Transcript Quality Improvement as Part of our Nursing Practice
Just Culture
Alison H. Page, MHA, MSN Chief Safety Officer Fairview Health Services
We’ve all been there……
Medication errror
Failure to check patient identification
Why did these accidents happen?
How what can we do to prevent them from happening again? How do we judge the clinicians involved?
How would you organization deal with a surgeon who used an unauthorized piece of equipment?
Percentage of those who believe Fairview would discipline the surgeon….if:
NO harmful outcome Harmful outcome -
19% of staff 0% of managers 11% of executives 0% of physicians
-
29% of staff 50% of managers 14% of executives 45% of physicians
We can do two things: 1. Design systems to accommodate human beings 2. Manage human behavior within the systems
NAVAL AVIATION MISHAP RATE
60 776 aircraft destroyed in 1954 FY 50-96 Angled Carrier Decks Naval Aviation Safety Center 50 40 30 20 10 NAMP est. 1959 RAG concept initiated 39 aircraft destroyed in 1996 NATOPS initiated 1961 Squadron Safety program System Safety Designated Aircraft ACT HFC’s
2.39
0 50 65 80 96 Fiscal Year
Managing Systems
“Systems produce precisely the outcomes they are designed for.”
Don Berwick
Epinephrine Ephedrine
Dopamine Dobutamine
EPInephrine EPHEDrine DOPamine DoBUTamine
Seven Design Strategies Important to Managing Risk • Knowledge • Skill • Performance Shaping Factors • Barriers • Redundancy • Recovery • Perception of High Risk
Managing human behavior is a bit harder.
Why?
Because – to error is human
Paris in the the spring
Nominal Human Error Rates
Activity
Error of commission (misreading a label) Error of omission without reminders Error of omission when items imbedded in a procedure Simple math error with self-checking Monitor or inspector fails to detect error Personnel on different shifts fail to check hardware unless required by checklist General error in high stress when dangerous activities occurring rapidly
Probability
0.003
0.01
0.003
0.03
0.1
0.1
0.25
Salvendy G. Handbook of human factors & ergonomics 1997.
Aoccdrnig to rscheearch at Cmabrigde Uinervtisy, it deosn't mttaer inwaht oredr the ltteers in a wrod are, the olny iprmoetnt tihng is that the frist and lsat ltteer be at the rghit pclae. The rset can be a total mses and you can sitll raed it wouthit porbelm. Tihs is bcuseae the huamn mnid deos not raed ervey lteter by istlef, but the wrod as awlohe.
The human brain cannot have multiple simultaneous foci of interest. This lack of cognitive resource is the single limiting factor of human activity.
Francois Clergue
Lessons from Human Factors Research
Errors are common The causes of errors are known Errors are byproducts of useful cognitive functions
Lessons from Human Factors Research
Many errors are caused by activities that rely on weak aspects of cognition short-term memory attention span Errors can be prevented by designing tasks and processes that minimize dependency on weak cognitive functions
Human Factors Principles & Systems Design
Avoid reliance on memory and vigilance
Use protocols and checklists
Simplify Standardize Use constraints and forcing functions
Human Factors Principles & Systems Design
Improve access to information Make potential errors obvious Increase feedback Reduce hand-offs Decrease look-alikes Automate very carefully
“We can’t change the human condition, but we can change the conditions under which humans work”
James Reason
However….
Humans
are
accountable for their behavioral choices
Just Culture
www.justculture.org
Just Culture is about:
Creating an open, fair, and just culture Creating a learning culture Designing safe systems Managing behavioral choices
Adverse Events Human Errors System Design Managerial and Staff Behaviors
Learning Culture / Just Culture
Managing for Safety Using Just Culture
In its 1999 report, “To Err is Human,” the Institute of Medicine reported that 44,000 to 98,000 individuals lose their lives to medical error in our nation’s hospitals every year.
Now, in addition to creating a healthcare delivery system that is more patient-centered, timely, efficient, equitable, and effective, we have been challenged to improve the safety of our nation’s healthcare system.
It has been said that every system is designed to achieve exactly the results it gets. In other words, we are getting the rate of accidental (iatrogenic) injury commensurate with the system we have built. To make a substantial step in patient safety, we must change the healthcare system.
This worksheet illustrates one critical element of that fundamental change - the creation of a more open, fair, and just culture. It is through a just culture that we will begin to see, understand, and mitigate the risks within the healthcare system.
Design Safe Systems…
The first cornerstone of patient safety is the design of safe systems. It is the system in which we work that has the greatest overall influence on the safety of the patient. We must design systems that anticipate human error, capture errors before they become critical, and permit recovery when errors do reach the patient.
Adverse Events Human Errors Manage Behavioral Choices...
The second cornerstone of patient safety is the management of behavioral choices. While we must anticipate that we as humans will make mistakes - it is our management of behavioral choices that will allow us to achieve the safety outcomes we desire .
outcome engineering dallas, tx www.outcome-eng.com
copyright 2005 System Design Managerial and Staff Behaviors Create an Open, Fair and Just Culture…
organizations must move away from an overly-punitive reaction to events and errors. We must instead recognize our A learning culture is the foundation of patient safety. It is and that we will drift away from what we at the individual and organizational level. Risk can be seen through events, near misses, or merely by observing have been taught. the design of the systems in which we work, our own behaviors, and the behaviors of those around us.
This document is not self-explanatory. It is to be used as an aid in the Safe Choices course.
Managing for Safety Using Just Culture
In its 1999 report, “To Err is Human,” the Institute of Medicine reported that 44,000 to 98,000 individuals lose their lives to medical error in our nation’s hospitals every year.
Now, in addition to creating a healthcare delivery system that is more patient-centered, timely, efficient, equitable, and effective, we have been challenged to improve the safety of our nation’s healthcare system.
It has been said that every system is designed to achieve exactly the results it gets. In other words, we are getting the rate of accidental (iatrogenic) injury commensurate with the system we have built. To make a substantial step in patient safety, we must change the healthcare system.
This worksheet illustrates one critical element of that fundamental change - the creation of a more open, fair, and just culture. It is through a just culture that we will begin to see, understand, and mitigate the risks within the healthcare system.
outcome engineering dallas, tx www.outcome-eng.com
copyright 2005 Design Safe Systems…
The first cornerstone of patient safety is the design of safe systems. It is the system in which we work that has the greatest overall influence on the safety of the patient. We must design systems that anticipate human error, capture errors before they become critical, and permit recovery when errors do reach the patient.
Adverse Events Human Errors Manage Behavioral Choices...
The second cornerstone of patient safety is the management of behavioral choices. While we must anticipate that we as humans will make mistakes - it is our management of behavioral choices that will allow us to achieve the safety outcomes we desire .
Create a Learning Culture… System Design Managerial and
safety. It is a culture that is hungry for knowledge - in the case of patient safety it is Learning Culture / Just Culture a culture that is hungry to see risk, both at the individual and organizational level. Risk can be seen through events, near misses, or merely by observing the design of the systems in which we work, our own behaviors, and the behaviors of those around us.
Create an Open, Fair and Just Culture…
To create a learning environment, organizations must move away from an overly-punitive reaction to events and errors. We must instead recognize our own fallibility - that we will make errors and that we will drift away from what we have been taught . This document is not self-explanatory. It is to be used as an aid in the Safe Choices course.
Managing for Safety Using Just Culture
In its 1999 report, “To Err is Human,” the Institute of Medicine reported that 44,000 to 98,000 individuals lose their lives to medical error in our nation’s hospitals every year.
Now, in addition to creating a healthcare delivery system that is more patient-centered, timely, efficient, equitable, and effective, we have been challenged to improve the safety of our nation’s healthcare system.
It has been said that every system is designed to achieve exactly the results it gets. In other words, we are getting the rate of accidental (iatrogenic) injury commensurate with the system we have built. To make a substantial step in patient safety, we must change the healthcare system.
This worksheet illustrates one critical element of that fundamental change - the creation of a more open, fair, and just culture. It is through a just culture that we will begin to see, understand, and mitigate the risks within the healthcare system.
Design Safe Systems…
The first cornerstone of patient safety
Adverse
is the design of safe systems. It is
Manage Behavioral Choices...
The second cornerstone of patient safety is the management of behavioral choices. While we must anticipate that we as humans will make mistakes - it is our management of behavioral choices that will allow us to achieve the safety outcomes we desire .
the system in which we work that has the greatest overall influence on the
Human Errors
safety of the patient. We must design systems that anticipate human error, capture errors before they become critical, and permit recovery when
System Managerial and
errors do reach the patient.
Staff Behaviors
Learning Culture / Just Culture
outcome engineering dallas, tx www.outcome-eng.com
copyright 2005 Create a Learning Culture…
A learning culture is the foundation of patient safety. It is a culture that is hungry for knowledge - in the case of patient safety it is a culture that is hungry to see risk, both at the individual and organizational level. Risk can be seen through events, near misses, or merely by observing the design of the systems in which we work, our own behaviors, and the behaviors of those around us.
Create an Open, Fair and Just Culture…
To create a learning environment, organizations must move away from an overly-punitive reaction to events and errors. We must instead recognize our own fallibility - that we will make errors and that we will drift away from what we have been taught . This document is not self-explanatory. It is to be used as an aid in the Safe Choices course.
Managing for Safety Using Just Culture
In its 1999 report, “To Err is Human,” the Institute of Medicine reported that 44,000 to 98,000 individuals lose their lives to medical error in our nation’s hospitals every year.
Now, in addition to creating a healthcare delivery system that is more patient-centered, timely, efficient, equitable, and effective, we have been challenged to improve the safety of our nation’s healthcare system.
It has been said that every system is designed to achieve exactly the results it gets. In other words, we are getting the rate of accidental (iatrogenic) injury commensurate with the system we have built. To make a substantial step in patient safety, we must change the healthcare system.
This worksheet illustrates one critical element of that fundamental change - the creation of a more open, fair, and just culture. It is through a just culture that we will begin to see, understand, and mitigate the risks within the healthcare system.
Manage Behavioral Choices...
The second cornerstone of patient safety is the management of behavioral
Design Safe Systems…
choices. While we must anticipate that design of safe systems. It is the system in which we work that has the greatest overall influence we as humans will make mistakes - it is systems that anticipate human error, capture
Events
our management of behavioral choices that will allow us to achieve the safety
Human Errors
outcomes we desire.
System Design Managerial and Staff Behaviors
Learning Culture / Just Culture
outcome engineering dallas, tx www.outcome-eng.com
copyright 2005 Create a Learning Culture…
A learning culture is the foundation of patient safety. It is a culture that is hungry for knowledge - in the case of patient safety it is a culture that is hungry to see risk, both at the individual and organizational level. Risk can be seen through events, near misses, or merely by observing the design of the systems in which we work, our own behaviors, and the behaviors of those around us.
Create an Open, Fair and Just Culture…
To create a learning environment, organizations must move away from an overly-punitive reaction to events and errors. We must instead recognize our own fallibility - that we will make errors and that we will drift away from what we have been taught . This document is not self-explanatory. It is to be used as an aid in the Safe Choices course.
A Model that Focuses on Three Duties balanced against Organizational and Individual Values The Three Duties The duty to avoid causing unjustified risk or harm The duty to produce an outcome The duty to follow a procedural rule Organizational and Individual Values Safety Cost Effectiveness Equity Dignity etc
Two Specific Classes of Duty
• Meet me at 7:00 pm at 410 Chestnut Street The Duty to Produce an Outcome • Leave the house at 6:45 pm. Go south on Independence Ave, turn right on Parker. At the third light, hang a left, go three blocks, turn right and go to the fourth house on the right.
The Duty to Follow a Procedural Rule
We know….to error is Human
But….To Drift is also Human
Managing Behavioral Choices: Everyone Takes Risks, Every Day
RISK SOCIAL UTILITY
The Behaviors We Can Expect
Human error - inadvertent action; inadvertently doing other that what should have been done; slip, lapse, mistake.
At-risk behavior - behavior 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.
Examples
Failure to check the name band
Accountability for our Behavioral Choices Human Error
Product of our current system design
Manage through changes in: • • • • • Processes Procedures Training Design Environment
At-Risk Behavior
Unintentional Risk-Taking
Manage through: • • • Removing incentives for at-risk behaviors Creating incentives for healthy behaviors Increasing situational awareness
Console Coach Reckless Behavior
Intentional Risk-Taking
Manage through: • • Remedial action Disciplinary action
Punish
Managing Human Error
• Two questions: – Did the employee make the correct behavioral choices in their task?
– Is the employee effectively managing their own performance shaping factors?
• If yes, the only answer is to console the employee – the error happened to him / her
Managing Multiple Human Errors
What is the source of a pattern of human errors?
– The system? If yes, address the system.
– If no, can the repetitive errors be addressed through non-disciplinary means?
– If no, how will disciplinary sanction reduce the rate of human error?
Managing At-Risk Behaviors
• A behavioral choice – Driven by perception of consequences • Immediate and certain consequences are strong • Delayed and uncertain consequences are weak • Rules are generally weak
Managing At-Risk Behaviors
• A behavioral choice – Managed by adding forcing functions (barriers to prevent non-compliance) – Managed by changing perceptions of risk – Managed by changing consequences – Coaching
Why not punish “at-risk” behavior?
Because….
1.
Somewhere along the line your organization has likely tacitly approved certain at-risk behaviors. 2. If you punish at-risk behavior people will likely not be honest about the at-risk behavior next time
Who judges risk and behaviors? • Risk = Severity x Likelihood • Safety ~ Reasonableness of Risk
Managing Reckless Behavior
• Reckless Behavior – Conscious disregard of substantial and unjustifiable risk • Manage through: – Disciplinary action
Managing Behavioral Choices
Human Error
Product of our current system design
Manage through changes in: • • • • • Processes Procedures Training Design Environment
At-Risk Behavior
Unintentional Risk-Taking
Manage through: • • • Removing incentives for at-risk behaviors Creating incentives for healthy behaviors Increasing situational awareness
Console Coach Reckless Behavior
Intentional Risk-Taking
Manage through: • • Remedial action Disciplinary action
Punish
Doves and Hawks
Summary
What is a JUST CULTURE about?
It’s About a Proactive Learning Culture
It’s not seeing events as things to be fixed It’s seeing events as opportunities to improve our understanding of risk System risk, and Behavioral risk
It’s About Reinforcing the Roles of Risk, Quality, and HR
Risk/Quality Helping improve the effectiveness of the learning process Providing tools to line managers Helping to redesign systems HR Protecting the learning culture Helping with managerial competencies Consoling Coaching Corrective Action
It’s About Changing Managerial Expectations
Knowing my risks Investigating the source of errors and at-risk behaviors Turning events into an understanding of risk Designing safe systems Facilitating safe choices Consoling Coaching Punishing
It’s About Changing Staff Expectations
Looking for the risks around me Reporting errors and hazards Helping to design safe systems Making safe choices
Following procedure Making choices that align with organizational values Maintaining situational awareness
A Shared Conceptual Model
Human Error
Product of our current system design
Manage through changes in: • • • • • Processes Procedures Training Design Environment
At-Risk Behavior
Unintentional Risk-Taking
Manage through: • • • Removing incentives for at-risk behaviors Creating incentives for healthy behaviors Increasing situational awareness
Console Coach Reckless Behavior
Intentional Risk-Taking
Manage through: • • Remedial action Disciplinary action
Punish
An Algorithm to Follow
Common language Common conversation
The Just Culture Algorithm
The analytical heart of the Just Culture is the Just Culture Algorithm™. It will serve as a guide when managers address employees whose behaviors do not align with organizational values or procedural rules. Developed around the Three Duties, the Algorithm provides both the organization and the employee a method to ensure that breaches in the system will be dealt with in a consistent manner throughout the organization. The Algorithm is the answer key for what to do when things go wrong.
Available at: https://www.justculture.org/store
We need…..
A culture that truly supports learning A common understanding about how to treat people when things happen
The Chain of Effect in Improving Health Care Quality Patient and Community Experience Aims:
Safe, timely, effective, efficient, equitable, and patient-centered
Microsystem
(e.g. cardiac team)
Process Simple rules/Design concepts:
(e.g. knowledge-based, customized, cooperation)
Organizational Context
(e.g. hospital)
Facilitator of Processes Design Concepts:
(e.g HR, IT, Leadership)
Environmental Context
(e.g. legislature)
Facilitator of facilitators Design Concepts:
(e.g. Legistaion, regulation, accreditation, education)
The Minnesota Agenda
Formation of a stakeholder group - The Minnesota Alliance for Patient Safety Change state law Developed principles of justice, learning and accountability Change the policies and practices of: The Boards The Dept of Health Delivery systems
Our Goal
The behavior of people involved in care delivery in the state of Minnesota will be judged using a common philosophy and a common set of principles across healthcare organizations, the Department of Health, the professional boards and professional associations
Minnesota Statement of Support
Given that: Medical errors and patient safety are a national concern to all involved in health care delivery.
We are legally and/or ethically obligated to hold individuals accountable for their competency and behaviors that impact patient care.
A punitive environment does not fully take into account system issues, and a blame-free environment does not hold individuals appropriately accountable
We resolve that our organization will: Strive for a culture that balances the need for a non-punitive learning environment with the equally important need to hold persons accountable for their actions.
Seek to judge the behavior, not the outcome, distinguishing between human error, at-risk behavior, and intentional reckless behavior. Foster a learning environment that encourages the identification and review of all errors, near-misses, adverse events, and system weaknesses.
Promote the use of a wide range of responses to safety-related events caused by lapses in human behavior, including coaching, non-disciplinary counseling, additional education or training, demonstration of competency, additional supervision and oversight and disciplinary action when appropriate to address performance issues.
Support and implement systems that enable safe behavior to prevent harm Work to share information across organizations to promote continuous improvement and ensure the highest level of patient and staff safety. Collaborate in efforts to establish a statewide culture of learning, justice, and accountability to provide the safest possible environment for patients.