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Safe ChoicesA Lesson in Just Culture
IAPIC Conference, 2018
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Reflection
Perfection is being right
Perfection is fear
Perfection is anger and frustration
Perfection is control
Perfection is judgment
Perfection is taking
Perfection is doubt
Perfection is pressure
Perfection is a destination
Excellence is willing to be wrong
Excellence is risk
Excellence is powerful
Excellence is spontaneous
Excellence is accepting
Excellence is giving
Excellence is confidence
Excellence is flowing
Excellence is a journey
©2014 Trinity Health - Livonia, MI 2
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What are you going to learn?
Copyright 2011 CHE Trinity Health - Novi, Michigan 3
At the end of this session, you should be able to
answer the following questions:
• What are the five essential elements of a Just Culture?
• What are the three human behaviors?
• What is your role within a Just Culture?
• How can safe behavioral choices reduce risk and improve
our culture of safety?
• How will Just Culture impact the team and organization?
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What is Just Culture?
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• Changes our way of thinking about safety
for patients and colleagues
• Allows us all to learn from undesirable
outcomes
• Recognizes the opportunities to reduce risk
• Supports a continuous learning environment
where we learn from our mistakes
• Reminds us to be finders and fixers of
defects within our work environment
©2012, 2015 Trinity Health - Livonia, MI
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2
5
3
1
Learning
Systems
Justice &
Accountability
Human
Behavior
Values &
Expectations
System
Design
Better
Outcomes
Communicate Values and Expectations
One step in creating better outcomes is to set expectations in a way that exhibit our commitment to our Mission, Core Values, and Vision.
Design Safe Systems
Good system design anticipates human error and captures errors before they become critical. Good system design also permits recovery when the consequences of our errors can cause harm. This is also defined as undesirable outcomes.
Manage Behavioral Choices
We anticipate that humans will
make mistakes and that
colleagues will drift from our
policies and procedures.
Create Learning Systems
We can identify risk by
observing the design of the
systems in which we work, our
behaviors, and the behaviors
of those around us.
Create a Just and Accountable Environment
We are imperfect and we will
drift from making safe choices.
We must hold one another
accountable for the quality of
our systems and our choices in
those systems.
Five Essential Elements
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Three Human Behaviors
6©2012, 2015 Trinity Health - Livonia, MI
At-Risk Behavior: a
behavioral choice that
increases risk where
risk is not
recognized, or is
mistakenly believed to
be justified.
Reckless Behavior: a
behavioral choice to
consciously
disregard a substantial
and unjustifiable risk.
Human Error: an
inadvertent action; a
slip, a lapse, a
mistake.
©2014 Trinity Health. All Rights Reserved. 7Copyright © 2013 CHE Trinity Health
Umpire Jim Joyce makes a human error that costs
Armando Galarraga a perfect game…
Human Error
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Source: LA Times, Train Engineer Sent Text Message Right Before Crash, October 2, 2008.
Train engineer is texting while on duty…
To Drift is Human
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Elizabeth Lambert has her own rules for playing soccer…
Occasionally, the Reckless Act
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Coach
Console
Discipline
Behavioral Responses to Human Behaviors
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Apply what we have learned
On a snowy winter night, John had to run to the store to buy milk. His car was parked in the driveway. John got into the car and turned his head to back out of the driveway. Although he carefully looked at the path behind the car, his vision was limited. He inadvertently hit his neighbor’s mailbox and destroyed it.
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Apply what we have learned
©2014 Trinity Health - Livonia, MI 12
On a snowy winter night, John had to run to the
store to buy a new formula for his colicky newborn.
His wife had not slept in 24 hrs. so tension in the
home was high. He got into the car and backed out
of the driveway looking at his upset wife in the
doorway, but not looking in his rear view mirror. In
his haste, he hit his neighbor’s mailbox and
destroyed it.
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Apply what we have learned
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On a snowy winter night… John yelled “yee haa,” closed his eyes and hit the gas. He never saw his neighbor’s mailbox.
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Wrap-Up: Causes
Copyright 2011 CHE Trinity Health - Novi, Michigan 14
System Design
• Systems are policies, procedures, protocols and actual equipment we use.
• Systems are the design of the work environment
• Sometimes we design the system and sometimes the system is designed for us
• We must always look at the system design around the errors or choices that we make
Human Behavior
• Human behaviors are manageable and fall into three categories
• Human Error is an inadvertent action – a slip, a lapse, a mistake
• At-Risk Behavior is a choice that we make, when we think we are in a safe place or we don’t recognize the risk
• Reckless behavior is when we consciously disregard a substantial and unjustifiable risk
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Expectation of Colleagues
Copyright 2011 CHE Trinity Health - Novi, Michigan 15
What should you do?
Peer Coaching Support each other in serving. Help your fellow
Colleagues see the risks they are taking.
Open Eyes and Ears Look at the risk around you. How can you help improve
the system design around you?
Speak Up If you see something, say something. Feel safe to
speak up and let your manager know the risks and
behaviors that you see.
Make Good Behavioral
Choices
Be mindful of your own behaviors and choices within
our systems.
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Expectations of Leaders
Copyright 2012 CHE Trinity Health - Novi, Michigan 16
Conducting fair and thorough investigations that focus on behaviors, choices and system improvement opportunities, and not the outcome
Seeking your input to identify risks and help design safer systems
Supporting you as we transform our organization into a continuous learning environment where we seek to learn from one another’s experiences
As appropriate, holding Colleagues accountable for their behavioral choices consistent with organizational policy
©2014 Trinity Health. All Rights Reserved. 17
• What factors lead to undesirable outcomes?
• System design and behavioral choices
• What are the five essential elements of a Just Culture?
• Values and Expectations, System Design, Human Behavior, Learning Systems and Justice and Accountability
• What are the three manageable human behaviors?
• Human Error, At Risk Behavior, and Reckless Behavior
• Why do we engage in at-risk behavior?
• When our at-risk behavior has nothing bad happening we tend to drift into more at-risk behaviors
• How can I reduce risk?
• By keeping my eyes open and choosing my own behaviors and to share with others when I see others at risk
17©2012, 2015 Trinity Health - Livonia, MI
Key Points