17
©2014 Trinity Health. All Rights Reserved. 1 Safe Choices A Lesson in Just Culture IAPIC Conference, 2018

A Lesson in Just Culture - Intermountain APIC...Perfection is being right Perfection is fear Perfection is anger and frustration ... Perfection is taking Perfection is doubt Perfection

  • Upload
    others

  • View
    18

  • Download
    1

Embed Size (px)

Citation preview

Page 1: A Lesson in Just Culture - Intermountain APIC...Perfection is being right Perfection is fear Perfection is anger and frustration ... Perfection is taking Perfection is doubt Perfection

©2014 Trinity Health. All Rights Reserved. 1

Safe ChoicesA Lesson in Just Culture

IAPIC Conference, 2018

Page 2: A Lesson in Just Culture - Intermountain APIC...Perfection is being right Perfection is fear Perfection is anger and frustration ... Perfection is taking Perfection is doubt Perfection

©2014 Trinity Health. All Rights Reserved. 2

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

Page 3: A Lesson in Just Culture - Intermountain APIC...Perfection is being right Perfection is fear Perfection is anger and frustration ... Perfection is taking Perfection is doubt Perfection

©2014 Trinity Health. All Rights Reserved. 3

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?

Page 4: A Lesson in Just Culture - Intermountain APIC...Perfection is being right Perfection is fear Perfection is anger and frustration ... Perfection is taking Perfection is doubt Perfection

©2014 Trinity Health. All Rights Reserved. 4

What is Just Culture?

4

• 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

Page 5: A Lesson in Just Culture - Intermountain APIC...Perfection is being right Perfection is fear Perfection is anger and frustration ... Perfection is taking Perfection is doubt Perfection

©2014 Trinity Health. All Rights Reserved. 5

4

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

Page 6: A Lesson in Just Culture - Intermountain APIC...Perfection is being right Perfection is fear Perfection is anger and frustration ... Perfection is taking Perfection is doubt Perfection

©2014 Trinity Health. All Rights Reserved. 6

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.

Page 7: A Lesson in Just Culture - Intermountain APIC...Perfection is being right Perfection is fear Perfection is anger and frustration ... Perfection is taking Perfection is doubt Perfection

©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

Page 8: A Lesson in Just Culture - Intermountain APIC...Perfection is being right Perfection is fear Perfection is anger and frustration ... Perfection is taking Perfection is doubt Perfection

©2014 Trinity Health. All Rights Reserved. 8

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

Page 9: A Lesson in Just Culture - Intermountain APIC...Perfection is being right Perfection is fear Perfection is anger and frustration ... Perfection is taking Perfection is doubt Perfection

©2014 Trinity Health. All Rights Reserved. 9

Elizabeth Lambert has her own rules for playing soccer…

Occasionally, the Reckless Act

Page 10: A Lesson in Just Culture - Intermountain APIC...Perfection is being right Perfection is fear Perfection is anger and frustration ... Perfection is taking Perfection is doubt Perfection

©2014 Trinity Health. All Rights Reserved. 10Copyright © 2013 CHE Trinity Health

Coach

Console

Discipline

Behavioral Responses to Human Behaviors

Page 11: A Lesson in Just Culture - Intermountain APIC...Perfection is being right Perfection is fear Perfection is anger and frustration ... Perfection is taking Perfection is doubt Perfection

©2014 Trinity Health. All Rights Reserved. 11

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.

Page 12: A Lesson in Just Culture - Intermountain APIC...Perfection is being right Perfection is fear Perfection is anger and frustration ... Perfection is taking Perfection is doubt Perfection

©2014 Trinity Health. All Rights Reserved. 12

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.

Page 13: A Lesson in Just Culture - Intermountain APIC...Perfection is being right Perfection is fear Perfection is anger and frustration ... Perfection is taking Perfection is doubt Perfection

©2014 Trinity Health. All Rights Reserved. 13

Apply what we have learned

©2014 Trinity Health - Livonia, MI 13

On a snowy winter night… John yelled “yee haa,” closed his eyes and hit the gas. He never saw his neighbor’s mailbox.

Page 14: A Lesson in Just Culture - Intermountain APIC...Perfection is being right Perfection is fear Perfection is anger and frustration ... Perfection is taking Perfection is doubt Perfection

©2014 Trinity Health. All Rights Reserved. 14

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

Page 15: A Lesson in Just Culture - Intermountain APIC...Perfection is being right Perfection is fear Perfection is anger and frustration ... Perfection is taking Perfection is doubt Perfection

©2014 Trinity Health. All Rights Reserved. 15

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.

Page 16: A Lesson in Just Culture - Intermountain APIC...Perfection is being right Perfection is fear Perfection is anger and frustration ... Perfection is taking Perfection is doubt Perfection

©2014 Trinity Health. All Rights Reserved. 16

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

Page 17: A Lesson in Just Culture - Intermountain APIC...Perfection is being right Perfection is fear Perfection is anger and frustration ... Perfection is taking Perfection is doubt Perfection

©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