CONSOLE, COACH, OR

PUNISH?

DAVID MARX

MARCH 8, 2017

2017 Michigan Patient Safety and Quality Symposium

THE TOPIC

THE PROBLEM

US – YOU, ME, THAT PERSON

SITTING NEXT TO YOU

We are inherently self-serving,

occasionally altruistic, happiness-

seeking, inescapably fallible,

pack animals blessed (or cursed)

with free will and a mis-tuned

ability to see and avoid hazards

in the world around us

ACCOUNTABILITY?

AN EXAMPLE

What does it take to

inadvertently back

over a child?

What roles does

“accountability” play?

THE DESIGN

Child hit

by car

Child

moves

into

harms

way

Driver does not

walk around car

Back up camera

does not warn

Three dice – so why do we kill two kids a week?

CLOSER TO REALITY?

Child hit by

carWhat kid?

THE NEW YORK

CITY SUBWAY

HEY YOU – DON’T FALL IN

THE TRACKS!

HOW ABOUT BETTER

SYSTEM DESIGN?

PERHAPS AN EXPECTATION

As for me and my house…

We will, where possible, put

ourselves three human errors

from patient harm

BACK TO US

We are inherently self-serving,

occasionally altruistic, happiness-

seeking, inescapably fallible,

pack animals blessed (or cursed)

with free will and a mis-tuned

ability to see and avoid hazards

in the world around us

THE PROBLEM: CHOICE

HUMAN

CHOICE

Hurry, Bob, the Cowboys

play the Packers in 10

minutes

I know, I know.

I can’t reach the top. Hey,

do we have a third ladder?

A SIMPLE MENTAL

MODEL

ActionInterpretation and Decision-MakingPerception

Pursuit of the

Mission

The

“Risk Monitor”(background

process, harm

focused)

Sight

Sound

Smell

Taste

Touch

OUR RISK

MONITORS

OUR RISK

MONITORS

THE LIMITS OF NATURAL

CONSEQUENCES

Choice

Desired

and

Undesired

Outcomes

The less likely the undesired outcome, the more

distant the undesired outcome, the harder it is to see

the link between a risky choice and the undesired

outcome it may cause.

HOW WE MAKE

CHOICES

• “Life, Liberty, and the Pursuit of Happiness”

• Pursue our individual mission, while trying to respect our

shared values

• We are NOT inherently rule followers (we take them

under advisement)

• We ARE hazard and threat avoiders

• Natural and man-made hazards

• Values-based threats

• Engineered threats

WE HUMANS PURSUE OUR INDIVIDUAL

MISSIONS, WHILE TRYING TO AVOID HAZARDS

Engineered

Threat

Man-Made

Hazard

Values-Based

Threat

AN ORDER OF

PREFERENCE?

1. I comply because I see the link between my deviation

and the potential harm being managed by the rule.

2. I comply because it’s a cultural expectation (peer

condemnation).

3. I comply to avoid organizational sanction.

I comply because it’s the rule

CHOICES =

CULTURE

Culture: the degree to which

human beings will, through their

choices, be protective of a

shared value. This often

appears as the “extra effort” it

takes to act in protection of a

value, in the face of a belief that

potential harm is uncertain,

delayed, or will simply happen

to someone else.

BACK TO US – JUST WHO

ARE WE?

WE MAKE MISTAKES

HUMAN BEHAVIOR

Human Error - inadvertent action;

inadvertently doing other that

what should have been done;

slip, lapse, mistake.

THE THREE BEHAVIORS

WE DRIFT

HUMAN BEHAVIOR

Human Error - inadvertent action;

inadvertently doing other that

what should have been done;

slip, lapse, mistake.

At-Risk Behavior - behavioral choice that

increases risk where risk is not

recognized or is mistakenly

believed to be justified.

THE THREE BEHAVIORS

WE GAMBLE

HUMAN BEHAVIOR

Human Error - inadvertent action; inadvertently doing other that what should have been done; 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.

THE THREE BEHAVIORS

Reckless

Behavior

Conscious Disregard of

Substantial and

Unjustifiable Risk

Manage through:

• Remedial action

• Punitive action

At-Risk

Behavior

A Choice: Risk Believed

Insignificant or Justified

Manage through:

• Removing incentives

for at-risk behaviors

• Creating incentives

for healthy behaviors

• Increasing situational

awareness

Human

Error

Product of Our Current

System Design and

Behavioral Choices

Manage through

changes in:

• Choices

• Processes

• Procedures

• Training

• Design

• Environment

Console Coach Sanction

A MORE “JUST” CULTURE?

Reckless

Behavior

Conscious Disregard of

Substantial and

Unjustifiable Risk

Manage through:

• Remedial action

• Punitive action

At-Risk

Behavior

A Choice: Risk Believed

Insignificant or Justified

Manage through:

• Removing incentives

for at-risk behaviors

• Creating incentives

for healthy behaviors

• Increasing situational

awareness

Human

Error

Product of Our Current

System Design and

Behavioral Choices

Manage through

changes in:

• Choices

• Processes

• Procedures

• Training

• Design

• Environment

Console Coach Sanction

A MORE “JUST” CULTURE?

• Design systems to be

tolerant of our

inescapable human

fallibility

• Design systems that

reduce the likelihood of

human error

• Accept the error that

does occur: don’t take

it out on your employee

Reckless

Behavior

Conscious Disregard of

Substantial and

Unjustifiable Risk

Manage through:

• Remedial action

• Punitive action

At-Risk

Behavior

A Choice: Risk Believed

Insignificant or Justified

Manage through:

• Removing incentives

for at-risk behaviors

• Creating incentives

for healthy behaviors

• Increasing situational

awareness

Human

Error

Product of Our Current

System Design and

Behavioral Choices

Manage through

changes in:

• Choices

• Processes

• Procedures

• Training

• Design

• Environment

Console Coach Sanction

A MORE “JUST” CULTURE?

• Use threat of sanction

to deter self-interested

choices

• Remove those

individuals who decide

to gamble with others

Reckless

Behavior

Conscious Disregard of

Substantial and

Unjustifiable Risk

Manage through:

• Remedial action

• Punitive action

At-Risk

Behavior

A Choice: Risk Believed

Insignificant or Justified

Manage through:

• Removing incentives

for at-risk behaviors

• Creating incentives

for healthy behaviors

• Increasing situational

awareness

Human

Error

Product of Our Current

System Design and

Behavioral Choices

Manage through

changes in:

• Choices

• Processes

• Procedures

• Training

• Design

• Environment

Console Coach Sanction

A MORE “JUST” CULTURE?

• Good system

design to deter

human drift

• Managerial

coaching

• Peer to peer

coaching

A housekeeping worker was waxing the floors around

10:00 pm. He could not find a wet floor sign and would

have had to have gone to another building to search for

one. Believing he was alone in the building, he did not

search for a warning sign. An accountant slipped on the

wet floor and severely damaged his knee. The

housekeeping staff frequently had to search for the wet

floor warning signs which caused them to get behind on

their work. The housekeeping manager was aware of the

unavailability of signs, but did not take any action to

purchase more.

SCENARIO 1

The CNO has been a patient in the ICU for three days. It’s

rumored that she’d acquired an infection here in the

hospital. Strangely, Sally Burchimer, a charge nurse on 6

West seems to think she may have caused the CNO’s

illness. Sally had been out ill for a week. She knows that

she met with the CNO directly upon her return, and is

fearful that she is the cause. To alleviate here angst, she

decided to look into the CNO’s chart, in hopes that the

CNO had fallen ill to another form of infection. An audit of

those who accessed the CNO’s record identified the

breach in privacy.

SCENARIO 2

SCENARIO 3

A brand new nurse to the OR (watching and learning the

processes and practices of her new employer) storms out

of the safety timeout ahead of surgery and right in the

Director of the OR’s office. She blurts out, “Are you

kidding me? The anesthesiologist is listened to his IPod

with those little things in his ears. He’s actually dancing a

bit, you know, moving to the beat, nodding his lead when

people look his way. I looked at everyone else in the

timeout, and no one seemed to notice. They look like

Zombies. Is this how we’re going to treat patient’s here?

Do anesthesiologists get a pass? Does anyone care?”

SCENARIO 4

The Engineering department has a large book in which the instructions

for repairing equipment are located. Policy requires that these

instructions be followed each time that a repair was performed. Last

week a technician made a mistake on the repair of an infusion pump by

omitting a required check upon re-assembly of the pump (relying on his

memory to perform the task). This check, called out in the manual,

would have confirmed that the infusion pump would not allow the free

(unregulated) flow of medication under a particular failure mode of the

pump.

The inoperable pump safety device was caught when a patient received

a free flow of heparin, leading to the death of the patient. Investigation

reveals that the technician regularly performs this specific maintenance.

Investigation also reveals that other technicians were performing this

task by memory, without the aid of the procedure manual.

An attending physician is about to perform minor surgery

(removal of a cyst). Ahead of the surgery, the nurse

comes in to have the consent signed by the patient. The

patient states that the physician did not discuss the risks –

therefore it would be inappropriate to sign the disclosure

form. The nurse said, “Look, we can make a mistake and

sometimes the outcome isn’t that great. Given that, you’re

probably better off having the surgery. So, just sign the

thing.” The patient complains to the physician, who says

“well, did you sign the consent, or not?”

SCENARIO 5

PATIENT SAFETY AND

WORKPLACE ACCOUNTABILITY?

Reliable

Systems

Good

Choices+Good

Outcomes=

UNDERSTAND WHAT

WE CAN CONTROL

Systems Choices+ Outcomes=

DO THE HARD WORK

• Articulate safety as an organizational value

• Design your systems to support safe choices

• Audit (look for safety supportive choices)

• Be a role model (resolve dilemmas in a manner that

demonstrates your commitment to safety)

• Mentor (help others resolve dilemmas in the right way)

• Coach (call it out when you see choices that are unsafe)

• Hold everyone accountable for the right choices

(unresponsive to coaching, or reckless -- go home)