A Culture of Safety/Just Culture

Introduction The Past The Present 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. 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.

What is “Just Culture” The term “Just Culture” refers 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. Staff, in turn, is accountable for the quality of their choices and for reporting both their errors and system vulnerabilities.

Goal 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 make good decisions and should make it more difficult to make an error. However, it is up to individuals to manage their behaviors and choices.

Just Culture Environment “Just Culture” is an environment where negligence is identified and discipline is applied appropriately after a systematic review of the error. To ensure a fair and just process, an established set of objective questions follow an algorithm to identify if the error occurred due to a system or process issue and/or due to human error. Staff is held accountable for their actions or behaviors. Staff is held blameless when there is a system or process that allowed the error to happen.

Just Culture Environment “Just Culture” environment recognizes that competent professionals make mistakes and acknowledges that even competent professionals will develop unhealthy norms (shortcuts, “routine rule violations”), but has zero tolerance for reckless behavior. “Just Culture” supports a learning culture and focuses on proactive management of system design and management of behavioral choices.

Just Culture An objective model for dealing with human errors and breeches Decision paths for allocating responsibility to either the system or the individual Based upon duty Not based upon severity of outcome

Just Culture Foundational Assumption About Risk: Humans will make errors and drift into at-risk behaviors as they become comfortable with processes Risk is managed by monitoring and measuring errors Judged using our values against what another reasonable person in a similar situation would do

Just Culture http://www.youtube.com/watch?v=2UzdKkLTphE You can embed the movie, David Marx Introduces the Just Culture, on this slide. A brief 2 minute overview of Just Culture from it’s founders.

The Just Culture Model Mission and Values Duty Breach Consequence Our reason for being… As individuals… Why do we come together as a group? Values: we must respect our values. We have 5 corporate values and many supporting values such as privacy and safety. Duty What we expect of each other and what we sign on for at hire when we agree to abide by policies, service standards, etc. We expect a lot and at times it seems like we expect perfection. However, we are inescapably fallible human beings and we live in a world of an imperfect systems. Relative to the mission Relative to values Procedures, processes Breach Failure to fulfill a duty By mistake By choice Without even knowing Consequence Our response to breach. Specific Deterrence, General deterrence, Incapacitation, Rehabilitation, Retribution. We must create realistic expectations for our organization to be successful. Consequence Days 1-3

The Just Culture Model: Mission/Values To 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. Dignity Collaboration Justice Stewardship Excellence Just Culture is premised upon our values. Define each value if necessary. Days 1-3

Just Culture Model: Duties Three Basic Duties 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. 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 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?

Just Culture Model: Breeches Organizations 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: 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.

The Just Culture Model: Consequences Conscious Disregard of Substantial and Unjustifiable Risk Managed Through: Remedial action Punitive action At-Risk Behavior A Choice: Risk Believed Insignificant or Justified Remove incentives for at-risk behaviors Create incentives for good behavior Increase situational awareness Product of Current System Design and Behavioral Choices Choices Processes Procedures Training Design Environment Human Error At-Risk Behavior Reckless Behavior Punishment is reserved for reckless behavior because it is a conscious disregard of the correct choice/behavior and also reserved for repetitive errors or repetitive at-risk behaviors that cannot be controlled or managed in other ways. It is the terminal course of action after other actions with the system and the employee have been applied. Console Coach Punish 14

Example of Behaviors Human Error At-Risk Reckless You are driving in your car and you are preoccupied by other things. You are driving home and suddenly realize you never stopped at the stop sign near your home. At-Risk You are running short on time and decide to drive faster to get to work. You are driving 75 miles/hour in a 65 mile/hour speed zone. Reckless You decide to go faster and switch lanes franticly to move through traffic faster.

Just Culture is Balance Life Harm Liberty Rule Just Culture is about balancing our pursuit of these goals with the restraining influence of our duties to each other and our employer and when our choices breech this balance, then Just Culture is about applying the correct (just) response for the action. Just Culture helps us shift our focus from errors, outcomes and punitive response to good system design and wise behavioral choices. Happiness Outcome Motivation Duty

It’s All About Patient Safety