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