just culture - wrh · 2018-09-19 · • culture is the values, beliefs, and behaviors that we...
TRANSCRIPT
Just Culture:
A Balance Between Punitive and
Blame Free Cultures to Create Cultures of
Safety
Sources: David Marx, www.justculture.com, Michelle Freeman, MScN, RN
What is Culture and How Does it
Relate to Safety?
• Culture is the values, beliefs, and behaviors that we share with other members of groups
• “The way we do things here…..”
• Unwritten rules governing behaviour
• Culture provides cues and clues on how to behave in normal and novel
situations
Culture is implicated in accidents and incidents in aviation and medicine
What is 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
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
What is a Just Culture?
Human Error Management
• The idea behind human error management is “simple” • Move the reliability curve to the
right and decrease the risk of human error
• How? – Design systems to reduce
errors
– Focus on human behaviours • Create a just culture
The Behaviors We Can Expect
• Human error - inadvertent action; inadvertently doing
other than 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 Three Behaviors
Reckless Behavior
Conscious Disregard of Unjustifiable Risk
Manage through: • Remedial action • Disciplinary action
At-Risk Behavior
A Choice: Risk Believed Insignificant or Justified
Manage through: • Removing incentives for
at-risk behaviors • Creating incentives for
healthy behaviors • Increasing situational
awareness
Human Error
Product of Our Current System Design
Manage through changes in: • Processes • Procedures • Training • Design
• Environment
Console Coach Discipline
Just Culture Facts
Fact: Humans will make mistakes.
• This does not equate to loss of accountability or that human errors are unmanageable
• Cannot manage error by simply expecting staff to be “error-free”
• Need to see errors and their effects as products of the system in which we put employees and their behavioural choices within that system
Fact: “To drift is human.” Humans will move
away from strict compliance
– “Drifting”- tendency for humans to engage in risky
behaviours and lose perception of the risks
– Often encouraged by pressures of work and workplace
cultures
– Need to accept this as part of being “human”
Just Culture Facts
Just Culture Facts
• Recognize that all human activities involve risk
• Task of manager is to recognize risks and diminish
(mitigate) risks
Fact: “Risk is everywhere.” Actively seek out
risks in the workplace.
Organizational Goals
for a Just Culture
• Create an environment of transparency around risk
• Learn why human errors and at-risk behaviours occur within the organization
• Learn to measure risk at both the unit and organizational levels
• Work with staff to design systems that reduce the rate of human error and at-risk behaviour or mitigate their effects
• Learn when to console, coach and discipline employees
• Focus on the risks inherent in systems and behavioural choices, not the actual outcomes of events
• Use data to build both unit and organizational models of risk
Organizational Goals
for a Just Culture