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Slide Notes
Good morning...
I'd like to thank the Peter for inviting me again to talk about something that is important me and hopefully will spark some interest in you.
Last time was slightly hurried, so Today we have a little more time to expand on the concept and you will also have an opportunity to practice.
I'd like to thank the Peter for inviting me again to talk about something that is important me and hopefully will spark some interest in you.
Last time was slightly hurried, so Today we have a little more time to expand on the concept and you will also have an opportunity to practice.
Just Culture - WiseR 2018
Published on Oct 24, 2016
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PRESENTATION OUTLINE
The Just Culture
Good morning...
I'd like to thank the Peter for inviting me again to talk about something that is important me and hopefully will spark some interest in you.
Last time was slightly hurried, so Today we have a little more time to expand on the concept and you will also have an opportunity to practice.
I'd like to thank the Peter for inviting me again to talk about something that is important me and hopefully will spark some interest in you.
Last time was slightly hurried, so Today we have a little more time to expand on the concept and you will also have an opportunity to practice.
Photo by Stuck in Customs
what happens
when things go wrong?
What happens in your hospital or department when things go wrong?
- a nurse gives medication to the wrong patient
- a piece of equipment fails during a critical procedure
- a doctor misses a ruptured AAA or
- a patient slips on a wet floor?
Are staff often stood down or reprimanded, or do you have a blame free system?
Healthcare is complex and largely reliant on well-trained and well-meaning yet fallible individuals.
How do we manage the risk to our patients and our organizations?
How do we foster a learning environment?
How do we develope a Culture of safety and risk awareness?
How do we produce better, more reliable outcomes?
The Just Culture is one such system.
- a nurse gives medication to the wrong patient
- a piece of equipment fails during a critical procedure
- a doctor misses a ruptured AAA or
- a patient slips on a wet floor?
Are staff often stood down or reprimanded, or do you have a blame free system?
Healthcare is complex and largely reliant on well-trained and well-meaning yet fallible individuals.
How do we manage the risk to our patients and our organizations?
How do we foster a learning environment?
How do we develope a Culture of safety and risk awareness?
How do we produce better, more reliable outcomes?
The Just Culture is one such system.
Photo by deepwarren
The 5 core skills
for leaders
In this session I am going to talk about the
- 5 skills needed by leaders
- 3 behavioural choices we need to manage and - - 1 Duty to rule them all!
As Leaders in healthcare, the JC suggests we need to develope the following skills:
- 5 skills needed by leaders
- 3 behavioural choices we need to manage and - - 1 Duty to rule them all!
As Leaders in healthcare, the JC suggests we need to develope the following skills:
Photo by Brett, The Wine Maestro
Untitled Slide
- Mission,Values,Expectations
- System design
- Learning systems
- Behavioural choices
- Justice & Accountability
So what to do we value?
Probably the most famous statement on human rights was written by Thomas Jefferson in 1776 in the Declaration of Independence and later made famous by Abraham Lincoln during the Gettysburg address when he said:
"We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness."
Probably the most famous statement on human rights was written by Thomas Jefferson in 1776 in the Declaration of Independence and later made famous by Abraham Lincoln during the Gettysburg address when he said:
"We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness."
Photo by RobiNZ
mission
First of all we need to determine our Mission - our reason for existing.
For example:
Landing a person on the moon and bringing him safely back to earth ....
Or shorting a motor vehicle into space ....
Or providing food within 5 minutes of the order!
this is the Mission or "promise statement" at our DHB.
Yours might be something similar.
At our ED we have further defined that by defining our CORE business.
For example:
Landing a person on the moon and bringing him safely back to earth ....
Or shorting a motor vehicle into space ....
Or providing food within 5 minutes of the order!
this is the Mission or "promise statement" at our DHB.
Yours might be something similar.
At our ED we have further defined that by defining our CORE business.
values
This Mission needs to be supported or sometimes restrained by our values.
These values are general to humanity, like
Life, Liberty and Pursuit of Happiness - but can also be specific to an organization.
Things like empathy, honesty, confidentiality, doing the right thing.
These are our DHB values.
These are very important. These are the criteria against which we judge behaviours and choices.
Sometimes there are overlapping and sometimes conflicting values like, best care and cost saving. confidentiality and smooth transfer of care.
These values are general to humanity, like
Life, Liberty and Pursuit of Happiness - but can also be specific to an organization.
Things like empathy, honesty, confidentiality, doing the right thing.
These are our DHB values.
These are very important. These are the criteria against which we judge behaviours and choices.
Sometimes there are overlapping and sometimes conflicting values like, best care and cost saving. confidentiality and smooth transfer of care.
expectations
Leaders set the expectations of their staff.
Mostly to do the right thing. To provide care to the best of their ability. to follow guidelines and policies.
What we cannot expect is perfection. All humans are fallible and error prone. What we have to do is try to enable them to make safe choices.
Mostly to do the right thing. To provide care to the best of their ability. to follow guidelines and policies.
What we cannot expect is perfection. All humans are fallible and error prone. What we have to do is try to enable them to make safe choices.
Photo by garryknight
tHE 3 "duties"
- Avoid causing Harm (risk)
- Follow a Procedure
- Produce an Outcome
Within the JC model there are 3 different categories of Duties that are required of staff.
The first is the Duty to avoid causing unjustifiable harm or risk.
This is often called the ""Universal" or "God-given" law and is also contained within our Hippocratic oath.
First do no harm
This applies to most breaches and includes not only harm to individuals, but also harm to the values or reputation of an organization.
You could say it's the One duty to Rule them All!
The 2nd is the duty to follow a procedural rule. This is any organizational policy or procedure, clinical guideline or pathway.
and 3rdly, the duty to produce an outcome. This includes contractual requirements, meeting attendances, accurate documentation etc.
The JC system then uses an algorithm to determine the appropriate action.
The first is the Duty to avoid causing unjustifiable harm or risk.
This is often called the ""Universal" or "God-given" law and is also contained within our Hippocratic oath.
First do no harm
This applies to most breaches and includes not only harm to individuals, but also harm to the values or reputation of an organization.
You could say it's the One duty to Rule them All!
The 2nd is the duty to follow a procedural rule. This is any organizational policy or procedure, clinical guideline or pathway.
and 3rdly, the duty to produce an outcome. This includes contractual requirements, meeting attendances, accurate documentation etc.
The JC system then uses an algorithm to determine the appropriate action.
Photo by bandita
2. system design
This is one of the key aspects of the JC system of producing best outcomes.
We have to design our system to achieve our mission.
This includes all aspects from infrastructure, personnel , staff levels, information systems, tools and guidelines.
We always have to bear in mind that no system is perfect and humans will make mistakes.
We design the system to produce the goals reliably. however, we also need to be aware that we can never achieve 100% reliability.
The airline industry has designed their system to allow defect per 5million flights.
Most DHB design their systems to allow 10-20 adverse events per 100 admissions. For example our diagnostic error rate in the ED is about 20%.
We have to design our system to achieve our mission.
This includes all aspects from infrastructure, personnel , staff levels, information systems, tools and guidelines.
We always have to bear in mind that no system is perfect and humans will make mistakes.
We design the system to produce the goals reliably. however, we also need to be aware that we can never achieve 100% reliability.
The airline industry has designed their system to allow defect per 5million flights.
Most DHB design their systems to allow 10-20 adverse events per 100 admissions. For example our diagnostic error rate in the ED is about 20%.
Photo by Bert Kaufmann
Untitled Slide
However, there is a limit to how far we can reduce error in any given area.
You can see from the Human reliability curve, that improving system drives human performance, but cannot entirely eliminate error.
As an example, take lab errors in the ED. Do any of you have a problem with this?
A few years ago we found we had an error rate over 5%. We looked at our systems. We changed ta number of systems and trained our staff and could still only drive error rate down to about 2%.
Further improvements in our ED were considered too expensive, so the organization has tacitly agreed to the 2% error rate,
You can see from the Human reliability curve, that improving system drives human performance, but cannot entirely eliminate error.
As an example, take lab errors in the ED. Do any of you have a problem with this?
A few years ago we found we had an error rate over 5%. We looked at our systems. We changed ta number of systems and trained our staff and could still only drive error rate down to about 2%.
Further improvements in our ED were considered too expensive, so the organization has tacitly agreed to the 2% error rate,
human performance
- Make no mistakes!!
- Knowledge/ skill
- Shaping factors
- Perception of risk
So what design strategies can we employ to improve outcomes?
Firstly we can look at improving Human performance.
The first and most unreliable method is simply to tell people they can not make any errors. This is common and bound to fail
Secondly we can employ skilled staff and train them well. However, you cannot train errors out of human beings!
One can improve performance enhancing strategies like staffing mix, reducing stress, streamlining or simplifying processes. Design the system to make easy to do the right thing.
We can also emphasise the perception of high risk in known vulnerable areas. For example, medication safety, mental health, critical diagnoses.
These last 2 are a key skill for leaders.
Firstly we can look at improving Human performance.
The first and most unreliable method is simply to tell people they can not make any errors. This is common and bound to fail
Secondly we can employ skilled staff and train them well. However, you cannot train errors out of human beings!
One can improve performance enhancing strategies like staffing mix, reducing stress, streamlining or simplifying processes. Design the system to make easy to do the right thing.
We can also emphasise the perception of high risk in known vulnerable areas. For example, medication safety, mental health, critical diagnoses.
These last 2 are a key skill for leaders.
Photo by Frederick Homes for Sale
engineering
- Barriers
- Recovery
- Redundancy
We can also borrow strategies from engineering :
Barriers prevent errors from occurring and can take the form of physical barriers (Pyxus machine) or specialised equipment or connections, needle less systems etc.
Recovery refers to a downstream catching of an error before it reaches its target, like a nurse or pharmacist checking a prescription or alarms on a machine.
Redundancy allows multiple paths to achieve success, like setting 2 alarms to wake you for an important meeting or back up power systems.
Barriers prevent errors from occurring and can take the form of physical barriers (Pyxus machine) or specialised equipment or connections, needle less systems etc.
Recovery refers to a downstream catching of an error before it reaches its target, like a nurse or pharmacist checking a prescription or alarms on a machine.
Redundancy allows multiple paths to achieve success, like setting 2 alarms to wake you for an important meeting or back up power systems.
Photo by Hatters!
3. learning
A learning culture and robust mechanism to translate data into improved reliability is at the heart of the JC.
Having a culture of openness and sharing risks without fear of unfair recriminations, is at the hear of the JC.
Having a culture of openness and sharing risks without fear of unfair recriminations, is at the hear of the JC.
Photo by highersights
4. Behavioural choices
Managing behavioural choices made by staff is the core principle of the JC. Choices are judged against values, rather than the severity of the outcomes.
Photo by shadowfax the second
3 behaviours
- Human Error
- At-risk
- Reckless
In this model we Identified the 3 types of choices we need to identify when investigating reports and incidents, namely:
human error, at-risk or reckless.
human error, at-risk or reckless.
Photo by Leonard J Matthews
1. human error
- Inadvertantly doing other than what should have been done
The first type of behavioural choice is Human Error.
This is doing something other than what was intended or what was supposed to be done.
A slip-up, a lapse or mistake.
We are all fallible and will make mistakes. This is bound to happen to everyone.
As leaders we need to anticipate errors and design our system to achieve the accepted level of reliability.
This is doing something other than what was intended or what was supposed to be done.
A slip-up, a lapse or mistake.
We are all fallible and will make mistakes. This is bound to happen to everyone.
As leaders we need to anticipate errors and design our system to achieve the accepted level of reliability.
Photo by Joaquin Villaverde Photography
Console the Error
So what should do about Error:
If you punish people for making mistakes, they will only report things that they can't hide and then we will lose the opportunities to learn about risk in our departments
So the JC recommends that we support or console the individual and look at our systems for ways to prevent our staff from making similar errors in the future.
If you punish people for making mistakes, they will only report things that they can't hide and then we will lose the opportunities to learn about risk in our departments
So the JC recommends that we support or console the individual and look at our systems for ways to prevent our staff from making similar errors in the future.
Photo by Alan Cleaver
2. AT-Risk
- "knowingly" deviate from correct practice
- risk not perceived or
- risk believed to be justified
The second and probably most prevalent are the At RISK behaviours.
this is where an individual decides on an action despite knowing it is not the right way, either because he doesn't perceive there is a risk to his organization or patient or believes the risk is justified.
These kind of choices pose the greatest risk to safety. In contrast to error which are sporadic, these are pervasive and can become habitual.
this is where an individual decides on an action despite knowing it is not the right way, either because he doesn't perceive there is a risk to his organization or patient or believes the risk is justified.
These kind of choices pose the greatest risk to safety. In contrast to error which are sporadic, these are pervasive and can become habitual.
Photo by bud ellison - from the street
Drift
Perception of risk
It is in our nature to drift away from correct behaviours. In our attempts to perform tasks faster or easier we start to deviate away from the rules.
Take speeding for example - when we first learn to drive, we appreciate the risk of driving 10k above the limit. Once we have been doing it for several years, we knowingly break the rule, but because we have not had any incidents because of of it, we feel there is NO risk.
Also the risk might be abstract or far removed. Take hand washing . We don't see the direct link between not washing our hands and an individual patient dying of MRSA , so we feel the risk is justified.
At-risk choices are also the most difficult to manage.
Take speeding for example - when we first learn to drive, we appreciate the risk of driving 10k above the limit. Once we have been doing it for several years, we knowingly break the rule, but because we have not had any incidents because of of it, we feel there is NO risk.
Also the risk might be abstract or far removed. Take hand washing . We don't see the direct link between not washing our hands and an individual patient dying of MRSA , so we feel the risk is justified.
At-risk choices are also the most difficult to manage.
Photo by www.ericcastro.biz
Coach the At-risk
In these cases we need to Coach the individual.
We need to have an open discussion with her, reminding her of the risks and possible consequences of her actions and informing her of the expected performance.
This can occur as part of the formal incident investigation or even better, in a truly safety conscious department, all staff will be aware of the risks to patients and be encouraged to watch out for risky choices and have the freedom to have open discussions with each other about the risks.
We need to have an open discussion with her, reminding her of the risks and possible consequences of her actions and informing her of the expected performance.
This can occur as part of the formal incident investigation or even better, in a truly safety conscious department, all staff will be aware of the risks to patients and be encouraged to watch out for risky choices and have the freedom to have open discussions with each other about the risks.
Photo by Henrico Prins
3. Reckless
- Conscious disregard
- known & substantial risk
Lastly are the Reckless behaviours.
These are fortunately relatively rare in health care.
This is where individuals consciously disregard organizational values or patient safety.
They are aware that their actions pose a significant threat but go ahead anyway.
These are individuals who place their own desires above the interest of others.
These are fortunately relatively rare in health care.
This is where individuals consciously disregard organizational values or patient safety.
They are aware that their actions pose a significant threat but go ahead anyway.
These are individuals who place their own desires above the interest of others.
Photo by Stuck in Customs
Punish the Reckless
In the JC system, these behaviours are not tolerated and disciplinary action is recommended, irrespective of whether harm has occurred or not.
Photo by kenteegardin
5. accountability
The Just Culture is defined as a shared accountability , where the organisation in held accountable for the system it has designed and the employees are accountable for the behavioural choices.
This neither a blame and shame nor a blame free system.
This neither a blame and shame nor a blame free system.
Photo by Sarah Hina
We are all Judges!
We are all Judges!
We judge our kids ........ our neighbors ..... politicians .......... other drivers .................... and especially our sports teams!
I must say, its really a difficult time to be a Black caps supporter.
Mostly, we judge them all based on their results.
This is a very important issue in the just culture which is more concerned about the quality of choices and behaviours, than the outcomes.
We judge our kids ........ our neighbors ..... politicians .......... other drivers .................... and especially our sports teams!
I must say, its really a difficult time to be a Black caps supporter.
Mostly, we judge them all based on their results.
This is a very important issue in the just culture which is more concerned about the quality of choices and behaviours, than the outcomes.
Photo by Robotclaw666
Untitled Slide
And of course, the healthcare profession is also subject to public scrutiny and judgement.
Untitled Slide
In New Zealand, we LOVE ourselves a scapegoat. I am sure this is true in most places.
If someone gets hurt, someone has to pay!
This is called Outcome bias.
If someone gets hurt, someone has to pay!
This is called Outcome bias.
outcome bias
- Punish "bad outcomes"
- "No harm - No foul"
This is called the Outcome bias.
in other words, where the nature of the response to any given situation depends on the severity of the outcome.
Despite living in an "enlightened age", most of us believe in the "Eye for an Eye" system of Justice!
This might mean being overly harsh in punishing a person who has committed a simple human error; because of a bad outcome - remember, we are dealing with fallible human beings.
On the other hand, we might ignore reckless behaviour because no harm has occurred.
Neither alternative leads to improved safety or culture.
in other words, where the nature of the response to any given situation depends on the severity of the outcome.
Despite living in an "enlightened age", most of us believe in the "Eye for an Eye" system of Justice!
This might mean being overly harsh in punishing a person who has committed a simple human error; because of a bad outcome - remember, we are dealing with fallible human beings.
On the other hand, we might ignore reckless behaviour because no harm has occurred.
Neither alternative leads to improved safety or culture.
Photo by John. Romero
Drunk driving
Jail time?
As an example of this, let's look at driving under the influence.
In NZ, how many times do you have to be caught before doing jail time?
First and 2nd time offenders usually get driving restrictions and fines. Jail time is relatively rare, as far as i can tell.
Is it similar Australia?
What about when a drunk driver crosses the centre line? Would the consequences for the driver be same if he crashes into another car and kills someone?
"Of course not!" you might say.
However, if you think about the actions of driver, they were the same in both scenarios. It was pure BAD LUCK that in one instance there happened to be another car on the road at that very moment!
The JC would suggest that the behaviour, in this case: deciding to drive drunk, should be punished consistently irrespective of the outcome. In this scenario, severely punishing drunk driving, even when no harm has occurred.
In NZ, how many times do you have to be caught before doing jail time?
First and 2nd time offenders usually get driving restrictions and fines. Jail time is relatively rare, as far as i can tell.
Is it similar Australia?
What about when a drunk driver crosses the centre line? Would the consequences for the driver be same if he crashes into another car and kills someone?
"Of course not!" you might say.
However, if you think about the actions of driver, they were the same in both scenarios. It was pure BAD LUCK that in one instance there happened to be another car on the road at that very moment!
The JC would suggest that the behaviour, in this case: deciding to drive drunk, should be punished consistently irrespective of the outcome. In this scenario, severely punishing drunk driving, even when no harm has occurred.
Photo by Elvert Barnes
The Just Culture Algorithm
Photo by Lars Plougmann
Untitled Slide
This is our Health Board's version of the JC Algorithm.
As you can see, it follows a course of "yes/ no" answers to a series of questions.
It asks questions like:
Was it the employees' purpose to cause harm?
Did he/ she knowingly cause harm?
Was the risk substantial and unjustified? and did he consciously disregard the risk?
Should he have known he was taking a risk? (this is where you apply the substitution test. Was the risk perceived by his peers)
The end of the process results in choices being classified as Criminal, Reckless, At-risk or simple Human Error.
We then know how to respond.
As you can see, it follows a course of "yes/ no" answers to a series of questions.
It asks questions like:
Was it the employees' purpose to cause harm?
Did he/ she knowingly cause harm?
Was the risk substantial and unjustified? and did he consciously disregard the risk?
Should he have known he was taking a risk? (this is where you apply the substitution test. Was the risk perceived by his peers)
The end of the process results in choices being classified as Criminal, Reckless, At-risk or simple Human Error.
We then know how to respond.
Practice case: 1
- Identify the "breaches"
- Which "Duty"?
- Behavioural choice
- Reporting?
- Enforcers
Photo by alicesallesaffonso
Untitled Slide
Photo by frankieleon
Case: 2
- What do you do?
- Adverse Outcome?
- Breach? Which?
- Behavioural Choice
- Response?
Photo by moore.owen38
Untitled Slide
Photo by ccPixs.com
case : 3
- Identify the outcome
- Which duties were breached?
- Identify Errors or At-risk choices
- Explain reasons
Photo by CJ Isherwood
Putting it all together
So now that we know how to use judge fairly, how do we use this knowledge to improve outcomes?
Photo by Erprofe
event investigation
- What happened?
- What usually happens?
- What does the Policy stipulate?
So very briefly, how does this work in practice?
When an event or potential incident is identified, we need a consistent approach in which to investigate and learn from it.
We identify all the choices that were made along the way and what lead to those choices.
We try to determine whether these choices are common in this situation.
Then we look at where it deviated from the expected procedure.
Each behavioural decision is categorized using a standard algorithm. All Human errors and At risk choices are explained.
When an event or potential incident is identified, we need a consistent approach in which to investigate and learn from it.
We identify all the choices that were made along the way and what lead to those choices.
We try to determine whether these choices are common in this situation.
Then we look at where it deviated from the expected procedure.
Each behavioural decision is categorized using a standard algorithm. All Human errors and At risk choices are explained.
Photo by frankieleon
Causal diagram
- Identify the Outcome
- Search for causes
- Build cause and effect
- Test the strength of the link
- Explain choices and errors
- Develope risk reduction strategy
Photo by tatadbb
Untitled Slide
- Safety culture
- Learning environment
- Better Outcomes
David Marx:
This is David Marx. He is considered the "Father" of the JC.
He started out as a Boeing Engineer and then went on to do a Law degree.
He did a lot of work in the Airline industry in event investigation and safety. He found his principles could be utilized in a number of industries, especially Healthcare.
He developed a system of justice which aims to Improve the Safety Culture of an organization and thereby improve outcomes.
He describes the JC as a Values supportive system which places less emphasis on Errors and Outcomes, but rather focuses on Risk identification, System design and managing behavioral choices.
This is where the JC runs counter to popular Justice.
He started out as a Boeing Engineer and then went on to do a Law degree.
He did a lot of work in the Airline industry in event investigation and safety. He found his principles could be utilized in a number of industries, especially Healthcare.
He developed a system of justice which aims to Improve the Safety Culture of an organization and thereby improve outcomes.
He describes the JC as a Values supportive system which places less emphasis on Errors and Outcomes, but rather focuses on Risk identification, System design and managing behavioral choices.
This is where the JC runs counter to popular Justice.
Just Culture Certification course
May 1 - 3
Waipuna Hotel
https://www.ivvy.com.au/event/JUST18
This is David Marx. He is considered the "Father" of the JC.
He started out as a Boeing Engineer and then went on to do a Law degree.
He did a lot of work in the Airline industry in event investigation and safety. He found his principles could be utilized in a number of industries, especially Healthcare.
He developed a system of justice which aims to Improve the Safety Culture of an organization and thereby improve outcomes.
He describes the JC as a Values supportive system which places less emphasis on Errors and Outcomes, but rather focuses on Risk identification, System design and managing behavioral choices.
This is where the JC runs counter to popular Justice.
He started out as a Boeing Engineer and then went on to do a Law degree.
He did a lot of work in the Airline industry in event investigation and safety. He found his principles could be utilized in a number of industries, especially Healthcare.
He developed a system of justice which aims to Improve the Safety Culture of an organization and thereby improve outcomes.
He describes the JC as a Values supportive system which places less emphasis on Errors and Outcomes, but rather focuses on Risk identification, System design and managing behavioral choices.
This is where the JC runs counter to popular Justice.
Photo by MrGluSniffer
