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Next, let's talk about, Just Culture,
and what it means in a high reliability and a patient safety environment.
Dr. Lucian Leape from Harvard has said,
"The single greatest impediment to error prevention in
the medical industry is that we punish people for making mistakes."
And I think this is really important to understand and how we respond to the errors that
do happen plays an important role in the safety culture that we develop.
It's about finding the right balance.
So we know that some organizations now,
but certainly in the past have had a more punitive response to error,
it's more of a name, shame, and blame environment.
Then some have swung to the other extreme and have created what they refer to as a,
blame free environment, where it almost
feels like there's amnesty for when errors do occur.
And it Just Culture is really about striking a balance between those two.
David Marx has developed this model for
understanding and responding to events in a just way.
The three behaviors he suggests,
these three behaviors kind of encompass
all the potential behaviors that would result in something adverse occurring.
First, the reckless behavior.
Those are behavioral choices where there's
a conscious disregard of a substantial and unjustified risk.
At-risk behaviors are defined as those that increase risk where risk is not recognized,
or is mistakenly believed to be justified.
And then the third behavior is really around human error,
where there's been an inadvertent action or a slip lapse or mistake that's occurred.
This model in a more expanded way looks at these three behaviors side by side.
But in the bottom row,
you see how Marx recommends we respond as managers to these three different behaviors.
How we respond is very different depending on the behavior that preceded the event.
So when human error occurs,
he suggests consoling the employee,
that really punishing an employee for
a human error is not an effective way to manage that event.
And in fact, by punishing a human error,
you may actually minimize the learning that can happen.
At risk behavior being unintentional risk taking,
It's really coaching that is going to be the better,
more appropriate response to those behaviors.
And then, reckless behavior where there's
an intentional disregard of safety and intentional risk taking,
that really is where a punitive response is most appropriate.
The principles of a Just Culture are these.
That we recognize that humans will err,
to err is human,
and that also drifting is human error.
We all know that it's difficult to stay within the speed limit, and periodically,
we look down and we find ourself going higher than the speed limit that's posted.
And that is about drift,
that's common, that's human nature.
We know that particularly in a health care environment, risk is everywhere.
Risk, particularly in some of our intensive care units, is very high.
And that we need to recognize that our employees and
we personally manage in support of our core values.
And so what values drive our behavior,
and that will also drive how we respond and that we are all accountable.
We need to recognize that everyone plays a role.
An important distinction in Just Culture is
looking at what drives our response to an error.
Are we more outcome driven or are we more behavior driven in our response?
When we're more outcome driven,
we look at what was the outcome of the event, was there harm?
And is the response,
the management response to an event based on whether or not harm occurred.
So, sometimes we hear no harm no foul to suggest that,
if the patient didn't get harmed then there's really nothing we need to do.
We just lucked out,
let's just be grateful nothing worse happened,
and we overlook the opportunities to learn in that way.
Because many times, whether a patient is harmed or not,
is a matter of luck.
But to be more behavior focused which the Just Culture model would suggest,
says that we are looking at the behaviors of the employee to determine what outcome,
or what response, or what consequences there might be.
So that if there's a behavior that really is
a dangerous behavior but just didn't maybe result in any harm,
it probably should be addressed in the same way as if if harm did occur.
So being very conscious about whether you were more outcome focused or behavior
focused is important in understanding the practice of Just Culture.
It's also important to reframe why events happen to help us understand Just Culture.
So when an event happens,
it's usually a combination of
an unsafe system design coupled with unsafe behavior choices.
When we look at it this way,
we recognize the fact that the way the system is designed
is sometimes as important as the behavior choice of the individual within that system.
And that these two play together.
How an employee responds and behaves may be the result of a way a system is designed,
and that this is what the accountability,
the accountability of everyone within the system to make sure events don't happen.
So why don't we use a Just Culture Framework?
Why? Well, by using such a framework to help you understand and respond to these errors,
we promote patient safety and quality in a way that examines the behavioral choices,
not just the outcome of the events,
as I previously mentioned.
It balances individual accountability with system accountability.
Like we said just now,
it's about the design of the system as much as the individual behavior choices.
It also leaves room to recognize the accountability of leaders in designing safe systems.
That if we punish employees for making mistakes or making
behavior choices that are driven by flaws in the design of a system,
that's not the employees fault,
those are decisions and problems that live elsewhere in the system,
and we need to recognize that.
A Just Culture Framework also promotes learning from errors,
and that it also,
this ability to distinguish between the human error the
at risk and the reckless behavior is important.
Because not all response to error should be the same,
it depends on the circumstances.
And in the end, we're all accountable.
And we need to understand what each of our roles are
in creating a system that allows employees to make
safe choices and design a system that is going to protect the patient.
Eileen Kasda
