Safe Choices A Lesson in Just Culture
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 Copyright 2012 Trinity Health - Novi, Michigan 2
What are you going to learn today? At the end of today s session, you should be able to answer the following questions: How does Just Culture fit within Trinity Health? 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? Copyright 2011 Trinity Health - Novi, Michigan 3
What is Just Culture? Just Culture is what we strive to be about at Trinity Health. Just Culture: Provides a simple and powerful approach to change our way of thinking about safety, both for patients and associates.. Helps us learn from undesirable outcomes and how the errors and behavioral choices that we make can impact our patients, each other, and the organization. Focuses on finding opportunities to reduce risk in our actions, environment, policies, and procedures, and systems. Helps us create a continuous learning environment where we seek to learn from each other s experiences to make a safer organization. Helps us be mindful of the opportunity to be finders and fixers of defects within our work environment. Copyright 2011 Trinity Health - Novi, Michigan 4
Why Just Culture? *The Safe Choices training and these materials do not modify the at-will employment relationship with our Trinity Health associates. Copyright 2011 Trinity Health - Novi, Michigan 5
How does Just Culture fit Trinity Health? We trust support communicate are all fully continuous and accountable. each present. assume other openly, learners. goodness in honestly, serving in our intentions. respectfully patients and Accountability We As communities. directly. One we must of trust the be key our fully is elements leaders one present of the and of in key a our each Just elements conversations other Culture and of is assume a the Just with learning Culture. our goodness It is a in patients, We are all imperfect human beings make mistakes. In system culture intentions, a Just each where Culture, which we other we includes will leaders hold and allow all our programs communicate for leaders. a true that and learning We allow associates clear need culture us expectations to to ensure learn to about we to accountable are develop. When the we commit a human error, we may console our fellow associates. risk clearly in our hearing for associate. When In organization. their your and behaviors we teams, seeing drift from you We the and safe will need risks the feel to quality to unsafe open around be open of to behavior, discuss us to their every choices. we events day. We continuously and are need all may risks to accountable coach openly help learn each with patients about to other your how and create on how fellow to our manage the to associates teams kind see the of workplace make safer and the risks choices. leaders. risks in our that where We You can people cause organizations. need will be undesired can to in count be a place We outcomes. on open to where can each start other. discuss you by how are sharing respected the to improve and risks the heard, that we system and see so that the with the team each error will does have other not greater and our reoccur. success leaders. in reporting and learning about the near misses or good catches. Copyright 2011 Trinity Health - Novi, Michigan 6
Just Culture and Culture of Safety Just Culture is a foundational element of a Culture of Safety Just Culture concepts and philosophy frame the way that we talk about safety in our organization. Just Culture supports and encourages open and honest reporting of near misses and occurrences. A Just Culture is based on an organizational learning approach that strives to prevent future error through better understanding and management of error. A Just Culture is an atmosphere of trust in which people are encouraged, and even rewarded, for providing essential safety-related information. A Culture of Safety cannot be reached without the principles of a Just Culture in place. Copyright 2011 Trinity Health - Novi, Michigan 7
Five Essential Elements Essential Element #3 #1 #2 #4 #5 Communicate Values and Expectations Design Manage Create Learning a Leaders Safe Behavioral Just will Systems and Systems Accountable Choices Environment set expectations with associates in a way that illustrates our Systems In We a commitment can must Just identify Culture, include recognize to risk technical we human our by know Mission, observing systems, that imperfection there Vision, equipment, are design and certain Core Values of behavioral the policies, behaviors systems drift, and Guiding process, that in while which are we Behaviors. training considered ensuring work, and accountability our unsafe operating behaviors, for our environment for and patients, behavioral the behaviors associates choices. of those and organization. around us. Yet, we We Good If We we must will cannot are examples anticipate look willing at the expect to of that investigate perfection system human we will design behaviors make from and strategies learn mistakes, and our leaders, from system include our and associates mistakes design that use even of that or and as might share highly physicians. safeguards, this skilled contribute learning associates, to double we an can undesired we checks, design will drift outcome more and from barriers. reliable safe instead choices systems. of focusing to unsafe only choices. on the outcome. Our Good We need success system This to developing will lies design be a in recognizing will big active anticipate change learning for that human us. we systems are error, all imperfect and capture an organizational and errors are early continuously commitment before By It is defining about they holding reach to the three working the the early each toward patient, behaviors identification other improved and accountable (Human permit of reliability. risk recovery Error, for in our the At-Risk when systems quality Behavior, the of and systems our and Reckless behaviors consequences and choices, Behavior), both and of before errors our we efforts establish can and cause to after continuously a events harm. framework occur. improve. for fair and consistent responses We It is must about design to doing human the systems behavior right thing that in will for our help our organization. patients, us make visitors, good decisions and within those associates. systems In a Just Culture, the goal is to work together to create a safer organization for our patients and each other. Copyright 2011 Trinity Health - Novi, Michigan 8
Three Human Behaviors Human Error: an inadvertent action; inadvertently doing other than what should have been done; a slip, a lapse, a mistake. 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. Copyright 2011 Trinity Health - Novi, Michigan 9
Three Scenarios Version #1 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. Version #2 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. Version #3 On a snowy winter night John yelled yee haa, closed his eyes and hit the gas. He never saw his neighbor s mailbox.
Safe Choices No Small Consequence The Safe Choices No Small Consequence video is a depiction of an event. We will learn in this video to begin identifying the human behaviors that are present in an organization. While watching the video, think about the behaviors of the characters and write them down on the handout: Errors Good choices Poor choices Copyright 2011 Trinity Health - Novi, Michigan 11
Wrap-Up: Behavioral Choices and Human Errors What were some of the good choices made by people in the video? What human errors were made by people in the video? What about the poor choices that were made by people in the video? Which of those poor choices was an at-risk behavior or a reckless behavior? What were some of the human and system factors that may have caused these choices or errors? Characters: Nurse Anne Margaret Bruce Dr. Jacobs Skinny Eli Technician at Factory Nurse Nicole Copyright 2011 Trinity Health - Novi, Michigan 12
Wrap-Up: Causes Copyright 2011 Trinity Health - Novi, Michigan 13
In My Team What about your department? Share some examples of what this might look like in your department. Human Error At-Risk Behavior Reckless Behavior Copyright 2011 Trinity Health - Novi, Michigan 14
What is the expectation for associates? What should you do? Peer Coaching Open Eyes and Ears Speak Up Support each other in serving. Help your fellow associates see the risks they are taking. Look at the risk around you. How can you help improve the system design around you? 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. Copyright 2011 Trinity Health - Novi, Michigan 15
My Commitment to You as Manager Copyright 2012 Trinity Health - Novi, Michigan 16
Key Points There are five essential elements of a just culture that we should all strive to work towards There are three manageable human behaviors that we should recognize and try to minimize Undesirable outcomes are the result of system design and behavioral choices My at-risk behavior can be reinforced by a positive outcome (nothing bad happened) I can reduce risk when I see risk both in the system design and my behavioral choices I can reduce risk when I contribute to a just culture that allows us to share with others the risk that I see Copyright 2011 Trinity Health - Novi, Michigan 17
Next Steps Log in to your HealthStream account and complete the Post-Test and Course Evaluation Stay tuned for more learning about making Safe Choices in a Just Culture Copyright 2012 Trinity Health - Novi, Michigan 18