the emergence of a just culture where we were where we may be where we need to go
TRANSCRIPT
The Emergence of The Emergence of a Just Culturea Just Culture
Where We Were Where We Were
Where We May BeWhere We May Be
Where We Need to GoWhere We Need to Go
Why Errors Occur in Why Errors Occur in HealthcareHealthcare
Patients as IndividualsPatients as Individuals ComplexityComplexity Coordination of Care with Other Coordination of Care with Other
DepartmentsDepartments Lack of Standardized ProcessesLack of Standardized Processes Communication IssuesCommunication Issues Hierarchal StructuresHierarchal Structures
Why Errors Occur in Why Errors Occur in HealthcareHealthcare
Autonomous disciplines – Silo Autonomous disciplines – Silo thinkingthinking
Patient Acuity, Volume, and Patient Acuity, Volume, and WorkloadWorkload
Hand-OffsHand-Offs Staff Recruitment/RetentionStaff Recruitment/Retention Human characteristicsHuman characteristics External FactorsExternal Factors
External Factors Limiting External Factors Limiting PerformancePerformance
StressStress Time pressuresTime pressures DistractionDistraction Goal ConflictsGoal Conflicts Environment – noiseEnvironment – noise Level of trainingLevel of training
Human Side of Medical Human Side of Medical ErrorError
Long term memory vs Working memoryLong term memory vs Working memory Chunking informationChunking information Storage and retrieval methods of Storage and retrieval methods of
informationinformation Limitation of attentionLimitation of attention Automatic and well established routinesAutomatic and well established routines Playing the odds – humans as risk Playing the odds – humans as risk
takers; cutting cornerstakers; cutting corners
How Do Organizations Deal How Do Organizations Deal with Error?with Error?
Punitive Culture – prior to 1990’sPunitive Culture – prior to 1990’s
Blame Free Culture – mid to late Blame Free Culture – mid to late 1990’s1990’s
Just Culture – new millenniumJust Culture – new millennium
Characteristics of Punitive Characteristics of Punitive CulturesCultures
Expectation was for perfect performanceExpectation was for perfect performance
Individual workers held solely accountable Individual workers held solely accountable for patient outcomesfor patient outcomes
Workers involved in error were counseled Workers involved in error were counseled or disciplined – who touched it last?or disciplined – who touched it last?
Disciplinary actions often based on Disciplinary actions often based on amount of harmamount of harm
Punitive Process for Dealing Punitive Process for Dealing with Errorwith Error
Focus on perceived individual weaknessesFocus on perceived individual weaknesses
Retraining, education, and vigilance Retraining, education, and vigilance
Improvement strategies – follow the five Improvement strategies – follow the five rightsrights
Procedural violations unacceptableProcedural violations unacceptable
Weed out “bad practitioners”Weed out “bad practitioners”
Effects of Punitive Effects of Punitive EnvironmentsEnvironments
Errors driven undergroundErrors driven undergroundFear of retribution, employment lossFear of retribution, employment lossFear of license terminationFear of license terminationEmbarrassmentEmbarrassment
Workarounds developedWorkarounds developed No reporting of near misses or errors No reporting of near misses or errors
waiting to happenwaiting to happen No news is good news mentalityNo news is good news mentality Top down management of errorTop down management of error
Why Punitive Environments Don’t Work
Change occurring from measures that involve Change occurring from measures that involve sanctions, threats, or appeals is not sustainablesanctions, threats, or appeals is not sustainable
Threats and sanctions are de-motivating and Threats and sanctions are de-motivating and inhibit safety progressinhibit safety progress
The precipitating causes of medical error are only The precipitating causes of medical error are only the last links in the chain of events and are the the last links in the chain of events and are the least manageableleast manageable
If punitive systems had worked, there would be If punitive systems had worked, there would be no conversationno conversation
So why do we place blame?So why do we place blame? Individuals as “free agents” – isolationIndividuals as “free agents” – isolation Captains of our own fateCaptains of our own fate Actions are seen as voluntary and Actions are seen as voluntary and
within our controlwithin our control
Traditionally, we have blamed Traditionally, we have blamed clinicians who have been involved in clinicians who have been involved in error with being careless or error with being careless or incompetentincompetent
“Experience suggests that the majority of unsafe acts - perhaps 90 percent or more- fall into the blameless category.”
Managing the Risks of Organizational Accidents- Reason
Is Blame Appropriate?Is Blame Appropriate?
““The common reaction to an error in medical care is The common reaction to an error in medical care is to blame the apparent perpetrator of the error. to blame the apparent perpetrator of the error.
Blaming the person does not necessarily solve Blaming the person does not necessarily solve the problem; more likely, it merely changes the the problem; more likely, it merely changes the
players in the error-conductiveplayers in the error-conductive situationsituation. The error . The error will occur again, only to be associated with another will occur again, only to be associated with another provider. provider. This will continue until the conditions that This will continue until the conditions that
induce error are identified and changed.”induce error are identified and changed.” Human Error in Medicine, Bogner, MS Human Error in Medicine, Bogner, MS
““The common reaction to an error in medical care is The common reaction to an error in medical care is to blame the apparent perpetrator of the error. to blame the apparent perpetrator of the error.
Blaming the person does not necessarily solve Blaming the person does not necessarily solve the problem; more likely, it merely changes the the problem; more likely, it merely changes the
players in the error-conductiveplayers in the error-conductive situationsituation. The error . The error will occur again, only to be associated with another will occur again, only to be associated with another provider. provider. This will continue until the conditions that This will continue until the conditions that
induce error are identified and changed.”induce error are identified and changed.” Human Error in Medicine, Bogner, MS Human Error in Medicine, Bogner, MS
Blame Free CultureBlame Free Culture Acknowledged human fallibilityAcknowledged human fallibility
Perfect performance no longer achievablePerfect performance no longer achievable
Unsafe acts are usually result of slips or Unsafe acts are usually result of slips or honest mistakeshonest mistakes
Anyone can make a mistake Anyone can make a mistake
Vigilance alone cannot overcome errorVigilance alone cannot overcome error
Blame Free Process for Blame Free Process for Dealing with ErrorDealing with Error
Employee held harmless Employee held harmless
Severity of error still taken into accountSeverity of error still taken into account
Investigation of systems issuesInvestigation of systems issues
Implementation of process changeImplementation of process change
Unsafe ActsUnsafe ActsWere the actions as intended?
Were the actions as intended?
Unauthorized Substance?
Unauthorized Substance?
Knowingly violated safe operating procedures?
Knowingly violated safe operating procedures?
Pass substitution
test?
Pass substitution
test?
History of unsafe acts?History of
unsafe acts?
Were the consequences as intended?
Were the consequences as intended?
Medical Conditions?
Medical Conditions?
Were procedures available, workable,
intelligible and correct?
Were procedures available, workable,
intelligible and correct?
Deficiencies in training and selection,
or inexperienced?
Deficiencies in training and selection,
or inexperienced?
Blameless Error
Blameless Error
Substance Abuse without mitigationSubstance Abuse
without mitigationSystem induced
violationSystem induced
violation Blameless Error, but corrective training or counseling indicated
Blameless Error, but corrective training or counseling indicated
Possible reckless violation
Possible reckless violation
System Induced Error
System Induced Error
Sabotage, malevolent damage,
suicide, etc.
Sabotage, malevolent damage,
suicide, etc.
Substance Abuse with mitigation
Substance Abuse with mitigation
Possible Negligent Behavior
Possible Negligent Behavior
CULPABLE GRAY AREA BLAMELESS
yes yes yes no noyes
no no no yes
no
yesno
yes
yes nono
yes
When faced with an accident or serious incident in which the unsafe acts of a particular person were implicated, we should perform the following mental test: Substitute the individual concerned for someone else.
When faced with an accident or serious incident in which the unsafe acts of a particular person were implicated, we should perform the following mental test: Substitute the individual concerned for someone else.
Could (or has) some well motivated, equally competent and comparably qualified individual
make (or made) the same kind of error under those or similar circumstances?
Could (or has) some well motivated, equally competent and comparably qualified individual
make (or made) the same kind of error under those or similar circumstances?
Substitution Test - Nelson Johnston
Substitution Test - Nelson Johnston
“A useful addition to the substitution test is to ask of the individual’s peers:
‘Given the circumstances that prevailed at the time, could you be sure that you would not have committed the same or similar type of unsafe act?’
If the answer is ‘probably not’ then blame is inappropriate
Effects of Blame FreeEffects of Blame Free
Increase in error reportingIncrease in error reporting
Reporting of near miss situationsReporting of near miss situations
Punishment has no benefit to safetyPunishment has no benefit to safety
Some lack of credibility or sense of justiceSome lack of credibility or sense of justice
Just CultureJust Culture Rewards reportingRewards reporting
Values open communicationValues open communication
Risks openly discussedRisks openly discussed
Continued emphasis on systemsContinued emphasis on systems
Stresses behavioral choicesStresses behavioral choices
Just Culture Process for Just Culture Process for Dealing with ErrorDealing with Error
Behavioral choices of staff are paramountBehavioral choices of staff are paramount
Acknowledgement of human fallibilityAcknowledgement of human fallibility
Understanding of certain at-risk behaviorsUnderstanding of certain at-risk behaviors
No tolerance for reckless behaviorNo tolerance for reckless behavior
Human ErrorHuman Error
UnintendedUnintended human act that does not human act that does not achieve the achieve the desireddesired goalgoal
A planned action is not carried out as A planned action is not carried out as intendedintended
Use of a wrong planUse of a wrong plan
No discipline because no intentNo discipline because no intent
At-Risk BehaviorsAt-Risk Behaviors
To Drift is HumanTo Drift is Human
We are programmed to drift into unsafe We are programmed to drift into unsafe habitshabits
We lose perception of the risk of everyday We lose perception of the risk of everyday behaviorsbehaviors
We may believe the risk is justifiedWe may believe the risk is justified
Why Do We DriftWhy Do We Drift Workers concerned with immediate Workers concerned with immediate
consequencesconsequences
Workers undervalue delayed consequencesWorkers undervalue delayed consequences
Workers try to do more with less Workers try to do more with less
Shortcuts evolveShortcuts evolve
We often reward at-risk behaviorWe often reward at-risk behavior
Dealing With At-Risk Dealing With At-Risk BehaviorBehavior
Uncover the reason Uncover the reason
Address unrealistic procedural demandsAddress unrealistic procedural demands
Coach on making better behavioral Coach on making better behavioral choiceschoices
Decrease staff toleranceDecrease staff tolerance
Reckless BehaviorReckless Behavior Worker always perceives the riskWorker always perceives the risk
Understands the risk is substantialUnderstands the risk is substantial
Behave intentionally with no justificationBehave intentionally with no justification
Knows that others are acting differentlyKnows that others are acting differently
Makes a Makes a consciousconscious choice to disregard the risks choice to disregard the risks for subjective reasonsfor subjective reasons
Behavior is blameworthyBehavior is blameworthy
Effects of Just CulturesEffects of Just Cultures Continued reporting of error and near missContinued reporting of error and near miss
Continued system investigationContinued system investigation
Continued process improvementContinued process improvement
Peer pressure to develop, implement, and Peer pressure to develop, implement, and follow realistic standards of practicefollow realistic standards of practice
Just Culture AccountabilityJust Culture Accountability
Accountability for things you have control over Accountability for things you have control over
Managers – systems design, proceduresManagers – systems design, procedures
Employees – behavioral choices, highlighting Employees – behavioral choices, highlighting unworkable proceduresunworkable procedures
Manager and peers as coach; observe daily behaviorsManager and peers as coach; observe daily behaviors
Eliminate rewards for at-risk behaviorsEliminate rewards for at-risk behaviors
Focus is on how to prevent the next errorFocus is on how to prevent the next error