just culture . just culture is about: creating an open, fair, and just culture creating an open,...
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Just CultureJust Culture
www.justculture.orgwww.justculture.org
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
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
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
We know….to error is HumanWe know….to error is Human
But….To Drift is also Human
Managing Behavioral Choices:Managing Behavioral Choices:Everyone Takes Risks, Every DayEveryone Takes Risks, Every Day
RISKSOCIAL UTILITY
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.
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
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
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
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
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
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.
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.