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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