the patient.

Manage Behavioral Choices...The second cornerstone of patient safety is the management of behavioral choices. While we must anticipate that we as humans will make mistakes - it is our management of behavioral choices that will allow us to achieve the safety

outcomes we desire.

This document is not self-explanatory. It is to be used as an aid in the Safe Choices course.

Managing for Safety Using Just Culture

Managing for Safety Using Just Culture

outcome engineeringdallas, txwww.outcome-eng.comcopyright 2005

In its 1999 report, “To Err is Human,” the Institute of Medicine reported that 44,000 to 98,000 individuals lose their lives to medical error in our nation’s hospitals every year.

Now, in addition to creating a healthcare delivery system that is more patient-centered, timely, efficient, equitable, and effective, we have been challenged to improve the safety of our nation’s healthcare system.

It has been said that every system is designed to achieve exactly the results it gets. In other words, we are getting the rate of accidental (iatrogenic) injury commensurate with the system we have built. To make a substantial step in patient safety, we must change the healthcare system.

This worksheet illustrates one critical element of that fundamental change - the creation of a more open, fair, and just culture. It is through a just culture that we will begin to see, understand, and mitigate the risks within the healthcare system.

Adverse Events

HumanErrors

Managerial and Staff Behaviors

System Design

Learning Culture / Just Culture

Create an Open, Fair and Just Culture…To create a learning environment, organizations must move away from an overly-punitive reaction to events and errors. We must instead recognize our own fallibility - that we will make errors and that we will drift away from what we have

been taught.

Design Safe Systems…The first cornerstone of patient safety is the

design of safe systems. It is the system in which we work that has the greatest overall influence on

the safety of the patient. We must design systems that anticipate human error, capture errors before they become critical, and permit recovery when errors do reach the patient.

Manage Behavioral Choices...The second cornerstone of patient safety is the management of behavioral choices. While we must anticipate that we as humans will make mistakes - it is our management of behavioral choices that will allow us to achieve the safety

outcomes we desire.

This document is not self-explanatory. It is to be used as an aid in the Safe Choices course.

Create a Learning Culture…A learning culture is the foundation of patient

safety. It is a culture that is hungry for knowledge - in the case of patient safety it is a culture that is hungry to see risk, both at

the individual and organizational level. Risk can be seen through events, near misses, or

merely by observing the design of the systems in which we work, our own

behaviors, and the behaviors of those around us.

outcome engineeringdallas, txwww.outcome-eng.comcopyright 2005

Managing for Safety Using Just Culture

In its 1999 report, “To Err is Human,” the Institute of Medicine reported that 44,000 to 98,000 individuals lose their lives to medical error in our nation’s hospitals every year.

Now, in addition to creating a healthcare delivery system that is more patient-centered, timely, efficient, equitable, and effective, we have been challenged to improve the safety of our nation’s healthcare system.

It has been said that every system is designed to achieve exactly the results it gets. In other words, we are getting the rate of accidental (iatrogenic) injury commensurate with the system we have built. To make a substantial step in patient safety, we must change the healthcare system.

This worksheet illustrates one critical element of that fundamental change - the creation of a more open, fair, and just culture. It is through a just culture that we will begin to see, understand, and mitigate the risks within the healthcare system.

Create a Learning Culture…A learning culture is the foundation of patient safety. It is a culture that is hungry for knowledge - in the case of patient safety it is a culture that is hungry to see risk, both at the

individual and organizational level. Risk can be seen through events, near misses, or merely by observing the

design of the systems in which we work, our own behaviors, and the behaviors of those around us.

Adverse Events

HumanErrors

Managerial and Staff Behaviors

System Design

Learning Culture / Just Culture

Create an Open, Fair and Just Culture…To create a learning environment, organizations must move away from an overly-punitive reaction to events and errors. We must instead recognize our own fallibility - that we will make errors and that we will drift away from what we have

been taught.

Design Safe Systems…The first cornerstone of patient safety

is the design of safe systems. It is the system in which we work that has the greatest overall influence on the

safety of the patient. We must design systems that anticipate human error, capture errors before they become critical, and permit recovery when

errors do reach the patient.

Manage Behavioral Choices...The second cornerstone of patient safety is the management of behavioral choices. While we must anticipate that we as humans will make mistakes - it is our management of behavioral choices that will allow us to achieve the safety

outcomes we desire.

This document is not self-explanatory. It is to be used as an aid in the Safe Choices course.

outcome engineeringdallas, txwww.outcome-eng.comcopyright 2005

In its 1999 report, “To Err is Human,” the Institute of Medicine reported that 44,000 to 98,000 individuals lose their lives to medical error in our nation’s hospitals every year.

Now, in addition to creating a healthcare delivery system that is more patient-centered, timely, efficient, equitable, and effective, we have been challenged to improve the safety of our nation’s healthcare system.

It has been said that every system is designed to achieve exactly the results it gets. In other words, we are getting the rate of accidental (iatrogenic) injury commensurate with the system we have built. To make a substantial step in patient safety, we must change the healthcare system.

This worksheet illustrates one critical element of that fundamental change - the creation of a more open, fair, and just culture. It is through a just culture that we will begin to see, understand, and mitigate the risks within the healthcare system.

Create a Learning Culture…A learning culture is the foundation of patient safety. It is a culture that is hungry for knowledge - in the case of patient safety it is a culture that is hungry to see risk, both at the

individual and organizational level. Risk can be seen through events, near misses, or merely by observing the

design of the systems in which we work, our own behaviors, and the behaviors of those around us.

Adverse Events

HumanErrors

Managerial and Staff Behaviors

System Design

Learning Culture / Just Culture

Create an Open, Fair and Just Culture…To create a learning environment, organizations must move away from an overly-punitive reaction to events and errors. We must instead recognize our own fallibility - that we will make errors and that we will drift away from what we have

been taught.

Design Safe Systems…The first cornerstone of patient safety is the

design of safe systems. It is the system in which we work that has the greatest overall influence on

the safety of the patient. We must design systems that anticipate human error, capture errors before they become critical, and permit recovery when errors do reach the patient.

Manage Behavioral Choices...The second cornerstone of patient

safety is the management of behavioral choices. While we must anticipate that we as humans will make mistakes - it is our management of behavioral choices that will allow us to achieve the safety

outcomes we desire.

This document is not self-explanatory. It is to be used as an aid in the Safe Choices course.

Managing for Safety Using Just Culture

A Model that Focuses on Three Duties A Model that Focuses on Three Duties balanced against Organizational and balanced against Organizational and

Individual ValuesIndividual Values The Three DutiesThe Three Duties

The duty to avoid The duty to avoid causing unjustified causing unjustified risk or harmrisk or harm

The duty to produce The duty to produce an outcomean outcome

The duty to follow a The duty to follow a procedural ruleprocedural rule

Organizational and Organizational and Individual ValuesIndividual Values SafetySafety CostCost EffectivenessEffectiveness EquityEquity DignityDignity etcetc

Two Specific Classes of Duty

• Meet me at 7:00 pm at 410 Chestnut Street

• Leave the house at 6:45 pm. Go south on Independence Ave, turn right on Parker. At the third light, hang a left, go three blocks, turn right and go to the fourth house on the right.

The Duty to Produce an Outcome

The Duty to Follow a

Procedural Rule

We know….to error is HumanWe know….to error is Human

But….To Drift is also Human

Managing Behavioral Choices:Managing Behavioral Choices:Everyone Takes Risks, Every DayEveryone Takes Risks, Every Day

RISKSOCIAL UTILITY

The Behaviors We Can ExpectThe Behaviors We Can Expect

Human errorHuman error - inadvertent action; - inadvertent action; inadvertently doing other that what should inadvertently doing other that what should have been done; slip, lapse, mistake.have been done; slip, lapse, mistake.

At-risk behaviorAt-risk behavior - behavior that - behavior that increases risk where risk is not recognized, increases risk where risk is not recognized, or is mistakenly believed to be justified.or is mistakenly believed to be justified.

Reckless behaviorReckless behavior - behavioral choice to - behavioral choice to consciously disregard a substantial and consciously disregard a substantial and unjustifiable risk.unjustifiable risk.

ExamplesExamples

Failure to check the name bandFailure to check the name band

Accountability for our Behavioral Accountability for our Behavioral ChoicesChoices

RecklessBehavior

Intentional Risk-Taking

Manage through: • Remedial action• Disciplinary action

At-RiskBehavior

Unintentional Risk-Taking

HumanError

Product of our current system design

Manage through changes in:

• Processes• Procedures• Training• Design• Environment

Console Coach Punish

Manage through:

• Removing incentives for at-risk behaviors

• Creating incentives for healthy behaviors

• Increasing situational awareness

Managing Human Error

• Two questions:– Did the employee make the correct behavioral

choices in their task?– Is the employee effectively managing their own

performance shaping factors?• If yes, the only answer is to console the employee –

the error happened to him / her

Managing Multiple Human Errors

What is the source of a pattern of human errors?– The system? If yes, address the system.– If no, can the repetitive errors be addressed

through non-disciplinary means?– If no, how will disciplinary sanction reduce the

rate of human error?

Managing At-Risk Behaviors

• A behavioral choice– Driven by perception of consequences

• Immediate and certain consequences are strong

• Delayed and uncertain consequences are weak

• Rules are generally weak

Managing At-Risk Behaviors

• A behavioral choice– Managed by adding forcing functions (barriers to

prevent non-compliance)– Managed by changing perceptions of risk– Managed by changing consequences– Coaching

Why not punish “at-risk” Why not punish “at-risk” behavior?behavior?

Because….Because….

1.1. Somewhere along the line your Somewhere along the line your organization has likely tacitly approved organization has likely tacitly approved certain at-risk behaviors. certain at-risk behaviors.

2.2. If you punish at-risk behavior people will If you punish at-risk behavior people will likely not be honest about the at-risk likely not be honest about the at-risk behavior next timebehavior next time

Who judges risk and behaviors?

• Risk = Severity x Likelihood• Safety ~ Reasonableness of Risk

Managing Reckless Behavior

• Reckless Behavior– Conscious disregard of substantial

and unjustifiable risk

• Manage through:– Disciplinary action

Managing Behavioral ChoicesManaging Behavioral Choices

RecklessBehavior

Intentional Risk-Taking

Manage through: • Remedial action• Disciplinary action

At-RiskBehavior

Unintentional Risk-Taking

HumanError

Product of our current system design

Manage through changes in:

• Processes• Procedures• Training• Design• Environment

Console Coach Punish

Manage through:

• Removing incentives for at-risk behaviors

• Creating incentives for healthy behaviors

• Increasing situational awareness

Doves and HawksDoves and Hawks

SummarySummary

What is a JUST CULTURE What is a JUST CULTURE about?about?

It’s About a Proactive It’s About a Proactive Learning CultureLearning Culture

It’s not seeing It’s not seeing events as things to events as things to be fixedbe fixed

It’s seeing It’s seeing events as events as opportunities to opportunities to improve our improve our understanding understanding of riskof risk System risk, and System risk, and Behavioral riskBehavioral risk

It’s About Reinforcing the Roles of It’s About Reinforcing the Roles of Risk, Quality, and HRRisk, Quality, and HR

Risk/QualityRisk/Quality Helping improve Helping improve

the effectiveness the effectiveness of the learning of the learning processprocess

Providing tools to Providing tools to line managersline managers

Helping to redesign Helping to redesign systemssystems

HRHR Protecting the Protecting the

learning culturelearning culture Helping with Helping with

managerial managerial competenciescompetencies

ConsolingConsoling CoachingCoaching Corrective ActionCorrective Action

It’s About Changing Managerial It’s About Changing Managerial ExpectationsExpectations

Knowing my risksKnowing my risks Investigating the source of errors and at-Investigating the source of errors and at-

risk behaviorsrisk behaviors Turning events into an understanding of Turning events into an understanding of

riskrisk Designing safe systemsDesigning safe systems Facilitating safe choicesFacilitating safe choices

ConsolingConsoling CoachingCoaching PunishingPunishing

It’s About Changing Staff ExpectationsIt’s About Changing Staff Expectations

Looking for the risks around meLooking for the risks around me Reporting errors and hazardsReporting errors and hazards Helping to design safe systemsHelping to design safe systems Making safe choicesMaking safe choices

Following procedureFollowing procedure Making choices that align with Making choices that align with

organizational valuesorganizational values Maintaining situational awarenessMaintaining situational awareness

A Shared Conceptual ModelA Shared Conceptual Model

RecklessBehavior

Intentional Risk-Taking

Manage through: • Remedial action• Disciplinary action

At-RiskBehavior

Unintentional Risk-Taking

HumanError

Product of our current system design

Manage through changes in:

• Processes• Procedures• Training• Design• Environment

Console Coach Punish

Manage through:

• Removing incentives for at-risk behaviors

• Creating incentives for healthy behaviors

• Increasing situational awareness

An Algorithm to FollowAn Algorithm to Follow

Common Common languagelanguage

Common Common conversationconversation

The Just Culture AlgorithmThe Just Culture Algorithm

The analytical heart of the Just Culture is the Just Culture Algorithm™. It will serve as a guide when managers address employees whose behaviors do not align with organizational values or procedural rules. Developed around the Three Duties, the Algorithm provides both the organization and the employee a method to ensure that breaches in the system will be dealt with in a consistent manner throughout the organization. The Algorithm is the answer key for what to do when things go wrong.

Available at: https://www.justculture.org/store

We need…..We need…..

A culture that truly supports learningA culture that truly supports learning

A common understanding about how to treat people A common understanding about how to treat people when things happenwhen things happen

The Chain of Effect in Improving Health Care Quality

Patient and Community Experience Aims: Safe, timely,effective, efficient, equitable,and patient-centered

Microsystem Process Simple rules/Design concepts:(e.g. cardiac team) (e.g. knowledge-based,

customized, cooperation)

Organizational Context Facilitator Design Concepts:(e.g. hospital) of Processes (e.g HR, IT, Leadership)

Environmental Context Facilitator Design Concepts:(e.g. legislature) of facilitators (e.g. Legistaion, regulation,

accreditation, education)

The Minnesota AgendaThe Minnesota Agenda Formation of a stakeholder group - The Minnesota Formation of a stakeholder group - The Minnesota

Alliance for Patient SafetyAlliance for Patient Safety Change state lawChange state law Developed principles of justice, learning and Developed principles of justice, learning and

accountabilityaccountability Change the policies and practices of:Change the policies and practices of:

The BoardsThe Boards The Dept of HealthThe Dept of Health Delivery systemsDelivery systems

Our GoalOur Goal

The behavior of people involved in care The behavior of people involved in care delivery in the state of Minnesota will be delivery in the state of Minnesota will be judged using a common philosophy and a judged using a common philosophy and a common set of principles across healthcare common set of principles across healthcare organizations, the Department of Health, organizations, the Department of Health, the professional boards and professional the professional boards and professional associationsassociations

Minnesota Statement of Minnesota Statement of SupportSupport

Given that:Given that: Medical errors and patient safety are a Medical errors and patient safety are a

national concern to all involved in health national concern to all involved in health care delivery.care delivery.

We are legally and/or ethically obligated to We are legally and/or ethically obligated to hold individuals accountable for their hold individuals accountable for their competency and behaviors that impact competency and behaviors that impact patient care.patient care.

A punitive environment does not fully take A punitive environment does not fully take into account system issues, and a blame-into account system issues, and a blame-free environment does not hold individuals free environment does not hold individuals appropriately accountableappropriately accountable

We resolve that our organization will:We resolve that our organization will:

Strive for a culture that balances the need Strive for a culture that balances the need for a non-punitive learning environment for a non-punitive learning environment with the equally important need to hold with the equally important need to hold persons accountable for their actions.persons accountable for their actions.

Seek to judge the behavior, not the Seek to judge the behavior, not the outcome, distinguishing between human outcome, distinguishing between human error, at-risk behavior, and intentional error, at-risk behavior, and intentional reckless behavior. reckless behavior.

Foster a learning environment that Foster a learning environment that encourages the identification and review of encourages the identification and review of all errors, near-misses, adverse events, all errors, near-misses, adverse events, and system weaknesses.and system weaknesses.

Promote the use of a wide range of responses to Promote the use of a wide range of responses to safety-related events caused by lapses in human safety-related events caused by lapses in human behavior, including coaching, non-disciplinary behavior, including coaching, non-disciplinary counseling, additional education or training, counseling, additional education or training, demonstration of competency, additional demonstration of competency, additional supervision and oversight and disciplinary action supervision and oversight and disciplinary action when appropriate to address performance issues.when appropriate to address performance issues.

Support and implement systems that enable safe Support and implement systems that enable safe behavior to prevent harmbehavior to prevent harm

Work to share information across organizations to Work to share information across organizations to promote continuous improvement and ensure the promote continuous improvement and ensure the highest level of patient and staff safety. highest level of patient and staff safety.

Collaborate in efforts to establish a statewide Collaborate in efforts to establish a statewide culture of learning, justice, and accountability to culture of learning, justice, and accountability to provide the safest possible environment for provide the safest possible environment for patients. patients.