Safe and Just Culture. Lori A. Paine RN, MS KHA Quality Conference March 18, 2015

Transcription

1 Safe and Just Culture Lori A. Paine RN, MS KHA Quality Conference March 18, 2015

2 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 March 17,

3 Objectives Understand significance of just culture in high reliability organizations Identify the five core principles of a just culture Define the behavioral concepts and methods for managing unsafe acts

4 JHU and JHHS,

5 HRO Characteristics Operate in unforgiving social and political environments Use complex processes to manage complex technologies have potential for surprises and adverse consequences Have limited opportunities for learning through experimentation Have widespread accountability with sanctions for substandard performance Source: Kathleen Sutcliffe JHU and JHHS,

6 6

7 Mindful Organizing Requirements Respectful Interactions Heedful Interrelations Mindful Infrastructure T. Vogus, 2014 JHU and JHHS,

8 Mindful Infrastructure: Five High Reliability Principles Preoccupation with failure Any lapse is a symptom that something may be wrong with the system Reluctance to Simplify Create a complete and nuanced picture Sensitivity to Operations Attentive to the front line where real work is done Commitment to Resilience Not error-free, rather errors don t disable the org Deference to Expertise Authority migrates to people with most expertise Source:

9 Components of Informed (Mindful) Culture Reporting Culture What gets reported when errors or near-misses occur Just Culture How/if people are blamed when something goes wrong Flexible Culture How readily we adapt to sudden and radical changes in pressure, pacing and intensity Learning Culture How adequately we can convert the lessons that are learned into reconfigured assumptions, frameworks and action Reason Weick & Sutcliffe

10 Just Culture Defined: How people apportion blame when something goes wrong - Weick & Sutcliffe (2007) March 17,

11 Just Culture: Where s the balance? Blame - Free Punitive ISMP Medication Safety Alert! Our long journey towards a safety-minded Just Culture Part I: Where we ve been 2006:11(18) ISMP Medication Safety Alert! Our long journey towards a safety-minded Just Culture Part II: Where we re going 2006:11(19)

12 Why use a Just Culture framework? Promotes patient safety and quality improvement that examines behavioral choices, NOT outcomes of events. Balances individual accountability with system accountability. Holds leaders accountable for safely designed systems Promotes learning from errors. Differentiates incidents resulting from human error, at-risk and reckless behavior.

13 We Are All Accountable Human error inadvertent action; 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 Source: David Marx, JD Just Culture Organization

14 Just Culture policies say You are a fallible human being, susceptible to human error and behavioral drift. As your employer, we must design systems around you in recognition of that fallibility. When errors do occur, you must raise your hand to allow the organization to learn. When you drift into a risky place, believing that you are still safe, we will coach you. When you knowingly put others in harm s way, we will take appropriate disciplinary action. Whack a Mole David Marx March 17,

15 Accountability for Our Behaviors Human Error At-Risk Behavior Reckless Behavior Product of our current system design Unintentional Risk-Taking Intentional Risk-Taking Manage through changes in: Processes Procedures Training Design Environment Manage through: Removing incentives for At- Risk Behaviors Creating incentives for healthy behaviors Increasing situational awareness Manage through: Remedial action Punitive action Console Coach Punish Source: David Marx, JD Just Culture Organization 15

16 Image source:

17 Drunk Driving Laws Image source:

18 Outcome vs. Behavior?

19 Just Culture Systems People Safe Design Safe Choices 19

20 Eric Cropp

21 Accountability for Our Behaviors Human Error At-Risk Behavior Reckless Behavior Product of our current system design Unintentional Risk-Taking Intentional Risk-Taking Manage through changes in: Processes Procedures Training Design Environment Manage through: Removing incentives for At- Risk Behaviors Creating incentives for healthy behaviors Increasing situational awareness Manage through: Remedial action Punitive action Console Coach Punish Source: David Marx, JD Just Culture Organization

22 Core Principles of a Just Culture To err is human To drift is human Risk is everywhere We must manage in support of our values We are all accountable Outcome Engineering, LLC. The Just Culture Community Just Culture Training for Healthcare Managers. 2008

23 To Err is Human

24 To Err is Human, unless you are a healthcare professional? Source:

25 To Err is Human, unless you are a healthcare professional? Correct Incorrect JHU and JHHS,

26 To Drift is Human

27 Risk is Everywhere Image source:

28 We Must Manage In Support of Our Values

29 We are All Accountable Image source:

30 Accountability for Our Behaviors Human Error At-Risk Behavior Reckless Behavior Product of our current system design Unintentional Risk-Taking Intentional Risk-Taking Manage through changes in: Processes Procedures Training Design Environment Manage through: Removing incentives for At- Risk Behaviors Creating incentives for healthy behaviors Increasing situational awareness Manage through: Remedial action Punitive action Console Coach Punish Source: David Marx, JD Just Culture Organization

31 Managing Human Error Ask: Did the employee make the correct behavioral choice in their task? Is the employee effectively managing their own performance shaping factors? If yes, CONSOLE Outcome Engineering, LLC. The Just Culture Community Just Culture Training for Healthcare Managers. 2008

32 Performance Shaping Factors Outcome Engineering, LLC. The Just Culture Community Just Culture Training for Healthcare Managers Photo source:

33 High concentration electrolytes Double checks vs barcoding Tall man lettering Post-op Xrays Fall mats Policy/ training taskforce

34 Accountability for Our Behaviors Human Error At-Risk Behavior Reckless Behavior Product of our current system design Unintentional Risk-Taking Intentional Risk-Taking Manage through changes in: Processes Procedures Training Design Environment Manage through: Removing incentives for At- Risk Behaviors Creating incentives for healthy behaviors Increasing situational awareness Manage through: Remedial action Punitive action Console Coach Punish Source: David Marx, JD Just Culture Organization

35 Managing Reckless Behavior Reckless Behavior is conscious disregard of substantial and unjustifiable risk Managed through disciplinary action Outcome Engineering, LLC. The Just Culture Community Just Culture Training for Healthcare Managers. 2008

36 Accountability for Our Behaviors Human Error At-Risk Behavior Reckless Behavior Product of our current system design Unintentional Risk-Taking Intentional Risk-Taking Manage through changes in: Processes Procedures Training Design Environment Manage through: Removing incentives for At- Risk Behaviors Creating incentives for healthy behaviors Increasing situational awareness Manage through: Remedial action Punitive action Console Coach Punish Source: David Marx, JD Just Culture Organization

37 Risky Behaviors Not checking the 5 rights Borrowing meds Not washing hands Not checking wrist bands Relying on memory Not listening to patients/families 37

38 Managing At-Risk Behavior A behavior choice Driven by perception of consequence Immediate and certain consequences are strong Delayed and uncertain consequences are weak Rules are generally weak Outcome Engineering, LLC. The Just Culture Community Just Culture Training for Healthcare Managers. 2008

39 Managing At-Risk Behavior A behavior choice Managed by adding forcing functions (barriers to prevent non-compliance) Managed by changing perceptions of risk Managed by changing consequences COACHING Outcome Engineering, LLC. The Just Culture Community Just Culture Training for Healthcare Managers. 2008

40 Coaching Risky Behavior Consider which unit behaviors get rewarded Consider unit behaviors that are undesirable Consider who trains new staff Explain processes designed to protect patients Consider how the system influences risky behavior Reward 2 nd order problem-solving Create a safe culture in which nurses can learn and make safe choices Outcome Engineering, LLC. The Just Culture Community Just Culture Training for Healthcare Managers

41 Just Culture recognizes most events occur: Unsafe System Design EVENT Unsafe Behavior Choices

42 Summary Just Culture provides a balance between Punitive and Blame-Free Just Culture holds people accountable for their behavioral choices and leaders for their duty to design safe systems Consideration of system design and behavioral choices should be taken Careful interpretation of behaviors should be performed when determining appropriate actions

43 Just Culture: Response to Human Error JHU and JHHS,