1. outcome engineering Errors: A Balance Between Learning and Accountability Presented to: The Michigan Health and Safety Coalition April 14, 2004 David Marx, JD

2. outcome engineering Let’s be Honest… MENWOMEN

3. outcome engineering Agenda An Introduction to Patient Safety and Just Culture Disciplinary Analysis The “Just Culture” Just Culture Implementation Questions

4. outcome engineering An Introduction to Discipline “There are activities in which the degree of professional skill which must be required is so high, and the potential consequences of the smallest departure from that high standard are so serious, that one failure to perform in accordance with those standards is enough to justify dismissal.” Lord Denning English Judge

5. outcome engineering An Introduction to Discipline “ People make errors, which lead to accidents. Accidents lead to deaths. The standard solution is to blame the people involved. If we find out who made the errors and punish them, we solve the problem, right? Wrong. The problem is seldom the fault of an individual; it is the fault of the system. Change the people without changing the system and the problems will continue. ” Don Norman Apple Fellow

6. outcome engineering An Introduction to Discipline 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 Testimony before Congress on Health Care Quality Improvement

7. outcome engineering An Introduction to Discipline “…No person may operate an aircraft in a careless or reckless manner so as to endanger the life or property of another.” Federal Aviation Regulations § 91.13 Careless or Reckless Operation

8. outcome engineering An Introduction to Discipline “As far as I am concerned, when I say “careless” I am not talking about any kind of “reckless” operation of an aircraft, but simply the most basic form of simple human error or omission that the Board has used in these cases in its definition of “carelessness.” In other words, a simple absence of the due care required under the circumstances, that is, a simple act of omission, or simply “ordinary negligence,” a human mistake.” National Transportation Safety Board Administrative Law Judge Engen v. Chambers and Langford

9. outcome engineering NCSBN Model Nursing Practice Act IX. Discipline and Proceedings, e. Unsafe Practice/Unprofessional Practice 1.Failure or inability to perform registered nursing, practical nursing, as defined in Article II, with reasonable skill and safety. 2. Unprofessional conduct, including a departure from or failure to conform to board standards of registered nursing, practical nursing, or advanced practice nursing. 6. Conduct or any nursing practice that may create unnecessary danger to a client’s life, health or safety.

10. outcome engineering An Introduction to Discipline WASHINGTON 1999 serious action rate: 2.49/1000 doctors 1999 ranking: 37th In Washington, there were disciplinary actions reported against 408 doctors including 11 who were disciplined for substance abuse, 25 for misprescribing or overprescribing drugs, 28 for sexual abuse of or sexual misconduct with a patient, 55 for substandard care, incompetence or negligence and 9 who were convicted of a crime.

11. outcome engineering The Tension To improve patient safety, we must make better use of minor human error events The threat of corporate disciplinary action and regulatory enforcement is a major obstacle to event reporting and investigation The role of disciplinary action must be addressed

12. outcome engineering Disciplinary Decision-Making

13. outcome engineering The Four Evils? The Words You Use Today Reckless Behavior (gross negligence) Negligent Behavior (carelessness) Human Error Knowing Violations

14. outcome engineering Distinguishing Negligent and Reckless Behavior Negligence –Should have been aware of a substantial and unjustifiable risk –Equivalent to social definition of human error –A compensatory concept in the law Recklessness –Conscious disregard of a substantial and unjustifiable risk –A punitive concept in the common law

15. outcome engineering The “Just Culture”

16. outcome engineering Human Reliability The Human Reliability Curve Factors Affecting Human Performance (including personal behaviors) PoorGood Human Error Successful Operation 100% 0%

17. outcome engineering Managing Risk – The Three Behaviors At-Risk Behavior Unintentional Risk- Taking Reckless Behavior Intentional Risk-Taking Manage through: Disciplinary action Manage through: Understanding our at-risk behaviors Removing incentives for at-risk behaviors Creating incentives for healthy behavior Increasing situational awareness Normal Error Product of our current system design Manage through changes in: Processes Procedures Training Design Environment

18. outcome engineering A Just Culture A Set of Beliefs –A recognition that professionals will make mistakes –A recognition that even professionals will develop unhealthy norms –A fierce intolerance for reckless conduct

19. outcome engineering A Just Culture A Set of Duties –To raise your hand and say “I’ve made a mistake” –To raise your hand when you see risk –To resist the growth of at-risk behavior –To participate in the learning culture –To absolutely avoid reckless conduct

20. outcome engineering Implementing a Just Culture

21. outcome engineering Create a Safety-Supportive Policy HOSPITAL WIDE POLICY Policy #:6.350 Page#:1 of 3 Origination Date:5/03 Reviewed:6/03 Revised: SUBJECT: NON-PUNITIVE CULTURE PURPOSE To encourage reporting of adverse medical events, near misses, existence of hazardous conditions, and related opportunities for improvement as a means to identify systems changes which have the potential to avoid future adverse events. To provide guidelines for the application of non-punitive processes versus disciplinary actions. POLICY PVHMC encourages reporting of all types of errors and hazardous conditions. The organization recognizes that if we are to succeed in creating a safe environment for our patients, we must create an environment in which it is safe for caregivers to report and learn from errors. It is recognized that competent and caring associates may make mistakes and it is the intention not to instill fear or punishment for reporting them. There must be a non-punitive, supportive environment for all staff to report errors and near misses. Error and near miss reporting are a critical component of the PVHMC patient safety and risk management program. Errors and accidents should be tracked in an attempt to determine trends and patterns to learn from them and prevent a reoccurrence, thus improving patient safety. The focus is on how systems and processes can be improved to help people avoid mistakes in the future In the process of evaluating errors and near misses, healthcare providers participate in reporting and developing improved processes GUIDELINES The focus of the program is performance improvement, not punishment. Employees are not subject to disciplinary action when making or reporting errors/injuries/near misses except in the following circumstances: The employee repeatedly fails to participate in the detection and reporting of errors/injuries/near misses and the system-based prevention remedies. There is reason to believe criminal activity or criminal intent may be involved in the making or reporting of an error/injury. False information is provided in the reporting, documenting, or follow-up of an error/injury. The employee knowingly acts with intent to harm or deceive. Reckless acts State the Purpose Draw the Bright Line Set the Expectations

22. outcome engineering Modify Your Toolset Safety-oriented event investigation –Explain every error –Explain every violation –What do events say about “future” risk Begin thinking prospectively –Chronic unease –Failure Modes and Effects Analysis –Probabilistic Risk Assessment –Proactive At-Risk Behavior Analysis

23. outcome engineering Train the Management Team (an example curriculum) Just Culture and Patient Safety An Intro to Human Error Managing Normal Error Managing At-Risk Behavior Managing Reckless Behavior Event Reporting and Investigation The Investigation Process The Role of Peer Review Making System Changes

24. outcome engineering Conclusion

25. outcome engineering Even the best of us are going to make mistakes…

26. outcome engineering … it’s our response that will make the difference It is more of what we teach our kids –An expectation that errors will be reported (transparency) –No expectation of perfection –Accountability for choosing to take risk –Expectations set at system level –Expectation that system safety will improve It is not Hammerhead (or Whack-a-Mole)

27. outcome engineering Questions?