1. Just Culture

2. “Just Culture” aka “Blame- worthy” (Responsibility/Accountability)

3. Content draws heavily from the excellent work of David Marx, JD and James Reason, PhD

4. Just Culture Emphasizes learning over blaming We want to promote open discussion of near misses and harm. (Culture of Safety) Assume people want to do reasonable things and help patients….then look at why there is a performance gap.

5. Learning Institution Yeah, we blow it from time to time. Learn from it, and then pursue excellence.

6. Accountability 80% of errors are from system failures 15% human cognitive factors 5% practitioner negligence View accountability in the context of individual and system influences. Individuals are accountable for their own performance but not for the system flaws.

7. Reporting Systems All providers – first and foremost constant goal is systems improvements and decrease harm to the next patient. Individuals are responsible for reporting untoward events and contribute to the elimination of system flaws. Part of CLER/NAS initiative

8. Just Culture Blaming individuals creates a culture of fear and defensiveness which decreases learning and capacity to improve systems. Single greatest impediment to error prevention is that we punish people for making mistakes. - Lucian Leape, M.D

9. Accountability Disciplining people for honest mistakes does little to improve system safety. Discipline does detour those who consciously disregard risks and intend harm to others.

10. Just Culture Inverse relationship between discipline and reporting. Increased discipline = decreased reporting Decreased reporting = decreased learning Decreased learning = less opportunity to improve systems = ongoing errors = eventual patient harm.

11. Paradigm Shift Not reporting one’s error, which prevents the system and others from learning, is the greatest evil of all. We are held accountable to make our system and profession safer to decrease harm to the patients who entrust their care to us. Lucian Leape, M.D. Harvard University

12. Just Culture Emphasizes learning over blaming Paradigm shift in due process

13. Paradigm Shift Proven in aviation and industrial injury prevention programs to increase reporting, decrease errors, and improve safety.

14. Just Culture Shame and Blame Learn or Lean

15. Just Culture Culpability based on intent and risk taking behavior….not outcome based which brings in severity bias. Replace “blame free” to “responsibility and accountability”

16. Reporting Systems Purpose of reporting system is to learn. Purpose of surveillance system is to monitor. (Trust but verify - accountable) If seeking accountability then monitor, don’t do through reporting If seeking to learn then spontaneous and stimulated reporting.

17. Accountability Individuals are responsible for surfacing errors, near misses, potential harm and for contributing to the elimination of system flaws. Failure to report error or mishap witnessed or personally done can lead to discipline.

18. Accountability Even small errors are to be reported. –Normative deviation – from walk-a-rounds accounts for 50% of aviation errors. –To determine policy/procedure changes or system redesign.

19. Just Culture No blame unless: –Premeditated or intentional acts of violence towards people or damage to equipment or property. –Reckless disregard towards the safety of patients, employees, or sig. economic harm to hospital. –Failure to report safety incidents or risk exposures.

20. Destruction of Hospital Property

21. Just Culture Disruptive behavior = individual action = willful engagement of unsafe behavior = discipline

22. Squealer

23. Repeat Offender/Negligence Is it secondary to poor system design, policy or procedure? Personal traumatic events in person’s life? Inadequate training, inappropriate granting of privileges, or bad hire? Proper orientation?

24. Overall Definition of Just Culture Environment which is: –Transparent –Non-punitive –Supportive –But accountable

25. Don’t Judge Too Quickly First party seems right……..until you talk to the other side. Policy to include speak with physician before finality determined. Level 2.5

26. Just Culture Please read!! –Patient Safety and the “Just Culture”:A Primer for Health Care Executives; David Marx, JD David Marx, JD and Reason J, Managing the Risks of Organizational Accidents. Ashgate Publishing; 1997; Fig 9.4 pg 209

27. Reason’s Diagram Modified with permission May use internally without publisher permission. If produced >200 copies for external teaching need to notify publisher for permission.

28. Differentiate Human Error vs. Unsafe Behavioral Choices Human error: “Console” “At Risk” Behaviors: “Coach” “Reckless” Behaviors: Consider disciplinary action 28 Outcomes Engineering/David Marx

29. Commitment to Change Statement

30. Second Victims Two parties involved…twin casualties –Patient and family –Healthcare Worker “Second Victims” –Dr Albert Wu – Johns Hopkins Bloomberg School of Public Health –Live with the aftermath of making an error

31. Second Victims Anxiety – two-thirds Insomnia Self-doubt about their professional abilities Decreased job confidence and satisfaction - 50% Surgeons 3X more likely to consider suicide

32. Second Victims Above symptoms often last for years. Shanafelt T, et. Al.; Archives of Surgery 2011;146(1):54-62 2008 - 7,905 participant survey Waterman, A; Joint Commission Journal on Quality and Patient Safety, August 2001 Vol. 33 Number 8; 467-475. - 2,989 participants

33. Healing Together Medically Induced Trauma Support Services (MITSS) Non-profit organization founded in June of 2002 by patient and physician Mission: “To Support Healing and Restore Hope” to patients, families, and clinicians who have been impacted by an adverse medical event.

34. Teamwork to Prevent Errors and Second Victims

35. Just Culture An atmosphere of trust in which people are encouraged (even rewarded) for providing essential safety-related information. Individuals trust they will not be held accountable for system failures; and are also clear about where the line must be drawn between acceptable and unacceptable behavior.

36. References – Just Culture Patient Safety and the "Just Culture": A Primer for Health Care Executives. http://psnet.ahrq.gov/resource.aspx?resou rceID=1582 http://psnet.ahrq.gov/resource.aspx?resou rceID=1582 www.justculture.org

37. Further Resources Reason J, Managing the Risks of Organizational Accidents. Ashgate Publishing; 1997; Fig 9.4 pg 209