THE JUST CULTURE CERTIFICATION TRAINING

THE JUST CULTURE CERTIFICATION TRAINING
Presented by Outcome Engineering David Marx Chief Executive Officer Fiona Lawton Manager, Consulting Services PRESENTED TO:

Agenda Day 1 The Downside of Life – Producing Undesired Outcomes
Introduction to Five Skills Introduction to the Three Behaviors Introduction to the Just Culture Algorithm™ Life, Liberty and the Pursuit of Happiness Legal Case: Palsgraf v. The Long Island Railroad Imposers and their Tools Day 2 Our Shared Fallibility – Intention and Consequences Levels of Culpability – What the Law Can Teach Us Legal Case: U.S. v. Morrisette Reporting or Justice – Reconciling Competing Values Where to Draw the Disciplinary Line The Reasonable Person Standard

Agenda Day 3 The Duty to Save? Outcome-Based Duties
Procedure-Based Duties Building a Socio-Technical System Using the Three Duties Using The Just Culture Algorithm™ The Duty to Avoid Causing Unjustifiable Risk or Harm Day 4 The Duty to Follow Procedural Rules The Duty to Produce an Outcome Repetitive Errors and At-Risk Behaviors Other Just Culture Algorithms Examinations of Current Policies and Practices Day 5 Just Culture Algorithm Q&A Testing Proficiency In Use of the Just Culture Algorithm The Five Skills Revisited – Fitting the Pieces Together Matters of Implementation – Lessons Learned for Implementation

The Downside of Life – Producing Undesired Outcomes
Day 1 – Setting the Stage The Downside of Life – Producing Undesired Outcomes Introduction to Five Skills Introduction to the Three Behaviors Introduction to the Just Culture Algorithm™ Life, Liberty and the Pursuit of Happiness Legal Case: Palsgraf v. Long Island Railroad Imposers and their Tools

The Downside of Life – Producing Undesired Outcomes
Days 1-3

Jacqueline Saburido

The Proposition Framed by the right systems of learning,
the right systems of justice, we can design systems and help humans make choices in those systems to produce better outcomes, at the individual, local, and societal level.

16 Design Laws

Design Laws Rule 1 Pursuit of individual happiness drives the human condition; it is the mission.

We are endowed with a free will to pursue our individual happiness.
Design Laws Rule 2 We are endowed with a free will to pursue our individual happiness.

Design Laws Rule 3 We pursue our happiness as inescapably fallible creatures. We will do things, that in hindsight, we never intended to do.

Design Laws Rule 4 We live in a world of limited resources. This drives the competitive nature of human beings.

Design Laws Rule 5 While happiness is the mission, it is life, liberty, and property that are the three primary values – these are the things we strive to protect against outside intrusion.

Design Laws Rule 6 One person’s pursuit of happiness will inevitably conflict with someone else’s pursuit of happiness.

Design Laws Rule 7 When faced with a dilemma between service to self and service to others, humans will often choose self over others. Altruism is a deliberate task requiring hard work.

Design Laws Rule 8 When more than two humans exist, coalitions will inevitably form to work to the benefit of the subgroup.

Collective happiness is important to our individual happiness.
Design Laws Rule 9 Collective happiness is important to our individual happiness.

Design Laws Rule 10 Because we humans are imperfect and resources are limited, systems are necessarily imperfect.

Design Laws Rule 11 All systems suffer from the design trades – maximizing performance toward one value will ultimately harm another value, or the mission itself. The closer we get to perfection toward any one value, the higher the costs to other values.

Design Laws Rule 12 Societies can advance across all values only when human productivity gains provide more resources to the world of still limited resources.

Design Laws Rule 13 Feedback (learning) systems are essential in our stewardship of limited resources, whether it be for our personal or collective happiness.

Design Laws Rule 14 Imposers are essential to our shared happiness. We create imposers to promote collective happiness by protecting the life and property of individuals. Most often, imposers use restraints on our liberty as the principal tool to exercise their control. The penalties for conformance involve restrictions on property, liberty, and sometimes life.

Design Laws Rule 15 We humans are system components. We exist in systems with notions of duty guiding our paths. Duties come from the imposers, guided by deity- or morality-based notions of right and wrong.

Design Laws Rule 16 Justice is the mechanism for responding to breaches of duty, for holding each other to account in our roles as societal components. Justice is the glue that holds social systems together.

The Five Skills Days 1-3

The Five Skills Values and Expectations Behavioral Choices System
Design Errors & Outcomes Learning Systems Justice & Accountability The Mission 1 2 3 4 5 26

Missions, Values, and Expectations
Days 1-3

Mission and Values Consider that you are the local school board and you are hiring a new high school football coach. How will articulate to that coach what his/her mission will be? Our Mission Our reason for acting

An Adverse Event Occurs
It’s the next to the last game of a very successful season. In the first quarter your star quarterback goes down as the result of a hit to the head. The trainer suggests he’s out for the game. It’s the fourth quarter, your team is down by 6 points. The quarterback’s father is yelling at the coach to put him back in the game. The fans are chanting for their star. The coach puts him back in, where in the very next play he’s hit again, rendering him unconscious. He’s taken by ambulance to the hospital where fully recovers.

An Adverse Event Occurs
It’s the final game. The coach is still suffering from the aftermath of last week’s close call. He takes his captain out to the 50 yard line for the toss of the coin, where he announces to the other team that in the in interest of player safety that he’s only going to let his team play “touch” football. No hitting allowed. After 5 minutes of discussion with the referee and the other team’s coach, the referee calls the game. Your team forfeits for failure to play by the rules of the game.

What do you value that you want to protect?
Mission and Values Our Mission What do you value that you want to protect? Our Primary Values Our reason for acting Values that are in play - that can be threatened by a overly zealous commitment to the mission

What do you value as a means to an end?
Mission and Values Our Mission Our Primary Values Our Supporting Values Our reason for acting Values that are in play - that can be threatened by a overly zealous commitment to the mission Values that are a means to an end – needed to support the mission and the primary values What do you value as a means to an end?

For Each Value: Inputs and Outputs
System Design Values and Expectations Errors & Outcomes Behavioral Choices

The Constraints Competing Values Limited Resources
System Design Values and Expectations Errors & Outcomes Behavioral Choices Competing Values Limited Resources Fallible Human Beings and, the Laws of Physics

Our Values Overlapping Duties? Competing Duties?
Yes Competing Duties? We Must Prioritize and Balance in Support of Our Values Customer Safety Efficiency Capacity Learning objective(s): With Just Culture you won’t hear us teaching that safety is or should be your most important value. Certainly, it should be one of your values, but it must compete with your other organizational values for it place in your hierarchy of values. Employee Safety Privacy Cost Control 35

So for each primary value, where do you want to be?
Possible Top-Level Design Criteria No single failure can cause harm (1960’s aviation) 1 in a billion risk of harm (1980’s aviation) 1 in 10,000 years (nuclear power) No two failures can cause harm (NASA Mars mission)

Setting System Expectations

Setting System Expectations
What level of reliability do we want? Relative to the mission Relative to the most critical value

Systems can be designed to be very reliable
System Reliability Systems can be designed to be very reliable Perfection is not possible We do our best with inherently flawed components (humans and equipment) Normal range of reliability – 1/1000 to one in a billion Reliability allocation is the process of specifying a level of reliability for each subsystem or module in a system so as to achieve a system reliability objective. This process should be performed early in the design cycle to guide designers in choosing components, materials, and a design topology that will meet system objectives.

A Range of Reliability One in a
Billion Commercial aviation design standard – one in a billion 10-9 Current fatal aviation accident rate – 1 in 6 million One in a Million 10-6 Six Sigma – 3 defects per million Current wrong site surgery rates – 1 in 30,000 One in a Thousand 10-3 Current rate of hospital iatrogenic death – 1 in 500 Current rate of space shuttle accident – 1 in 60

Managing System Reliability
100% 100% System Failure Design for system reliability… Successful Operation Human factors design to reduce the rate of error Barriers to prevent failure Recovery to capture failures before they become critical Redundancy to limit the effects of failure Learning objective(s): We are talking about managing systems and behaviors of those that manage or work within the systems. Systems will never be 100% perfect. We have to manage the factors that influence reliability. Facilitator information: There are really two pieces to review: there is system reliability an human reliability – humans being a component of the system. What we are trying to design for system reliability, knowing that the system can never be perfect. We don’t design nuclear power plants never to melt down; we don’t design aircraft never to crash…we design it reducing the likelihood to a level that we hope it’s never going to happen in our life time or our kids lifetime, but the notion of it never happening changes how we would manage the risk. The only way we could to say that it is never going to happen is to believe that the components of the system are going to be perfect an good system design says No! No! No! You’re going to be imperfect. Parts are going to fail, humans are going to be fallible, now how do we build in good system reliability. So we design and a good place to see this is in surgical counts. We could say to the surgeon , Look you were taught to clean up your room as a kid, just clean up after surgery. Just don’t leave things behind. You can’t accountable for this. You’re suppose to know what body part you’re doing it on and you’re suppose to clean up when you’re done. But, that’s not how we design our system to prevent the retention of objects (instruments). What we did is we said we are going to have the scrub nurse count, we are going to have the circulator count, and if it is going to be left behind, it is going to take three independent errors…the surgeon going to have to miss it, the scrub nurse is going to have to miss it and the circulator is going to have to miss it. And, if they ever feel that process doesn’t work, what do we do? We say let’s make everything visible via x-ray, and if there is ever any doubt. We will x-ray the patient and catch it. This is reasonable system design. 0% 0% Poor Good Good Factors Affecting System Performance … knowing that systems will never be perfect Days 1-3 41

Aviation Expectations
Where do we want to be Perfection is not a viable option Better results come from admitting to our shared fallibility, both at the individual and system level Better results come from admitting the competing values and the limited resources

Managing Human Reliability
100% 100% Human Error Design for human reliability… Information Equipment/tools Design/configuration Job/task Qualifications/skills Perception of risk Individual factors Environment/facilities Organizational environment Supervision Communication Successful Operation 0% Learning objective(s): Factors that improves the reliability of their choices. Factors affecting human performance. The second piece is human reliability. These go hand in hand. As your system reliability improves, the management of your human reliability must also improve. We’ve listed some here, but there are many more that you could put in place. Even though we have the surgeon, the scrub nurse, and the circulator doing their job, we need them to be as reliable as they can be. We don’t want to scrub nurse and the circulator to fall into an at-risk behavior where the scrub nurse holds up the sponge and the circulator counts the sponge. We want them to independently counting so that we are three independent failures from harm. We want to maximize system reliability, we want to maximize human reliability, but knowing that humans are never going to be perfect. We can’t have an expectation of a perfect human being in our system, but we are going to design around them good robust systems to give us the results we want. Poor Good Factors Affecting Human Performance … knowing humans will never be perfect Days 1-3 43

Designing Effective Systems
Controlling Contributing Factors Changing the rate of human error and at-risk behavior Adding Barriers Trying to prevent individual errors Adding Recovery Trying to catch errors downstream Adding Redundancy Trying to add parallel elements

Human Fallibility Days 1-3

Fallibility Main Entry: fal·li·bil·i·ty
Pronunciation: \ˌfa-lə-ˈbi-lə-tē\ Function: noun Date: 1634 : liability to err

The Letter “E” is Defective How many E’s are in the paragraph below?
FRED IS A FIREFIGHTER. FRED IS FEARFUL THAT HE MIGHT ERR IN HIS FIELD OF WORK, AND SUBSEQUENTLY FEEL THE HAMMER OF THE LAW FOR HIS FAILURE TO CONFORM TO HIS FIELD’S DUTY OF CARE. YOU EXPLAIN THAT THE PURPOSE OF NEGLIGENCE LAW IS TO ENSURE THAT AGGRIEVED PARTIES ARE MADE WHOLE BY MAKING THE PERSON WHO ERRS PAY FOR THE DAMAGES. IN FRED’S CASE, FRED WORKS FOR THE CITY, WHO MUST CARRY THE BURDEN FOR HIS ERROR. YOU FURTHER EXPLAIN TO FRED THAT IN THE CRIMINAL LAW, NEGLIGENCE HAS NOT GENERALLY BEEN CONSIDERED A CRIME BECAUSE NEGLIGENCE DID NOT HAVE THE REQUIRED MENS REA, OR “EVIL MIND.” TODAY, HOWEVER, WE HOLD INDIVIDUALS ACCOUNTABLE FOR THEIR ERRORS BECAUSE THE PUBLIC SHOULD EXPECT NOTHING LESS FROM HIGHLY TRAINED FIREFIGHTERS. AFTER ALL, EVERYONE SHOULD BE ABLE TO LIVE UP TO EXPECTATIONS, EVEN A GROUP OF HEALTHCARE’S FINEST SIMPLY COUNTING THE LETTER “E.”

How about something a little easier?
5+3+2÷2=?

The Behaviors We Can Expect
Human Error Inadvertent action; inadvertently doing other that what should have been done; slip, lapse, mistake. Behavioral choice that increases risk where risk is not recognized, or is mistakenly believed to be justified. Behavioral choice to consciously disregard a substantial and unjustifiable risk At-Risk Behavior Reckless Behavior Days 1-3

Three Scenarios Version #1
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. Version #2 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. Version #3 On a snowy winter night… John yelled “yee haa,” closed his eyes and hit the throttle. He never saw his neighbor’s mailbox. Days 1-3

The Just Culture Algorithm
One method that works across all values One method that works both pre- and post-event Days 1-3 52

Life, Liberty, and the Pursuit of Happiness – Rejection of the King
Days 1-3

Rejection of the King The Declaration of Independence The Constitution

Helen Palsgraf v. The Long Island Railroad
Days 1-3

Imposers – Their Role in Society
Days 1-3

The Need for Imposers Main Entry: im·pose Pronunciation: \im-ˈpōz\ Function: verb Inflected Form(s): im·posed; im·pos·ing Etymology: Middle French imposer, from Latin imponere, literally, to put upon (perfect indicative imposui), from in- + ponere to put — more at position Date: 1581 transitive verb 1 a : to establish or apply by authority <impose a tax> <impose new restrictions> <impose penalties> b : to establish or bring about as if by force

Government as Imposer Who are the Imposers? What are their tools?

Broad Areas of Gov’t Imposition
Criminal Law Regulation Tort Contracts Property

Workplace Controls Days 1-3

Employers Who are the Imposers? What are their tools?

Fiduciary Controls Days 1-3

Fiduciaries Who are the Imposers? What are their tools?

Clubs, Gangs, Homeowner’s Associations
Days 1-3

Clubs, Gangs, and Homeowners Asso.
Who are the Imposers? What are their tools?

Oddball Imposers Days 1-3

Oddball Imposers Who are the Imposers? What are their tools?

Today’s Imposers? What Do They Do With Human Fallibility?

Governmental Imposers
“…No person may operate an aircraft in a careless or reckless manner so as to endanger the life or property of another.” Federal Aviation Regulations § Careless or Reckless Operation Days 1-3 69

“As far as I am concerned, when I say ‘careless’ I am not talking about any kind of ‘reckless’ operation of an aircraft, but simply the most basic form of simple human error or omission that the Board has used in these cases in its definition of ‘carelessness.’ In other words, a simple absence of the due care required under the circumstances, that is, a simple act of omission, or simply ‘ordinary negligence,’ a human mistake.” National Transportation Safety Board Administrative Law Judge Engen v. Chambers and Langford Days 1-3 70

The following conduct, acts, or conditions constitute unprofessional conduct… The commission of any act involving moral turpitude, dishonesty, or corruption… Misrepresentation or fraud… The willful betrayal of a practitioner-patient privilege… Abuse of a client or patient or sexual contact with a client or patient… Incompetence, negligence, or malpractice which results in an injury to a patient or which creates an unreasonable risk that a patient may be harmed… RCW § Unprofessional Conduct Days 1-3

Employers as Imposers Gross Misconduct
Where an offense is so serious as to breach the basis of the employment contract, then this will be regarded as gross misconduct and will normally lead to summary dismissal, unless there are sound mitigating circumstances. Indecency Theft Fraud Assault Sexual Harassment Malicious Damage Corruption Being Unfit for Duty Serious Breach of Confidentiality Also, Gross Carelessness / Negligence – any action or failure to act which threatens the health or safety of patient, members of public or other staff Norfolk and Norwich Community Hospital

Society as Imposers

All in the name of the game….
You are the imposer What say you?

Day 2 – Drawing the Line Our Shared Fallibility ─ Intention and Consequences Levels of Culpability ─ What the Law Can Teach Us Legal Case: U.S. v. Morrisette Reporting v. Justice – Reconciling Competing Values Where to Draw the Disciplinary Line The Reasonable Person Standard

Thinking About Human Intention
Action Four Options Intend Consequences Do Not Intend Consequences Intend Action Do Not Intend Action Intention Consequence of Action

Thinking about Human Intention
Levels of Intention Purpose Knowledge Reckless Negligence At-Risk Behavior Human Error Action Intention Consequence of Action

The Model Penal Code Purposefully Knowingly Recklessly Negligently
Conscious objective to engage in conduct to cause such a result Knowingly Practically certain that his conduct will cause such a result Recklessly Conscious disregard of a substantial and unjustifiable risk will result from conduct Involves a gross deviation from the standard of conduct that a law-abiding person would observe in the actor’s situation Negligently Should be aware of a substantial and unjustifiable risk that will result form conduct

US v. Morrisette

Justice Versus Safety

Justice Versus Safety: A Look at Two Programs
The Aviation Safety Reporting System Why build the program? What are the ground rules? Aviation Safety Action Programs Why build the program? What are the ground rules?

The Reasonable Person

The Reasonable Man (circa 1837)
Court of Common Pleas Vaughn builds a hay rick near the edge off Menlove’s property Menlove, the neighbor, warns Vaughn that his design was dangerous Vaughn says “he would chance it”

Court of Common Pleas Haystack catches fire, burns down two of Menlove’s cottages Vaughn held to “reasonable man” test – “caution such as a man of ordinary prudence would observe”

Hall v. Brooklands Auto-Racing Club Did racetrack take reasonable caution in it design of the track? What would the bald-headed man at the back of the Clapham omnibus do?

Wears all the right gear Looks both ways before crossing the street Never puts others at risk

Procedure-Based Duties
Day 3 – Duty The Duty to Save? Outcome-Based Duties Procedure-Based Duties Building a Socio-Technical System Using the Three Duties Using The Just Culture Algorithm™ The Duty to Avoid Causing Unjustifiable Risk or Harm

“Thirty Eight Who Saw Murder Didn’t Call Police”
The Duty to Save? “Thirty Eight Who Saw Murder Didn’t Call Police” NY Times

What About A Duty to Self?
“Thirty Eight Who Saw Murder Didn’t Call Police” NY Times

Outcome-Based Duties System Design Values and Expectations Errors & Outcomes Behavioral Choices Under what circumstances will we stand in judgment of the outcome? Under what criteria will we consider disciplinary action?

Procedure-Based Duties
System Design Values and Expectations Errors & Outcomes Behavioral Choices Under what circumstances will we stand in judgment of procedural compliance? Under what criteria will we consider disciplinary action?

Kitchie’s Ice Cream Parlor

Kitchie’s Ice Cream Parlor
Target five areas of possible imposition: Employee safety (exposure to bacteria, sharp edges) Customer safety (tainted food, salmonella) Employee work hour/salary requirements (working teenagers beyond reasonable hours, not paying overtime) Customer satisfaction (varieties of flavors, taste) Fashion patrol (offensive, suggestive, or tacky clothing) Identify the Imposers (e.g., employer, department of health) Which classes of duty (avoid unjustifiable risk or harm, procedural, outcome) you would have each imposer use.

The Just Culture Algorithm™

The Basis for the Tool Science Law The Goals Systems Engineering
Human Factors Behavioral Psychology The Model Penal Code Contract Law The Common Law / Equity The Goals Maximize system performance (justice as a secondary value) Justice (a primary value)

The Three Behaviors Human Error At-Risk Behavior Reckless Behavior
Product of Our Current System Design and Behavioral Choices A Choice: Risk Believed Insignificant or Justified Conscious Disregard of Substantial and Unjustifiable Risk Manage through changes in: Choices Processes Procedures Training Design Environment Manage through: Removing incentives for at-risk behaviors Creating incentives for healthy behaviors Increasing situational awareness Manage through: Remedial action Punitive action Expect employees to follow the rules… a rule, a regulation, or perhaps a verbal commitment to another. Within the duty to follow a procedural rule, the employee’s obligation is simply to follow the rule. They are not accountable for the output of the system, only for being a reliable, successful component in the system. Take for example, the job of a technician. Is he responsible for delivering an on-time flight? Or, is he one component of the aviation system that produces the output of an on-time flight? The answer is that the pilot is a component of a system – accountable for his or her contribution to the system. Technicians are a component in the system…Here, the employee is working within the employer’s system. Technician forgets to do the leak check of the system… yes there is a rule, but she forgets. In maintenance, anytime a aircraft is released into service and has the wrong part installed, a system not reactivated, its out of conformance to the type certificate. Routine rule violations are the “at-risk violation”, and the issue with ASAP. Console Coach Punish 97

The Just Culture Algorithms
One method that works across all values One method that works both pre- and post-event The Algorithm is designed to help you determine what to do when your employee has made an error, or not met a duty to the organization. The Just Culture Algorithm simply allows us to independently assess each breach of a duty. The Algorithm addresses the conflicts that might arise with overlapping duties when you apply the social utility test. 1-39 98

The Five Skills Values and Expectations Human Behavior System Design
Better Outcomes Learning Systems Justice & Accountability The Mission 1 2 3 4 5 99

Examples of Learning Systems
Internal and External-Based Audits / Inspections Voluntary Reporting Programs Digital / Video Surveillance Safety (Value) Management Systems Risk-Based Assessments Failure Mode Effects Analysis (FMEA) Hotlines / Whistle-Blower Complaints Customer Feedback / Employee Surveys Event Investigations

The Role of Event Investigation
101

It’s About a Proactive Learning Culture
Management decisions are based upon where our limited resources can be applied to minimize the risk of harm, knowing our system is comprised of sometimes faulty equipment, imperfect processes, and fallible human beings. 102

The Basics of Event Investigation
What happened? What normally happens? Increasing value What does procedure require? Learning objective(s): Many organizations begin their investigation with What does procedure require? This may put employees on the defensive. And sends a message that we are assess rule violation as the harm, when this is not generally the case. Instead we want to create an environment that is not threatening so we can learn What happened ? and What normally happens? What normally happens in managing this occurrence – how do we normally respond, what would have been the normal actions of people and systems in this event. If what normally happens is not what happened on this occasion – why? Why didn’t we do what we normally do? System, performance shaping factors? One ‘out of the box’? Then we can ask What does the procedure require? We ask that at this time because now we understand what normally happens and what happened on this occasion. Now we need to understand what have we defined as ‘should’ have happened. If what happened is not aligned with the procedure, is it because the procedure doesn’t allow us to achieve the outcome as intended, or have we perhaps drifted from what was intended? If so, we need to investigate and assess why that has occurred and address it. Why did it happen – this time? What was it that caused the event to occur and the harm or potential harm to be realized? What was the trigger? What actions, errors, choices, system contributors an /or personal performance shaping factors played into it? How were we managing the risk in the first place? If this risk was already known, how had we been managing it – through education, training, systems, equipment, barriers, processes, policy etc? We need to articulate at the end of the event investigation how we WERE managing the risk. If we are recommending changes – why and how will it manage risk better moving forward. If we are not, demonstrate why no changes are required. Your good work above will already help you to do that. Why did it happen? How were we managing it?

Five Rules of Causation
Causal statements should clearly show the “cause and effect” relationship Negative descriptors should not be used in causal statements (i.e., poorly, inadequately, etc…) Each human error should have a preceding cause Each “at risk” behavior/procedural deviation should have a preceding cause Failure to act is only causal when there was a pre-existing duty to act

3. Each human error has preceding cause
Rule 3 – each human error must have a preceding cause 4. Each ARB/deviation has a preceding cause Rule 3 – each human error must have a preceding cause Rule 4 – each violation must have a preceding cause

Fifth Rule of Causation
Failure to act is only causal when there was a pre-existing duty. Many investigations mix causes and prevention strategies into one narrative – leaving the reader to guess at the cause and effect relationships. 106 106

Understanding Causation
107

Causal Language Root Cause/s The initiating cause of a causal chain
Direct Cause The cause is virtually certain to result in the effect Probabilistic Cause The cause increases the likelihood of the effect Correlation An observed co-incidence of two or more conditions. 108

The Diagram Decode The Undesired Outcome Human Error Behavioral Choice
A Cause of the Human Error A Cause of the Behavioral Choice 109

Do not put non-causal data on the cause and effect chart
The Process Start with outcome(s) on right side of page Work right to left identifying causal links One-to-one, one-to-many, and many-to-one are all allowable Do not put non-causal data on the cause and effect chart 110

The Basic Structure Condition A Condition B The causal link 111

“Cause and Effect” (IV pump not started)
Patient distracted the nurse with a personal request while the nurse was hanging an IV Piggyback IV pump not set for the piggyback Patient did not receive ordered medication How are we managing risks in which staff (technicians and inspectors) are not familiar with a task, and yet still attempt to do the work? Why would the instruments be “placed” in the panel and left alone? To what extent are streamers used in the maintenance check check? The Undesired Outcome Human Error A Cause of the Behavioral Choice A Cause of the Human Error Behavioral Choice 112

Housekeeping Scenario
A housekeeping worker was waxing the floors around 10:00 p.m. He could not find a ‘wet floor’ sign and would have had to go to another building to search for one. Believing he was alone in the building, he did not search for a warning sign. An accountant, working late slipped on the wet floor and severely damaged his knee. The housekeeping staff frequently had to search for the ‘wet floor’ warning signs, which caused them to get behind on their work. The manager was aware of the unavailability of signs, but did not take any action to purchase more.

Housekeeping Scenario
Accountant Slips On Floor Wet Floor Why? Signs Far Away “Wet” Sign Not Placed Manager Did Not Buy More Signs Housekeeper Thought He Was Alone Severe Damage To Knee The Undesired Outcome Human Error A Cause of the Behavioral Choice A Cause of the Human Error Behavioral Choice

Knowing You Have the Right Cause: The Checklist
Do you know what happened? Do you know what normally happens? Do the causal statement(s) explain the difference? Are the errors and behaviors explained? Do the causal statement(s) make sense? 116 116

Finishing the Review: Are the Right Actions Being Taken to Address the Risks Identified?
117

The One Stop Rule: Leave Systemic Causes to Multiple Event Analysis
We can establish three levels of causation. The first is mere identification of the error as the cause of the undesirable outcome. The next level includes the local factors that we usually identify through the single investigation. The third level are the more attenuated causes, best left to analysis of a class of event. 118

Keys to Understanding the Algorithm
Duty to Produce an Outcome vs. Duty to Follow a Procedural Rule Purpose and Knowledge Risk vs. Rule-based The Severity Bias Who determines “substantial and unjustifiable”? “Conscious disregard” and the Objective Standard Organizational accountability in drawing the “bright line” Remediation and levels of punishment Repetitive behaviors Regulator’s use of the Algorithm

Resume Scenario A new operations manager is found to have lied on his resume. He did not have the college degree that he showed on his resume. An investigation of why this oversight has occurred found that a human resources clerk did not do the required background check. The human resources manager had never had a candidate lie about a college degree in their 8 years of managing, and simply told his overworked clerk to skip the check. Corporate policies require that the check be completed. Both the clerk and the manager were aware of the policy.

Resume Scenario Staff member lied about having a college degree
Financial and reputation harm to company HR manager told HR clerk to skip check HR clerk did not confirm with school Why? The Undesired Outcome Human Error A Cause of the Behavioral Choice A Cause of the Human Error Behavioral Choice

Near Miss: Wrong Procedure
75 year old female patient was admitted to an outpatient surgery center for insertion of a pacemaker. Patient was in the pre-operative area when surgical RN A came into the pre-op area, grabbed a chart off the counter, and called out a patient name, at which point, the patient nodded her head. Upon arrival to the OR, the anesthesiologist was busy, and immediately placed the patient on ECG monitor, and induced anesthesia. The surgeon entered the OR after the patient was sedated, and asked if a timeout had been completed. RN A indicated that a “mini” time out was done and gave the surgeon the chart with the consent form. The surgeon begins to prep the chest area when a cardiologist enters the OR and asks if this is her patient who was there for a pacemaker. The surgeon indicates the patient was there for a Port –A- Cath insertion. At this point, the surgeon checks the armband, and notes that it does not match the chart. Anesthesia is reversed and the patient is moved to another room for the pacemaker insertion. 122

Probabilistic Cause Direct Cause(s)
What is the organizational culture? Did the surgeon understand his role in the time out? The surgeon was running late and the anesthesiologist had already sedated the patient No procedural time out done by surgical team Near miss wrong procedure. Patient receives sedation Group Norm vs. Individual Norm??? What usually happens? How are we managing risks in which staff (technicians and inspectors) are not familiar with a task, and yet still attempt to do the work? Why would the instruments be “placed” in the panel and left alone? To what extent are streamers used in the maintenance check check? The RN assumed the patient nodding her head indicated she was the right patient RN did not do two patient identifiers in the pre-op area The Undesired Outcome Human Error A Cause of the Behavioral Choice A Cause of the Human Error Behavioral Choice 123 123 123

Day 4 – Gaining Proficiency
Gaining Proficiency in the Algorithm™ Coaching & Mentoring The Big Healthcare Event Other Just Culture Algorithms

Managing Behaviors Behaviors We Can Expect
Human Error: an inadvertent action; inadvertently doing other that what should have been done; slip, lapse, 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. Learning objective(s): Humans are not always going to do the right thing. There are three big actions that they are going to take. They are going to make mistakes. The human error. The inadvertent slip, the lapse. They are going to drift into at-risk behavior where they make a noncompliant choice when they thought they were in a safe place. The reckless behavior. I know I am in an unsafe place an I choose to stay there. Copyright 2007, Outcome Engineering, LLC. All rights reserved. Copyright 2007, Outcome Engineering, LLC. All rights reserved. 125

Managing Human Error Two Questions:
Did the employee make the correct behavioral choices in their task? Is the employee effectively managing their own performance shaping factors? If yes, the only answer is to console the employee – that the error happened to them And then examine the system for improvement opportunities Learning objective(s): If the answer to these questions is yes, then we console the employee and look to the system we have placed them in to see how the system contributed to the outcome. Facilitator notes or Learning objective(s)? What is consoling? A learning conversation. Why the event happened and what can be done to prevent it from happening again. Coaching is assessing the quality of their choice. Providing the perception of risk that they lost. Copyright 2007, Outcome Engineering, LLC. All rights reserved. Copyright 2007, Outcome Engineering, LLC. All rights reserved.

Managing At-Risk Behavior
A behavioral choice that increases risk without perceiving the risk (i.e., unintentional risk taking), or is mistakenly believed to be justified Driven by perception of consequences Immediate and certain consequences are strong Delayed and uncertain consequences are weak Rules are generally weak Learning objective(s): ARB is where we make a choice. But we make a choice thinking we are in a safe place. You make a choice not to follow the law (policy or procedure) but we do not choose to have an adverse outcome. When we deviate from the standard, we call this drift. We drift thinking we are OK. Facilitator information: Where were you taught to place your hands on the wheel when you drive? 10 and 2. Where were they when you drove to work today? What about your speed when you drive? Driving 69 in a 60 when that green Kawasaki Ninja come flying by doing a wheelie at 100 mph. We look down our noses and say He’s reckless! He’s different from me; I’m a safe violator! The lesson I learn from the Steve Irwin incident is that sometimes, the better you are at what you do as a professional, the less likely you are to recognize that you are in a risky place. In an interview following the incident, Steve Irwin said, You people don’t understand. I’m a professional. I would never do anything to put my son in harms way; as if he were immune to making a mistake. We are in a sense the products of our own experience. Think about driving a car, talking on our cell phone, listening to the radio, drinking a Starbucks. We do this largely because nothing bad has happened to us so far. Each time we do this and nothing bad happens, we reinforce the at-risk behavior. We begin to think it’s OK. We begin to think we are in a safe place. ARB is our biggest challenge, but it is also our biggest opportunities for improvement. When you think about your organization, think about the number of people engaged in ARB. That’s where you opportunities will be. You will see people in your organization who make mistakes and you will see a few who are occasionally reckless, but most of your organization will be engaged in ARB of one type or another at some time throughout the day. Errors are not always rooted in the predictable slips, trips, and lapses that humans make. Some arise because people knowingly choose to circumvent defined safety practices. These choices either increase the likelihood of error or they remove downstream opportunities to catch errors. Marx places behavioral choices that increase risk into 2 broad categories: "at-risk behavior" or "reckless behavior." Copyright 2007, Outcome Engineering, LLC. All rights reserved. Copyright 2007, Outcome Engineering, LLC. All rights reserved. 127

Managing At-Risk Behaviors
A behavioral choice Managed by adding forcing functions (barriers to prevent non-compliance) Managed by changing perceptions of risk (Coaching) Managed by changing consequences AND Examine the system for improvement opportunities 128

Managing Reckless Behavior
Conscious Disregard of Substantial and Unjustifiable Risk Manage through: Disciplinary action Punishment as a deterrent Reckless Behavior Note: Remediation is always available 129

Coaching & Mentoring in a Just Culture

What Is the Difference Between…
Role-Modeling? Mentoring? Consoling? Coaching? Counseling? Punishing?

Role Modeling: “Walking the Talk”
In a Just Culture, role modeling can be the first step in building the five skills: Mission, Values, and Expectations Creating a Learning Culture Creating an Open and Fair Culture Designing Safe Systems Managing Behavioral Choices

Mentoring Mentoring can include one or more of the following:
Sharing stories of personal experiences, including mistakes and risky choices that you may have made or observed Providing information or lessons learned from past events and reports in a specific work area Sharing information and lessons learned from relevant events outside of the organization (e.g., industry events at other organizations) Brainstorming with employees, identifying strategies for mitigating and managing risk in the organization Acknowledging, recognizing, and thanking individuals for their safe choices and for self-reporting errors and at-risk behaviors Facilitator notes: Old school: make no mistakes New school: Humans are fallible, systems are fallible Mentoring one more way to mitigate risk and model good behavioral choices

Supporting (Consoling) (The Response to Human Error)
A Learning Conversation Discussing why the event happened and what can be done to prevent it from happening again Alleviating the Grief, Sense of Loss, or Trouble by Comforting the Employee Remember, the Manager Also Investigates the System and Makes Changes as Appropriate Algorithm: Consoling is the response to human error with regard to Duty to Follow A Procedural Rule or Duty to Avoid Causing Unjustifiable Risk or Harm Peer/Peer consoling

Coaching (The Response to At-Risk Behavior)
To understand how to effectively coach, let’s look at the following four basic steps representing human behavior whenever risk is present: Perception Interpretation Decision-Making Action

The PIDA Model

Coaching (The Response to At-Risk Behavior)
We Are Creating a Learning Opportunity by: Understanding the situation from their point of view Describing the at-risk behavior Explaining how the at-risk behavior does not align with our shared values Establishing a plan, if necessary, with follow-up actions What you don’t correct, you condone!

Peer-to-Peer Coaching
Facilitator notes: Manager/Manager Non-clinician/Non-clinician Nurse/Nurse Doctor/Doctor Source: BC Hydro

Peer-to-Peer Coaching
A Strong Marker of Culture is an Openness to Peer-to-Peer Coaching The willingness to approach a peer in a productive manner The receptiveness of the peer being coached Managers Should Model Effective Coaching Behaviors and Be a Resource to Employees

Counseling (Repetitive Human Error or At-Risk Behavior)
A first step disciplinary action: putting the employee on notice that performance is unacceptable Facilitator notes: Each organization is different with regards on when and how counseling should be conducted. Please refer to your organizations HR Policy for guidelines. Algorithm: Same as previous slide. Add Duty to Produce an Outcome if addressed in organizations HR policy

Discipline Record of Conversation Counseling Discipline
Punitive Action

Punishing (The Response to Reckless Behavior)
Behavioral choice to consciously disregard a substantial and unjustifiable risk Manage through Remedial action Punitive action

The Three Duties The Duty to Avoid Causing Unjustifiable Risk or Harm The Duty to Produce an Outcome The Duty to follow a Procedural Rule OR 143

The Duty to Produce an Outcome
Meet me at 7:00 pm at 410 Chestnut Street The Duty to Produce an Outcome Learning objective(s): Who controls the system that creates the outcome? Facilitator information: In the case of showing up at work on time, it is generally the employee who has control of the system. The employer sets the expectation, and the employee strives to meet the expectation. In other terms, the employer identifies the duty, and the employee, by virtue of taking the job, agrees to accept the duty. Now, do we ever expect an employee to breach the duty – yes! We are not perfect, and there are always life reasons that can cause us to be late to work. The nature of the duty, however, is to deliver an outcome to the employer – an outcome within the control of the employee.

The Duty to Produce an Outcome for the System
Acceptable Rate of Undesired Outcome Unacceptable Rate of Undesired Outcome Product of Employee’s System and Behaviors Product of Employee’s System and Behaviors Continue to allow employee to manage rate Intervene in employee's system, - or - Consider: Remedial action Disciplinary action Accept Discipline

Categories of Possible Physician Breach
Insufficient prevention, diagnosis or treatment of patient disease or condition Iatrogenic harm – caused by the physician incidental to the practice of medicine Inappropriate conduct not directly related to the delivery of care Clinical Review Administrative Review 146

Duty to Produce an Outcome*
This path applies when a physician is largely in control of the system by which the outcome is produced. Examples from each category of possible physician breach include: High patient return rate to the emergency department High prescription error rate Violations in meeting OR start time or call coverage rules * This path can be applied when the failure rate is assessed based on statistically valid, risk adjusted data and the adverse event rate is deemed unacceptable. 147

Two Specific Classes of Duty
Meet me at 7:00 pm at 410 Chestnut Street Leave your house at 6:45pm. Only drive 35 MPH. 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. Learning objective(s): Expect employees to follow the rules… a rule, a regulation, or perhaps a verbal commitment to another. Within the duty to follow a procedural rule, the employee’s obligation is simply to follow the rule. They are not accountable for the output of the system, only for being a reliable, successful component in the system. The Duty to Produce an Outcome The Duty to Follow a Procedural Rule

The Duty to Follow a Procedural Rule
“The fastest way to get yourself killed on a manned space flight is to not follow standard operating procedure.” “The second quickest way to get yourself killed is to always follow standard operating procedure.” Karol Joseph "Bo" Bobko

The Duty to Follow a Procedural Rule
Human Error At-Risk Behavior Reckless Behavior Product of Our Current System Design and Behavioral Choices A Choice: Risk Believed Insignificant or Justified Conscious Disregard of Substantial and Unjustifiable Risk Manage through changes in: Choices Processes Procedures Training Design Environment Manage through: Removing incentives for at-risk behaviors Creating incentives for healthy behaviors Increasing situational awareness Manage through: Remedial action Punitive action Expect employees to follow the rules… a rule, a regulation, or perhaps a verbal commitment to another. Within the duty to follow a procedural rule, the employee’s obligation is simply to follow the rule. They are not accountable for the output of the system, only for being a reliable, successful component in the system. Take for example, the job of a technician. Is he responsible for delivering an on-time flight? Or, is he one component of the aviation system that produces the output of an on-time flight? The answer is that the pilot is a component of a system – accountable for his or her contribution to the system. Technicians are a component in the system…Here, the employee is working within the employer’s system. Technician forgets to do the leak check of the system… yes there is a rule, but she forgets. In maintenance, anytime a aircraft is released into service and has the wrong part installed, a system not reactivated, its out of conformance to the type certificate. Routine rule violations are the “at-risk violation”, and the issue with ASAP. Console Coach Punish 150

Duty to Follow a Procedural Rule
This path applies when the physician works within a system and is responsible for following a procedural (i.e., “how to”) rule created by the system. Examples from each category of possible physician breach include: Failure to use medical staff approved order sets for community acquired pneumonia Not participating in a required pre-procedural time-out Not completing date and time documentation according to policy 151

The Duty to Avoid Causing Unjustifiable Risk or Harm
Human Error At-Risk Behavior Reckless Behavior Product of Our Current System Design and Behavioral Choices A Choice: Risk Believed Insignificant or Justified Conscious Disregard of Substantial and Unjustifiable Risk Manage through changes in: Choices Processes Procedures Training Design Environment Manage through: Removing incentives for at-risk behaviors Creating incentives for healthy behaviors Increasing situational awareness Manage through: Remedial action Punitive action Expect employees to follow the rules… a rule, a regulation, or perhaps a verbal commitment to another. Within the duty to follow a procedural rule, the employee’s obligation is simply to follow the rule. They are not accountable for the output of the system, only for being a reliable, successful component in the system. Take for example, the job of a technician. Is he responsible for delivering an on-time flight? Or, is he one component of the aviation system that produces the output of an on-time flight? The answer is that the pilot is a component of a system – accountable for his or her contribution to the system. Technicians are a component in the system…Here, the employee is working within the employer’s system. Technician forgets to do the leak check of the system… yes there is a rule, but she forgets. In maintenance, anytime a aircraft is released into service and has the wrong part installed, a system not reactivated, its out of conformance to the type certificate. Routine rule violations are the “at-risk violation”, and the issue with ASAP. Console Coach Punish 152

Duty to Avoid Causing Unjustifiable Risk or Harm*
This path applies for any situation that actually or potentially leads to harm of persons or property. Examples from each category of possible physician breach include: Not ordering an indicated diagnostic test Writing a contraindicated prescription Disruptive operating room behavior * This path can be applied in conjunction with suspected breaches in either the Duty to Follow Procedural Rule or the Duty to Produce an Outcome 153

The Just Culture Algorithm

The Three Duties The Duty to Avoid Causing Unjustifiable Risk or Harm Society sets the expectation for the behavior Organization assesses risk was being managed Employee is assessed for their behavior and quality of their choices Objective standard (reasonable person standard) is applied If there is no acceptable rate The Duty to Produce an Outcome The Duty to follow a Procedural Rule OR Imposer sets the expectation for the result Employee owns the system, i.e. “How you do that is up to you…we just judge if you did it or not” Don’t assess HE, ARB or RB Rate based expectation Imposer sets the expectation for compliance with the rule Employer owns the system, i.e. “Do it our way, as defined, every time for reliable results” Be a reliable component in our system 155

Working in the Algorithm

Scheduling Scenario A near-term pregnant patient is told by her doctor that she needs to return to the clinic within one week for her next prenatal check up. The scheduler was new to the job and made a mistake with the scheduling system. Flipping to the wrong week, the scheduler inadvertently booked the patient for an appointment in two weeks. Before her scheduled appointment, the mother goes into labor and the baby is stillborn. The physician angrily tells the clinic manager that the baby might have lived if the mother’s appointment had been scheduled correctly.

Scheduling Scenario Patient Harm Why? Scheduler flipped to wrong page in appointment book, scheduled appointment too late The Undesired Outcome Human Error A Cause of the Behavioral Choice A Cause of the Human Error Behavioral Choice

Basketball Scenario An off-duty railroad maintenance technician and a supervisor are waiting at a platform for a train to go to the San Antonio Spurs basketball game. They are playing catch with a basketball. The basketball falls in to the track area. The two discuss retrieving the ball, and decide that the technician, Sherman, will jump into the track area to get the ball. While standing in the tracks, Sherman noticed open wires protruding from an electrical box under the platform. To Sherman, it appeared that the electrical box had been hit by something, exposing the wiring. Sherman, as a technician, knew that the wires would pose a safety concern. However, Sherman knew also that there was no reason for him to know of the damaged electrical box unless he was on the tracks. Sherman does not report the problem with the electrical box. 159

NICU Scenario A nurse is going to administer a medication to a baby in the neonatal ICU. The ICU has an automated dispensing system. The automated dispensing system opens a drawer with four bins. As he has always done, he reached into the second bin where the vial of medication is, confirms the blue cap on the vial, grabs the medication and takes it to deliver the medication. At no time in the process did the nurse actually confirm the medication label, instead relied on location in the dispensing system and color of cap to confirm medication. In this case, pharmacy had put the wrong concentration in the dispensing system. The nurse caught the error by glancing at the vial when drawing up the medication.

NICU Scenario Increased Risk Of Patient Harm
The Undesired Outcome Human Error A Cause of the Behavioral Choice A Cause of the Human Error Behavioral Choice Increased Risk Of Patient Harm Pharmacy Mis-Stocks Dispensing System Relied On Color Of Cap, Did Not See Risk Nurse Does Not Confirm Drug Why?

Fire Safety: Near Miss One of the considerations to prevent surgical fires is strict control of the electrical surgical (ES) pencil. The policy at one surgical facility is to house the ES pencil in its holster and to anchor the holster onto the Mayo stand. An abdominoplasty was being performed and two ES pencils were placed onto the surgical field and anchored to the Mayo stand. During the case, one of the holsters kept coming dislodged and the two ES lines kept getting tangled; the surgeons were frustrated. At the surgeon’s request and in order to keep peace, the scrub nurse anchored the second ES pencil and holster to the sterile drape with a towel clip near the head of the sterile field. Frequently during the case, the ES pencil at the head would slip out of the holster and rest on the drape. No matter how she tried, the scrub nurse could not contain the ES pencil.

Fire Safety: Near Miss Holster repeatedly dislodged; ES lines were tangled Surgeon requested ES pencil/holster be re-positioned Scrub Nurse anchored ES pencil/holster to sterile drape Increased Risk of Surgical Fire OR staff did not object to physician’s request Why? The Undesired Outcome Human Error A Cause of the Behavioral Choice A Cause of the Human Error Behavioral Choice

Patient Falls When passing a patient room, a nurse manager sees that a patient is about to fall out of the bed. The nurse manager rushes to the patient and catches the patient before they fell to the ground. The nurse manager did not wash or sanitize her hands before touching the patient.

Day 5 – The Journey Begins
The Big Healthcare Event Banner Policy Review HR & HIPAA Alternative Algorithms 16 Design Laws Refresh the Five Skills Implementation Best Practices The Role of the Just Culture Champion

The Big Healthcare Event

Nurse F did not know of the requirement to have two nurses hang blood
Nurse C told her to go and hang the blood on her own as she responded to a code Nurse F did not have second nurse present when hanging blood Nurse F assumed Nurse C had checked the blood Nurse F asked only patient name and not DOB Chg Nurse instructed other nurses not to replace it ? Nurse F did not check blood when she went to hang the blood Patient given other patient’s blood Mr Delta did not have wristband on as he had been agitated by it Other nurses chose to breach the rule ? Other nurses did not report the breach ? Nurse C did not check blood when picking it up at nurse’s station Nurse C assumed it was the overdue blood for her patient Nurse C selects wrong bag at nurse’s station

Banner Policy Review

HR Model Policy Language
“Employees are required to follow company policies, to make behavioral choices that are supportive of organizational values, and required to avoid causing unjustified risk or harm to self or others. Nevertheless, we fully expect that every employee will face circumstances where a breach of one of these duties occurs, whether justified or not. Where working under a Duty to Produce an Outcome, an employee will be held accountable as directed by the code of conduct and individual policies. These policies put the employee on notice to the duty, and prescribe acceptable outcomes attached to each duty (e.g., time and attendance, dress code, harassment). When working under a Duty to Follow a Procedural Rule within a system, an employee will be subject to disciplinary action when he or she has recklessly disregarded the risks associated with breaking the rule. At all times, an employee will be subject to the Duty to Avoid Causing Harm to himself, to fellow employees, patients, visitors, and to the organization. Under this duty, employees will be open to disciplinary action when their actions involve a conscious disregard of a substantial and unjustifiable risk of harm. In addition to these actions stemming from single events, an employee who has committed a series of human errors or at-risk behaviors whose cause does not originate within the work system, will be subject to disciplinary action when non-punitive remedial action (e.g., education, coaching) is not effective in changing behavior. Decision-making in accordance with these provisions will use an objective standard, except where the employee may show subjectively that they had a good faith basis for believing that a particular breach was justified. Actions taken will be guided by the Just Culture Algorithm, version 3.1, which is supportive of these provisions.” “Employees are required to follow company policies, to make behavioral choices that are supportive of organizational values, and required to avoid causing unjustified risk or harm to self or others. Nevertheless, we fully expect that every employee will face circumstances where a breach of one of these duties occurs, whether justified or not. Where working under a duty to produce an outcome, an employee will be held accountable as directed by the code of conduct and individual policies. These policies put the employee on notice to the duty, and prescribe acceptable outcomes attached to each duty (e.g., time and attendance, dress code, harassment). When working under a duty to follow a procedural rule within a system, an employee will be subject to disciplinary action when he or she has recklessly disregarded the risks associated with breaking the rule. At all times, an employee will be subject to the duty to avoid causing harm to himself, to fellow employees, patients, visitors, and to the organization. Under this duty, employees will be open to disciplinary action when their actions involve a conscious disregard of a substantial and unjustifiable risk of harm. In addition to these actions stemming from single events, an employee who has committed a series of human errors or at- risk behaviors whose cause does not originate within the work system, will be subject to disciplinary action when non-punitive remedial action (e.g., education, coaching) is not effective in changing behavior. Decision-making in accordance with these provisions will use an objective standard, except where the employee may show subjectively that they had a good faith basis for believing that a particular breach was justified. Actions taken will be guided by the Just Culture Algorithm, version 3.0, which is supportive of these provisions.” “Employees are required to follow company policies, to make behavioral choices that are supportive of organizational values, and required to avoid causing unjustified risk or harm to self or others. Nevertheless, we fully expect that every employee will face circumstances where a breach of one of these duties occurs, whether justified or not. Where working under a duty to produce an outcome, an employee will be held accountable as directed by the code of conduct and individual policies. These policies put the employee on notice to the duty, and prescribe acceptable outcomes attached to each duty (e.g., time and attendance, dress code, harassment). When working under a duty to follow a procedural rule within a system, an employee will be subject to disciplinary action when he or she has recklessly disregarded the risks associated with breaking the rule. At all times, an employee will be subject to the duty to avoid causing harm to himself, to fellow employees, patients, visitors, and to the organization. Under this duty, employees will be open to disciplinary action when their actions involve a conscious disregard of a substantial and unjustifiable risk of harm. In addition to these actions stemming from single events, an employee who has committed a series of human errors or at- risk behaviors whose cause does not originate within the work system, will be subject to disciplinary action when non-punitive remedial action (e.g., education, coaching) is not effective in changing behavior. Decision-making in accordance with these provisions will use an objective standard, except where the employee may show subjectively that they had a good faith basis for believing that a particular breach was justified. Actions taken will be guided by the Just Culture Algorithm, version 3.0, which is supportive of these provisions.” .Focus HR policies on the behavioral choices of managers and staff, with less emphasis on errors and their undesired outcomes. The objective is to evolve to an HR system that is proactive toward risk and behavioral choices, rather than reactive toward errors and outcomes. .Ensure that policies and actions (system redesign, consoling an employee, coaching, or disciplinary action) are all related to the risk associated with a behavior, not the actual outcome. .Remove any policy references to negligent or careless conduct as a basis for disciplinary action to reduce confusion. The term, “negligent” has a legal meaning that is out of place in a just culture. .Remove any policy references to criminal conduct as a basis for disciplinary action. The term “criminal conduct” refers only to a societal view that punishment should follow a particular type of conduct. Unfortunately, in many legislative schemes, mere human error is criminal conduct (e.g., criminal negligence). .Ensure that managers fully understand the three duties and three behaviors. Ensure that managers have the skills to console, coach, discipline, and initiate system redesign where indicated. .Ensure that the substance of Just Culture concepts, as shown in the model policy language at right, are supported by general disciplinary policies as well as section or domain specific policies. .Ensure that event reporting and investigation system design and policies support these provisions. .Focus HR policies on the behavioral choices of managers and staff, with less emphasis on errors and their undesired outcomes. The objective is to evolve to an HR system that is proactive toward risk and behavioral choices, rather than reactive toward errors and outcomes. .Ensure that policies and actions (system redesign, consoling an employee, coaching, or disciplinary action) are all related to the risk associated with a behavior, not the actual outcome. .Remove any policy references to negligent or careless conduct as a basis for disciplinary action to reduce confusion. The term, “negligent” has a legal meaning that is out of place in a just culture. .Remove any policy references to criminal conduct as a basis for disciplinary action. The term “criminal conduct” refers only to a societal view that punishment should follow a particular type of conduct. Unfortunately, in many legislative schemes, mere human error is criminal conduct (e.g., criminal negligence). .Ensure that managers fully understand the three duties and three behaviors. Ensure that managers have the skills to console, coach, discipline, and initiate system redesign where indicated. .Ensure that the substance of Just Culture concepts, as shown in the model policy language at right, are supported by general disciplinary policies as well as section or domain specific policies. .Ensure that event reporting and investigation system design and policies support these provisions.

What to look for? Does the language align with Just Culture?
Is the Purpose clear? Does it distinguish between Consoling, Coaching and Discipline? Can I breach any of the requirements or expectations through HE alone? Is there allowance for the justifiable breach? Does it allow for managing ARB? Does it allow for managing RB? How does it manage repetitive behaviors – HE or ARB or RB? Is there anything missing?

Changing Current Policies
Model HR Polices Changing Current Policies .Focus HR policies on the behavioral choices of managers and staff, with less emphasis on errors and their undesired outcomes. The objective is to evolve to an HR system that is proactive toward risk and behavioral choices, rather than reactive toward errors and outcomes. .Ensure that policies and actions (system redesign, consoling an employee, coaching, or disciplinary action) are all related to the risk associated with a behavior, not the actual outcome. .Remove any policy references to negligent or careless conduct as a basis for disciplinary action to reduce confusion. The term “negligent” has a legal meaning that is out of place in a Just Culture. .Remove any policy references to criminal conduct as a basis for disciplinary action. The term “criminal conduct” refers only to a societal view that punishment should follow a particular type of conduct. Unfortunately, in many legislative schemes, mere human error is criminal conduct (e.g., criminal negligence). .Ensure that managers fully understand the three duties and three behaviors. Ensure that managers have the skills to console, coach, discipline, and initiate system redesign where indicated. .Ensure that the substance of Just Culture concepts, as shown in the model policy language, are supported by general disciplinary policies as well as section or domain specific policies. .Ensure that event reporting and investigation system design and policies support these provisions.

Alternative Models of Accountability

Jim Reason’s Unsafe Acts Algorithm

Start with driving examples:
Speeding 70 mph in a 65 mph zone (At-Risk Behavior) Doesn’t get caught by police Gets caught by police Accident Blundering into a school zone driving over the speed limit (Human Error)

The NHS Incident Decision Tree

The NHS Decision Tree A limited purpose tool
Designed only for patient safety events A tool to help change culture Does not change facility HR practices “The organisation should move to a fair and just culture with appropriate accountability. The focus should be on system failure rather than individual blame. This means that no disciplinary action will result from the reporting of adverse incidents, mistakes or near misses, except where there have been criminal or malicious activities, professional malpractice, acts of gross misconduct, or where repeated errors or violations have not been reported.” NHS Bolton, Patient Safety Strategy, March 2009