just culture . just culture is about: creating an open, fair, and just culture creating an open,...

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Just Culture Just Culture www.justculture.org www.justculture.org

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Page 1: Just Culture . Just Culture is about: Creating an open, fair, and just culture Creating an open, fair, and just culture Creating a

Just CultureJust Culture

www.justculture.orgwww.justculture.org

Page 2: Just Culture . Just Culture is about: Creating an open, fair, and just culture Creating an open, fair, and just culture Creating a

Just Culture is about:Just Culture is about:

Creating an open, Creating an open, fair, and just culturefair, and just culture

Creating a learning Creating a learning cultureculture

Designing safe Designing safe systemssystems

Managing Managing behavioral choicesbehavioral choices

AdverseEvents

HumanErrors

Managerialand Staff

Behaviors

SystemDesign

Learning Culture / Just Culture

Page 3: Just Culture . Just Culture is about: Creating an open, fair, and just culture Creating an open, fair, and just culture Creating a

A Model that Focuses on Three Duties A Model that Focuses on Three Duties balanced against Organizational and balanced against Organizational and

Individual ValuesIndividual Values The Three DutiesThe Three Duties

The duty to avoid The duty to avoid causing unjustified causing unjustified risk or harmrisk or harm

The duty to produce The duty to produce an outcomean outcome

The duty to follow a The duty to follow a procedural ruleprocedural rule

Organizational and Organizational and Individual ValuesIndividual Values SafetySafety CostCost EffectivenessEffectiveness EquityEquity DignityDignity etcetc

Page 4: Just Culture . Just Culture is about: Creating an open, fair, and just culture Creating an open, fair, and just culture Creating a

Two Specific Classes of Duty

• Meet me at 7:00 pm at 410 Chestnut Street

• 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 Produce an Outcome

The Duty to Follow a

Procedural Rule

Page 5: Just Culture . Just Culture is about: Creating an open, fair, and just culture Creating an open, fair, and just culture Creating a
Page 6: Just Culture . Just Culture is about: Creating an open, fair, and just culture Creating an open, fair, and just culture Creating a

We know….to error is HumanWe know….to error is Human

Page 7: Just Culture . Just Culture is about: Creating an open, fair, and just culture Creating an open, fair, and just culture Creating a

But….To Drift is also Human

Page 8: Just Culture . Just Culture is about: Creating an open, fair, and just culture Creating an open, fair, and just culture Creating a

Managing Behavioral Choices:Managing Behavioral Choices:Everyone Takes Risks, Every DayEveryone Takes Risks, Every Day

RISKSOCIAL UTILITY

Page 9: Just Culture . Just Culture is about: Creating an open, fair, and just culture Creating an open, fair, and just culture Creating a

The Behaviors We Can ExpectThe Behaviors We Can Expect

Human errorHuman error - inadvertent action; - inadvertent action; inadvertently doing other that what should inadvertently doing other that what should have been done; slip, lapse, mistake.have been done; slip, lapse, mistake.

At-risk behaviorAt-risk behavior - behavior that - behavior that increases risk where risk is not recognized, increases risk where risk is not recognized, or is mistakenly believed to be justified.or is mistakenly believed to be justified.

Reckless behaviorReckless behavior - behavioral choice to - behavioral choice to consciously disregard a substantial and consciously disregard a substantial and unjustifiable risk.unjustifiable risk.

Page 10: Just Culture . Just Culture is about: Creating an open, fair, and just culture Creating an open, fair, and just culture Creating a

Accountability for our Behavioral Accountability for our Behavioral ChoicesChoices

RecklessBehavior

Intentional Risk-Taking

Manage through: • Remedial action• Disciplinary action

At-RiskBehavior

Unintentional Risk-Taking

HumanError

Product of our current system design

Manage through changes in:

• Processes• Procedures• Training• Design• Environment

Console Coach Punish

Manage through:

• Removing incentives for at-risk behaviors

• Creating incentives for healthy behaviors

• Increasing situational awareness

Page 11: Just Culture . Just Culture is about: Creating an open, fair, and just culture Creating an open, fair, and just culture Creating a

We need…..We need…..

A culture that truly supports learningA culture that truly supports learning

A common understanding about how to treat people A common understanding about how to treat people when things happenwhen things happen

Page 12: Just Culture . Just Culture is about: Creating an open, fair, and just culture Creating an open, fair, and just culture Creating a

The Minnesota AgendaThe Minnesota Agenda Formation of a stakeholder group - The Minnesota Formation of a stakeholder group - The Minnesota

Alliance for Patient Safety (MAPS)Alliance for Patient Safety (MAPS) Change state lawChange state law Developed principles of justice, learning and Developed principles of justice, learning and

accountabilityaccountability Change the policies and practices of:Change the policies and practices of:

The BoardsThe Boards The Dept of HealthThe Dept of Health Delivery systemsDelivery systems

Page 13: Just Culture . Just Culture is about: Creating an open, fair, and just culture Creating an open, fair, and just culture Creating a

Our GoalOur Goal

The behavior of people involved in care The behavior of people involved in care delivery in the state of Minnesota will be delivery in the state of Minnesota will be judged using a common philosophy and a judged using a common philosophy and a common set of principles across healthcare common set of principles across healthcare organizations, the Department of Health, organizations, the Department of Health, the professional boards and professional the professional boards and professional associationsassociations

Page 14: Just Culture . Just Culture is about: Creating an open, fair, and just culture Creating an open, fair, and just culture Creating a

Minnesota Statement of Minnesota Statement of SupportSupport

Given that:Given that: Medical errors and patient safety are a Medical errors and patient safety are a

national concern to all involved in health national concern to all involved in health care delivery.care delivery.

We are legally and/or ethically obligated to We are legally and/or ethically obligated to hold individuals accountable for their hold individuals accountable for their competency and behaviors that impact competency and behaviors that impact patient care.patient care.

A punitive environment does not fully take A punitive environment does not fully take into account system issues, and a blame-into account system issues, and a blame-free environment does not hold individuals free environment does not hold individuals appropriately accountableappropriately accountable

Page 15: Just Culture . Just Culture is about: Creating an open, fair, and just culture Creating an open, fair, and just culture Creating a

We resolve that our organization will:We resolve that our organization will:

Strive for a culture that balances the need Strive for a culture that balances the need for a non-punitive learning environment for a non-punitive learning environment with the equally important need to hold with the equally important need to hold persons accountable for their actions.persons accountable for their actions.

Seek to judge the behavior, not the Seek to judge the behavior, not the outcome, distinguishing between human outcome, distinguishing between human error, at-risk behavior, and intentional error, at-risk behavior, and intentional reckless behavior. reckless behavior.

Foster a learning environment that Foster a learning environment that encourages the identification and review of encourages the identification and review of all errors, near-misses, adverse events, all errors, near-misses, adverse events, and system weaknesses.and system weaknesses.

Page 16: Just Culture . Just Culture is about: Creating an open, fair, and just culture Creating an open, fair, and just culture Creating a

Promote the use of a wide range of responses to Promote the use of a wide range of responses to safety-related events caused by lapses in human safety-related events caused by lapses in human behavior, including coaching, non-disciplinary behavior, including coaching, non-disciplinary counseling, additional education or training, counseling, additional education or training, demonstration of competency, additional demonstration of competency, additional supervision and oversight and disciplinary action supervision and oversight and disciplinary action when appropriate to address performance issues.when appropriate to address performance issues.

Support and implement systems that enable safe Support and implement systems that enable safe behavior to prevent harmbehavior to prevent harm

Work to share information across organizations to Work to share information across organizations to promote continuous improvement and ensure the promote continuous improvement and ensure the highest level of patient and staff safety. highest level of patient and staff safety.

Collaborate in efforts to establish a statewide Collaborate in efforts to establish a statewide culture of learning, justice, and accountability to culture of learning, justice, and accountability to provide the safest possible environment for provide the safest possible environment for patients. patients.