Just Culture:

A Balance Between Punitive and Blame Free Cultures to Create Cultures of

Safety

Michelle Freeman RN BSN MSN Adapted from presentations and resources from:

David Marx, JD California Patient Safety Action Coalition (CAPSAC) and www.justculture.com

The Problem: Expectation of Perfection

“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

The Reality

“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

The Reality

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

The Problem: Labeling The Behavior

“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

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

The Four Evils? The Words You Use Today

Reckless

Behavior

(gross negligence)

Negligent

Behavior

(carelessness)

Human

Error

Knowing

Violations

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

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 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

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

Leadership Accountabilities

• Provides the vision—demonstrates a commitment to safe, reliable delivery of high quality care

• Establishes a sense of urgency around managing risks

• Creates an environment of internal transparency around risk

• Demonstrates an open, fair and learning culture, including response to behaviors, errors, and events

• Encourages trust and participation to improve safety and other core values

• Uses data to measure performance and build both unit and organizational models for the allocation of resources

Just Culture Does not Exist in A Vacuum

• Create an Open and Fair Culture – Move away from an overly

punitive culture and strike a middle ground between punitive and blame free

– Recognize human fallibility

• Humans will make mistakes

• Humans will drift away from what we have been taught

• Create a Learning Culture – Develop culture that is eager

to recognize risk at both the individual and organizational level

– Risk is seen through events, near misses, and observations of system design and behavioral choices

– Without learning we are destined to make the same mistakes

Just Culture Does not Exist in A Vacuum

• Design Safe Systems – Reduce opportunity for human

error

– Capture errors before they become critical

– Allow recovery when the consequences of our error reaches the patient

– Facilitate our employees making good decisions

• Manage Behavioral Choices – Humans will make mistakes.

We must manage behavioral choices in a way that allows us to achieve the outcomes we desire

– Cultures will drift into unsafe places

– Coaching each other around reliable behaviors

Implementing a Just Culture

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

• Set the

Expectations

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

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

• Making System Changes

Even the best of us are going to make mistakes…

Think of A Just Culture……

• 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

David Marx