1. Just Culture www.justculture.org

2. Just Culture is about: Creating an open, fair, and just culture Creating an open, fair, and just culture Creating a learning culture Creating a learning culture Designing safe systems Designing safe systems Managing behavioral choices Managing behavioral choices Adverse Events Human Errors Managerial and Staff Behaviors System Design Learning Culture / Just Culture

3. A Model that Focuses on Three Duties balanced against Organizational and Individual Values The Three Duties The Three Duties The duty to avoid causing unjustified risk or harm The duty to avoid causing unjustified risk or harm The duty to produce an outcome The duty to produce an outcome The duty to follow a procedural rule The duty to follow a procedural rule Organizational and Individual Values Organizational and Individual Values Safety Safety Cost Cost Effectiveness Effectiveness Equity Equity Dignity Dignity etc etc

4. 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

6. We know….to error is Human

7. But….To Drift is also Human

8. Managing Behavioral Choices: Everyone Takes Risks, Every Day RISK SOCIAL UTILITY

9. The Behaviors We Can Expect Human error - inadvertent action; inadvertently doing other that what should have been done; slip, lapse, mistake. Human error - inadvertent action; inadvertently doing other that what should have been done; slip, lapse, mistake. At-risk behavior - behavior that increases risk where risk is not recognized, or is mistakenly believed to be justified. At-risk behavior - behavior 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. Reckless behavior - behavioral choice to consciously disregard a substantial and unjustifiable risk.

10. Accountability for our Behavioral Choices Reckless Behavior Intentional Risk-Taking Manage through: Remedial action Disciplinary action At-Risk Behavior Unintentional Risk-Taking Human Error Product of our current system design Manage through changes in: Processes Procedures Training Design Environment ConsoleCoachPunish Manage through: Removing incentives for at-risk behaviors Creating incentives for healthy behaviors Increasing situational awareness

11. We need….. A culture that truly supports learning A culture that truly supports learning A common understanding about how to treat people when things happen A common understanding about how to treat people when things happen

12. The Minnesota Agenda Formation of a stakeholder group - The Minnesota Alliance for Patient Safety (MAPS) Formation of a stakeholder group - The Minnesota Alliance for Patient Safety (MAPS) Change state law Change state law Developed principles of justice, learning and accountability Developed principles of justice, learning and accountability Change the policies and practices of: Change the policies and practices of: The Boards The Boards The Dept of Health The Dept of Health Delivery systems Delivery systems

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

14. Minnesota Statement of Support Given that: Medical errors and patient safety are a national concern to all involved in health care delivery. Medical errors and patient safety are a national concern to all involved in health care delivery. We are legally and/or ethically obligated to hold individuals accountable for their competency and behaviors that impact patient care. We are legally and/or ethically obligated to hold individuals accountable for their competency and behaviors that impact patient care. A punitive environment does not fully take into account system issues, and a blame-free environment does not hold individuals appropriately accountable A punitive environment does not fully take into account system issues, and a blame-free environment does not hold individuals appropriately accountable

15. We resolve that our organization will: Strive for a culture that balances the need for a non-punitive learning environment with the equally important need to hold persons accountable for their actions. Strive for a culture that balances the need for a non-punitive learning environment with the equally important need to hold persons accountable for their actions. Seek to judge the behavior, not the outcome, distinguishing between human error, at-risk behavior, and intentional reckless behavior. Seek to judge the behavior, not the outcome, distinguishing between human error, at-risk behavior, and intentional reckless behavior. Foster a learning environment that encourages the identification and review of all errors, near-misses, adverse events, and system weaknesses. Foster a learning environment that encourages the identification and review of all errors, near-misses, adverse events, and system weaknesses.

16. Promote the use of a wide range of responses to safety-related events caused by lapses in human behavior, including coaching, non-disciplinary counseling, additional education or training, demonstration of competency, additional supervision and oversight and disciplinary action when appropriate to address performance issues. Promote the use of a wide range of responses to safety-related events caused by lapses in human behavior, including coaching, non-disciplinary counseling, additional education or training, demonstration of competency, additional supervision and oversight and disciplinary action when appropriate to address performance issues. Support and implement systems that enable safe behavior to prevent harm Support and implement systems that enable safe behavior to prevent harm Work to share information across organizations to promote continuous improvement and ensure the highest level of patient and staff safety. Work to share information across organizations to promote continuous improvement and ensure the highest level of patient and staff safety. Collaborate in efforts to establish a statewide culture of learning, justice, and accountability to provide the safest possible environment for patients. Collaborate in efforts to establish a statewide culture of learning, justice, and accountability to provide the safest possible environment for patients.