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Minnesota Alliance for Patient Safety
Improving Regulation Discussion
Operations Committee January 7, 2014
Human ErrorNear Misses
Adverse
Events
Learning
Systems
Workplace
Fairness
Values and Culture
System
Design
Behavioral
Choices
Human ErrorNear Misses
Adverse
EventsAn organization with a culture of safety places less focus on events, errors, and outcomes, and more focus on risk, system design, and the management of behavioral choices. In this model, errors and adverse events are the outputs to be monitored; system design and the behavioral choices are the inputs to be managed and measured.
How Do We Measure a Regulator’s Success?
• Effectiveness in:– Identifying risk– Mitigating risk or influencing risk
management
• Efficiency– Resources required to protect our
value(s)
Two Primary Measures
Measures of Regulatory Success
• Accidents / sentinel events / adverse outcomes
• Near misses / close calls• Inspector surveillance• Digital surveillance• External reporting by:
– Operators– Individuals– Public
• Predictive methodologies
How Do Regulators Learn About Risk in:
• Systems?
•Behaviors?
•Culture?
“Seeing” Socio-Technical Risk
How Do Regulators Learn About Risk in:
• Systems?
• Behaviors?
• Culture?
Human ErrorNear Misses
Adverse
Events
Learning
Systems
Workplace
Fairness
Values and Culture
System
Design
Behavioral
Choices
Human ErrorNear Misses
Adverse
Events
Human ErrorNear Misses
Adverse
Events
Learning
Systems
Workplace
Fairness
Values and Culture
System
Design
Behavioral
Choices
Human ErrorNear Misses
Adverse
Events
Managing Socio-Technical RiskWhat the Regulator “Sees”
Human ErrorNear Misses
Adverse
Events
Learning
Systems
Workplace
Fairness
Values and Culture
System
Design
Behavioral
Choices
Human ErrorNear Misses
Adverse
Events
Managing Socio-Technical RiskWhat Cultural Surveys “See”
Human ErrorNear Misses
Adverse
Events
Learning
Systems
Workplace
Fairness
Values and Culture
System
Design
Behavioral
Choices
Human ErrorNear Misses
Adverse
Events
The Key Window for the Manager
Human ErrorNear Misses
Adverse
Events
Learning
Systems
Workplace
Fairness
Values and Culture
System
Design
Behavioral
Choices
Human ErrorNear Misses
Adverse
Events
Managing Socio-Technical RiskA Better View
Human ErrorNear Misses
Adverse
Events
Learning
Systems
Workplace
Fairness
Values and Culture
System
Design
Behavioral
Choices
Human ErrorNear Misses
Adverse
Events
“Seeing” the Entire Pyramid
.• A Change in Focus:– From outcomes and errors– To system design and behavioral choices
Organizations produce outcomes:
To do this, they must design good systems and help employees make
good choices
Individuals participate as components:
To do this, they must make good behavioral choices within the
system
Aviation Safety Action Partnerships (ASAPs) have demonstrated that less than 1% of the
risks identified through these programs would have been known to the FAA outside
these programs
Identifying Risk through PartnershipsAviation Safety Action Partnerships (ASAPs)
Benefits:• More effective oversight by the regulator• Improved regulatory compliance• Better outcomes for the consumer• Better outcomes for the public
“When your only tool is a hammer, you tend to see every
problem as a nail.”
-- Abraham Maslow
Next Steps For MAPS?• Facilitated forum/Outside speaker– Board?– MAPS members?– Plus regulators/agencies? – Open to all? – Combination of above
• Pilot – Provider organization + regulator partnership (a la ASAP
or North Carolina BoN)?• Support for specific proposals – topic expertise
