Just Just Culture Culture Ahmad ThaninAhmad Thanin

Definition Definition

• It is refer to a safety-supportive system of shared accountability where health care organizations are accountable for the systems they have designed and for responding to the behaviors of their staffs in fair and just manners.

is there any possibility is there any possibility for error for error

Who we are going to Who we are going to blame?blame?

How do you describe this How do you describe this behavior?behavior?

Do you have comment? Do you have comment?

What is the difference?What is the difference?

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

• What can we do to prevent them What can we do to prevent them from happening again? from happening again?

• How do we judge the How do we judge the people involved?people involved?

How would your organization deal with ?

1- Wrong prescription from a doctor.

2- Ignoring the patient ring bell.

3- Nurse miss 2 dose antibiotics.

4- Giving fake lab result.

5- Sleeping on duty,

6- Pre-Documentation.

7- Leave duty without endorsement

The pastThe past• The culture of health care in

the past focuses on placing blame on healthcare providers whenever there was an error or bad outcomes occurred. With this kind of culture, health care providers were hesitant to report any errors due to fear of punishment. As a result such occurrences were never reported.

The present The present To improve reporting of errors,

organizations moved to blameless culture, however, this type of culture did not succeed due to lack of accountability and the practice did not promote a learning environment that promoted patient safety.

Today, the focus of health care is patient safety and “Just Culture” balances the assessment of systems, processes and human behavior when an error or event is reported.

Goal of Just CultureGoal of Just Culture

The goal of a “Just Culture” environment is to design safe systems that will reduce the opportunity for human error and capture errors before they reach the patient.

Safe systems should facilitate the staff to Safe systems should facilitate the staff to make good decisions and should make it make good decisions and should make it more difficult to make an error. However, it more difficult to make an error. However, it is up to individuals to manage their is up to individuals to manage their behaviors and choices.behaviors and choices.

The Just Culture ModelThe Just Culture Model

MissionMissionTo contribute to the health of our community through the provision of quality services delivered in a compassionate and cost effective manner. We collaborate with others in the community to improve the quality of life.

Values Values • Dignity • Collaboration• Justice• Stewardship• Excellence

Three basic duties Three basic duties Duty to produce an outcome. Duty to produce an outcome. If an individual knows the

desired outcome and should be able to produce it (e.g., safe removal of an inflamed appendix), failure to do so represents breach of this duty. Did the employee breach a duty to produce an outcome?

Duty to follow a procedural rule. Duty to follow a procedural rule. If the individual knows the proper procedure and it is possible to follow the rule (e.g., the procedure for inserting a central venous catheter), failure to do so represents a breach of this duty. Did the employee breach a duty to follow a procedural rule in a system designed by the employer?

Duty to avoid causing unjustifiable risk or harmDuty to avoid causing unjustifiable risk or harm. Breach of this duty occurs when an individual intentionally harms the patient or acts recklessly. Did the employee put an organizational interest or value in harm’s way?

BreechBreechOrganizations must recognize that humans make mistakes. It is

the behavior choices that must be manage. The behaviors to be expected when assessing an event are:

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

2. At-risk behavior –behavioral choice that increases risk where risk is not recognized or is mistakenly believed to be justified.

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

Consequences Consequences

Why should we put just Why should we put just culture into practice?culture into practice?

• There is a need to learn from accidents There is a need to learn from accidents and incidents through safety and incidents through safety investigation so as to take appropriate investigation so as to take appropriate action to prevent the repetition of such action to prevent the repetition of such events.events.

Human Errors Examples Human Errors Examples

At Risk Behavior At Risk Behavior

Reckless Behavior Reckless Behavior

Thank Thank YouYou