1. A Lesson in Just Culture
Safe Choices
A Lesson in Just Culture
IAPIC Conference, 2018

2. Reflection
Perfection is being right Perfection is fear Perfection is anger and frustration Perfection is control Perfection is judgment Perfection is taking Perfection is doubt Perfection is pressure Perfection is a destination
Excellence is willing to be wrong Excellence is risk Excellence is powerful Excellence is spontaneous Excellence is accepting Excellence is giving Excellence is confidence Excellence is flowing Excellence is a journey
©2014 Trinity Health - Livonia, MI

3. What are you going to learn?
At the end of this session, you should be able to answer the following questions:
What are the five essential elements of a Just Culture?
What are the three human behaviors?
What is your role within a Just Culture?
How can safe behavioral choices reduce risk and improve our culture of safety?
How will Just Culture impact the team and organization?
Copyright 2011 CHE Trinity Health - Novi, Michigan

4. What is Just Culture?
Changes our way of thinking about safety for patients and colleagues
Allows us all to learn from undesirable outcomes
Recognizes the opportunities to reduce risk
Supports a continuous learning environment where we learn from our mistakes
Reminds us to be finders and fixers of defects within our work environment
Go over these points
©2012, 2015 Trinity Health - Livonia, MI

5. Five Essential Elements2
Manage Behavioral Choices
We anticipate that humans will make mistakes and that colleagues will drift from our policies and procedures.
Create Learning Systems
We can identify risk by observing the design of the systems in which we work, our behaviors, and the behaviors of those around us.
Create a Just and Accountable Environment
We are imperfect and we will drift from making safe choices. We must hold one another accountable for the quality of our systems and our choices in those systems.
Design Safe Systems
Good system design anticipates human error and captures errors before they become critical. Good system design also permits recovery when the consequences of our errors can cause harm. This is also defined as undesirable outcomes.
Communicate Values and Expectations
One step in creating better outcomes is to set expectations in a way that exhibit our commitment to our Mission, Core Values, and Vision.
System
Design 1
Values &
Better
Expectations 3
Outcomes
Human
Behavior
Cover high level these five essential elements – inform students this is not a linear activity and we are striving for better outcomes. 4 5
Learning
Justice &
Systems
Accountability

6. Three Human Behaviors
Human Error: an inadvertent action; a slip, a lapse, a mistake.
At-Risk Behavior: a behavioral choice that increases risk where risk is not recognized, or is mistakenly believed to be justified.
Reckless Behavior: a behavioral choice to consciously disregard a substantial and unjustifiable risk.
©2012, 2015 Trinity Health - Livonia, MI

7. Human Error
Umpire Jim Joyce makes a human error that costs Armando Galarraga a perfect game…

8. To Drift is Human Train engineer is texting while on duty…
Source: LA Times, Train Engineer Sent Text Message Right Before Crash, October 2, 2008.

9. Occasionally, the Reckless Act
Elizabeth Lambert has her own rules for playing soccer…

10. Behavioral Responses to Human Behaviors
Console
Coach
Discipline

11. Apply what we have learned
On a snowy winter night, John had to run to the store to buy milk. His car was parked in the driveway. John got into the car and turned his head to back out of the driveway. Although he carefully looked at the path behind the car, his vision was limited. He inadvertently hit his neighbor’s mailbox and destroyed it.
Days 1-3

12. Apply what we have learned
On a snowy winter night, John had to run to the store to buy a new formula for his colicky newborn. His wife had not slept in 24 hrs. so tension in the home was high. He got into the car and backed out of the driveway looking at his upset wife in the doorway, but not looking in his rear view mirror. In his haste, he hit his neighbor’s mailbox and destroyed it.
©2014 Trinity Health - Livonia, MI

13. Apply what we have learned
On a snowy winter night… John yelled “yee haa,” closed his eyes and hit the gas. He never saw his neighbor’s mailbox.
©2014 Trinity Health - Livonia, MI

14. Wrap-Up: Causes Wrap-Up: Causes System Design Human Behavior
Systems are policies, procedures, protocols and actual equipment we use.
Systems are the design of the work environment
Sometimes we design the system and sometimes the system is designed for us
We must always look at the system design around the errors or choices that we make
Human Behavior
Human behaviors are manageable and fall into three categories
Human Error is an inadvertent action – a slip, a lapse, a mistake
At-Risk Behavior is a choice that we make, when we think we are in a safe place or we don’t recognize the risk
Reckless behavior is when we consciously disregard a substantial and unjustifiable risk
Copyright 2011 CHE Trinity Health - Novi, Michigan

15. Expectation of Colleagues
What should you do?
Peer Coaching
Support each other in serving. Help your fellow Colleagues see the risks they are taking.
Open Eyes and Ears
Look at the risk around you. How can you help improve the system design around you?
Speak Up
If you see something, say something. Feel safe to speak up and let your manager know the risks and behaviors that you see.
Make Good Behavioral Choices
Be mindful of your own behaviors and choices within our systems.
Copyright 2011 CHE Trinity Health - Novi, Michigan

16. Expectations of Leaders
Conducting fair and thorough investigations that focus on behaviors, choices and system improvement opportunities, and not the outcome
Seeking your input to identify risks and help design safer systems
Supporting you as we transform our organization into a continuous learning environment where we seek to learn from one another’s experiences
As appropriate, holding Colleagues accountable for their behavioral choices consistent with organizational policy
Copyright 2012 CHE Trinity Health - Novi, Michigan

17. Key Points What factors lead to undesirable outcomes?
System design and behavioral choices
What are the five essential elements of a Just Culture?
Values and Expectations, System Design, Human Behavior, Learning Systems and Justice and Accountability
What are the three manageable human behaviors?
Human Error, At Risk Behavior, and Reckless Behavior
Why do we engage in at-risk behavior?
When our at-risk behavior has nothing bad happening we tend to drift into more at-risk behaviors
How can I reduce risk?
By keeping my eyes open and choosing my own behaviors and to share with others when I see others at risk
©2012, 2015 Trinity Health - Livonia, MI