Just Culture

Alison H. Page, MHA, MSN

Chief Safety Officer
Fairview Health Services
We’ve all been there……
Medication errror
 Failure to check
patient identification
 Why did these accidents
happen?

How what can we do to prevent

them from happening again?

How do we judge the

clinicians involved?
 How would you organization deal with a
surgeon who used an unauthorized piece of
equipment?

Percentage of those who believe Fairview

would discipline the surgeon….if:

NO harmful outcome Harmful outcome

- 19% of staff - 29% of staff

- 0% of managers - 50% of managers
- 11% of executives - 14% of executives
- 0% of physicians - 45% of physicians
 We can do two things:

1. Design systems to
accommodate human
beings

2. Manage human
behavior within the systems
 NAVAL AVIATION MISHAP RATE
776 aircraft
destroyed in FY 50-96
1954
Angled Carrier Decks
60
Class A Mishaps/100,000 Flight Hours

Naval Aviation Safety Center

50 NAMP est. 1959 39 aircraft
RAG concept initiated destroyed in
40 1996
NATOPS initiated 1961
Squadron Safety program
30
System Safety
Designated Aircraft
20
ACT
10 HFC’s 2.39
0
50 65 80 96
Fiscal Year
Managing Systems
“Systems produce precisely
the outcomes they are
designed for.”
Don Berwick
Epinephrine
Ephedrine
 Dopamine
Dobutamine
EPInephrine
EPHEDrine
DOPamine
DoBUTamine
 Seven Design Strategies
Important to Managing Risk

• Knowledge
• Skill
• Performance Shaping Factors
• Barriers
• Redundancy
• Recovery
• Perception of High Risk
Managing human
behavior is
a bit harder.

Why?
Because – to error is human
 Paris
in the
the spring
 Nominal Human Error Rates
Activity Probability
Error of commission (misreading a label) 0.003

Error of omission without reminders 0.01

Error of omission when items imbedded 0.003

in a procedure
Simple math error with self-checking 0.03

Monitor or inspector fails to detect error 0.1

Personnel on different shifts fail to check 0.1
hardware unless required by checklist
General error in high stress when 0.25
dangerous activities occurring rapidly

Salvendy G. Handbook of human factors & ergonomics 1997.

 Aoccdrnig to rscheearch at
Cmabrigde Uinervtisy,
it deosn't mttaer inwaht oredr the ltteers in
a wrod are, the olny iprmoetnt tihng is that
the frist and lsat ltteer be at the rghit
pclae. The rset can be a total
mses and you can sitll raed it
wouthit porbelm. Tihs is bcuseae the
huamn mnid deos not raed ervey lteter by
istlef, but the wrod as awlohe.
 The human brain cannot
have multiple simultaneous
foci of interest. This lack of
cognitive resource is the
single limiting factor of
human activity.
Francois Clergue
 Lessons from Human Factors
Research

 Errors are common

 The causes of errors are known
 Errors are byproducts of useful cognitive
functions
 Lessons from Human Factors
Research
 Many errors are caused by activities that
rely on weak aspects of cognition
 short-term memory
 attention span
 Errors can be prevented by designing
tasks and processes that minimize
dependency on weak cognitive functions
 Human Factors Principles &
Systems Design

 Avoid reliance on memory and

vigilance
 Use protocols and checklists
 Simplify
 Standardize

 Use constraints and forcing functions

 Human Factors Principles &
Systems Design
 Improve access to information
 Make potential errors obvious

 Increase feedback

 Reduce hand-offs
 Decrease look-alikes

 Automate very carefully

“We can’t change the human
condition, but we can change
the conditions under which
humans work”

James Reason
 However….

Humans are accountable

for their behavioral choices
Just Culture

www.justculture.org
Just Culture is about:

 Creating an open, fair, Adverse

Events

and just culture

 Creating a learning Human
Errors
culture
 Designing safe
systems System
Design
Managerial
and Staff

 Managing behavioral Behaviors

choices
Learning Culture / Just
Culture
 Managing for Safety Using
Just Culture Manage Behavioral Choices...
The second cornerstone of patient safety is the
management of behavioral choices. While we
must anticipate that we as humans will make
In its 1999 report, “To Err is Human,” the Institute of Medicine mistakes - it is our management of behavioral
reported that 44,000 to 98,000 individuals lose their lives to choices that will allow us to achieve the safety
medical error in our nation’s hospitals every year. outcomes we desire.
Design Safe Systems…
Now, in addition to creating a healthcare delivery system that is
The first cornerstone of patient safety is the
more patient-centered, timely, efficient, equitable, and
design of safe systems. It is the system in which
effective, we have been challenged to improve the safety of
we work that has the greatest overall influence
our nation’s healthcare system.
on the safety of the patient. We must design Adverse
systems that anticipate human error, capture Events
It has been said that every system is designed to achieve
errors before they become critical, and permit
exactly the results it gets. In other words, we are getting the
recovery when errors do reach the patient.
rate of accidental (iatrogenic) injury commensurate with the
system we have built. To make a substantial step in patient
safety, we must change the healthcare system.
Human
This worksheet illustrates one critical element of that Errors
fundamental change - the creation of a more open, fair, and
just culture. It is through a just culture that we will begin to
see, understand, and mitigate the risks within the healthcare
system.

System Managerial and

Design Staff Behaviors

Create an Open, Fair and Just

Culture…
To create a learning
Learning Culture / Just Culture environment,
organizations must move away from an
overly-punitive reaction to events and
errors. We must instead recognize our
Create a Learning Culture…
own fallibility - that we will make errors
A learning culture is the foundation of patient safety. It is
a culture that is hungry for knowledge - in the case of
and
patient safety it is a culture that is hungry that
to see risk, both we will drift away from what we
at the individual and organizational level. Risk can be
seen through events, near misses, or merely by observing
the design of the systems in which we work, our own
have been taught.
outcome engineering behaviors, and the behaviors of those around us.
dallas, tx
www.outcome-eng.com
copyright 2005

This document is not self-explanatory. It is to be used as an aid in the Safe Choices course.
 Managing for Safety Using
Just Culture
Manage Behavioral Choices...
The second cornerstone of patient safety is the
management of behavioral choices. While we
must anticipate that we as humans will make
In its 1999 report, “To Err is Human,” the Institute of Medicine mistakes - it is our management of behavioral
reported that 44,000 to 98,000 individuals lose their lives to choices that will allow us to achieve the safety
medical error in our nation’s hospitals every year. outcomes we desire.
Design Safe Systems…
Now, in addition to creating a healthcare delivery system that is
The first cornerstone of patient safety is the
more patient-centered, timely, efficient, equitable, and
design of safe systems. It is the system in which
effective, we have been challenged to improve the safety of
we work that has the greatest overall influence
our nation’s healthcare system.
on the safety of the patient. We must design Adverse
systems that anticipate human error, capture Events
It has been said that every system is designed to achieve
errors before they become critical, and permit
exactly the results it gets. In other words, we are getting the
recovery when errors do reach the patient.
rate of accidental (iatrogenic) injury commensurate with the
system we have built. To make a substantial step in patient
safety, we must change the healthcare system.
Human
This worksheet illustrates one critical element of that Errors
fundamental change - the creation of a more open, fair, and
just culture. It is through a just culture that we will begin to
see, understand, and mitigate the risks within the healthcare
system.

Create a Learning Culture… System Managerial and

A learning culture is the foundation of patientStaff Behaviors

Design

safety. It is a culture that is hungry for

knowledge - in the case of patient safety it is
Learning Culture / Just Culture
a culture that is hungry to see risk, both at
the individual and organizational level. Risk
can be seen through events, near misses, or
merely by observing the design of the
systems in which we work, our own Create an Open, Fair and Just Culture…
behaviors, and the behaviors of those move To create a learning environment, organizations must
away from an overly-punitive reaction to events and
errors. We must instead recognize our own fallibility - that

outcome engineering
around us. we will make errors and that we will drift away from what
we have been taught.
dallas, tx
www.outcome-eng.com
copyright 2005

This document is not self-explanatory. It is to be used as an aid in the Safe Choices course.
Managing for Safety
Using Just Culture
In its 1999 report, “To Err is Human,” the Institute of Medicine
reported that 44,000 to 98,000 individuals lose their lives to
medical error in our nation’s hospitals every year.
Now, in addition to creating a healthcare delivery system that is
more patient-centered, timely, efficient, equitable, and
effective, we have been challenged to improve the safety of
our nation’s healthcare system.
The first cornerstone of patient safety
It has been said that every system is designed to achieve
exactly the results it gets. In other words, we are getting the
rate of accidental (iatrogenic) injury commensurate with the
system we have built. To make a substantial step in patient
the system in which we work that has
safety, we must change the healthcare system.
This worksheet illustrates one critical element of that
fundamental change - the creation of a more open, fair, and
just culture. It is through a just culture that we will begin to
safety of the patient. We must design
see, understand, and mitigate the risks within the healthcare
system.
outcome engineering
dallas, tx
www.outcome-eng.com
copyright 2005
Design Safe Systems…
is the design of safe systems. It is
the greatest overall influence on the
systems that anticipate human error,
capture errors before they become
critical, and permit recovery when
System
errors do reach the patient. Design
Learning Culture / Just Culture
Create a Learning Culture…
A learning culture is the foundation of patient safety. It is
a culture that is hungry for knowledge - in the case of
patient safety it is a culture that is hungry to see risk, both
at the individual and organizational level. Risk can be
seen through events, near misses, or merely by observing
the design of the systems in which we work, our own
behaviors, and the behaviors of those around us.
This document is not self-explanatory. It is to be used as an aid in the Safe Choices course.
Manage Behavioral Choices...
The second cornerstone of patient safety is the
management of behavioral choices. While we
must anticipate that we as humans will make
mistakes - it is our management of behavioral
choices that will allow us to achieve the safety
outcomes we desire.
Adverse
Events
Human
Errors
Managerial and
Staff Behaviors
Create an Open, Fair and Just Culture…
To create a learning environment, organizations must
move away from an overly-punitive reaction to events and
errors. We must instead recognize our own fallibility - that
we will make errors and that we will drift away from what
we have been taught.
Managing for Safety Using
Just Culture Manage Behavioral Choices...
In its 1999 report, “To Err is Human,” the Institute of Medicine
reported that 44,000 to 98,000 individuals lose their lives to
The second cornerstone of patient
medical error in our nation’s hospitals every year.
safety is the management of behavioral
Design Safe Systems…
Now, in addition to creating a healthcare delivery system that is
more patient-centered, timely, efficient, equitable, and
effective, we have been challenged to improve the safety of
choices. While we must anticipate that
The first cornerstone of patient safety is the
design of safe systems. It is the system in which
we work that has the greatest overall influence
our nation’s healthcare system.
we as humans will make mistakes - it is
on the safety of the patient. We must design
systems that anticipate human error, capture
Adverse
Events
It has been said that every system is designed to achieve
exactly the results it gets. In other words, we are getting the
rate of accidental (iatrogenic) injury commensurate with the
our management of behavioral choices
errors before they become critical, and permit
recovery when errors do reach the patient.
system we have built. To make a substantial step in patient
safety, we must change the healthcare system. that will allow us to achieve the safety
Human
This worksheet illustrates one critical element of that Errors
fundamental change - the creation of a more open, fair, and
just culture. It is through a just culture that we will begin to
see, understand, and mitigate the risks within the healthcare outcomes we desire.
system.

System Managerial and

Design Staff Behaviors

Learning Culture / Just Culture

Create a Learning Culture…

A learning culture is the foundation of patient safety. It is
a culture that is hungry for knowledge - in the case of
patient safety it is a culture that is hungry to see risk, both
at the individual and organizational level. Risk can be
seen through events, near misses, or merely by observing
the design of the systems in which we work, our own
outcome engineering behaviors, and the behaviors of those around us.
dallas, tx
www.outcome-eng.com
copyright 2005
Create an Open, Fair and Just Culture…
To create a learning environment, organizations must
move away from an overly-punitive reaction to events and
errors. We must instead recognize our own fallibility - that
we will make errors and that we will drift away from what
we have been taught.

This document is not self-explanatory. It is to be used as an aid in the Safe Choices course.
 A Model that Focuses on Three Duties
balanced against Organizational and
Individual Values
 The Three Duties  Organizational and
 The duty to avoid Individual Values
causing unjustified risk  Safety
or harm
 Cost
 The duty to produce an
 Effectiveness
outcome
 Equity
 The duty to follow a
procedural rule  Dignity
 etc
 Two Specific Classes of Duty

• Meet me at 7:00 pm at • Leave the house at 6:45

410 Chestnut Street pm. Go south on
Independence Ave, turn
right on Parker. At the
The Duty to third light, hang a left, go
Produce an three blocks, turn right and
Outcome go to the fourth house on
the right.

The Duty to
Follow a
Procedural Rule
We know….to err is Human
But….To Drift is also Human
Managing Behavioral Choices:
Everyone Takes Risks, Every Day

SOCIAL
RISK UTILITY
 The Behaviors We Can Expect
 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.
 Reckless behavior - behavioral choice to
consciously disregard a substantial and
unjustifiable risk.
 Examples

Failure to check the name band

 Accountability for our Behavioral
Choices

Human At-Risk Reckless

Error Behavior Behavior

Product of our current Unintentional Risk-Taking Intentional Risk-Taking

system design

Manage through changes in: Manage through: Manage through:

• Processes • Removing incentives for
• Procedures • Remedial action
at-risk behaviors
• Training • Disciplinary action
• Creating incentives for
• Design healthy behaviors
• Environment • Increasing situational
awareness

Console Coach Punish

 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 –
the error happened to him / her
 Managing Multiple Human Errors

What is the source of a pattern of human errors?

– The system? If yes, address the system.
– If no, can the repetitive errors be addressed
through non-disciplinary means?
– If no, how will disciplinary sanction reduce the
rate of human error?
 Managing At-Risk Behaviors

• A behavioral choice
– Driven by perception of consequences
• Immediate and certain consequences are strong
• Delayed and uncertain consequences are weak
• Rules are generally weak
 Managing At-Risk Behaviors

• A behavioral choice
– Managed by adding forcing functions (barriers to
prevent non-compliance)
– Managed by changing perceptions of risk
– Managed by changing consequences
– Coaching
 Why not punish “at-risk”
behavior?
Because….

1. Somewhere along the line your organization

has likely tacitly approved certain at-risk
behaviors.

2. If you punish at-risk behavior people will likely

not be honest about the at-risk behavior next
time
 Who judges risk and behaviors?

• Risk = Severity x Likelihood

• Safety ~ Reasonableness of Risk
 Managing Reckless Behavior

• Reckless Behavior
– Conscious disregard of substantial
and unjustifiable risk
• Manage through:
– Disciplinary action
 Managing Behavioral Choices

Human At-Risk Reckless

Error Behavior Behavior

Product of our current Unintentional Risk-Taking Intentional Risk-Taking

system design

Manage through changes in: Manage through: Manage through:

• Processes • Removing incentives for
• Procedures • Remedial action
at-risk behaviors
• Training • Disciplinary action
• Creating incentives for
• Design healthy behaviors
• Environment • Increasing situational
awareness

Console Coach Punish

Doves and Hawks
 Summary
What is a JUST CULTURE about?
 It’s About a Proactive
Learning Culture
 It’s not seeing events  It’s seeing events
as things to be fixed as opportunities to
improve our
understanding of
risk
 System risk, and
 Behavioral risk
 It’s About Reinforcing the Roles of
Risk, Quality, and HR

 Risk/Quality  HR
 Helping improve the  Protecting the
effectiveness of the learning culture
learning process  Helping with
 Providing tools to line managerial
managers competencies
 Helping to redesign  Consoling
Coaching
systems 

 Corrective Action
 It’s About Changing Managerial
Expectations
 Knowing my risks
 Investigating the source of errors and at-risk
behaviors
 Turning events into an understanding of risk
 Designing safe systems
 Facilitating safe choices
 Consoling
 Coaching
 Punishing
It’s About Changing Staff Expectations

 Looking for the risks around me

 Reporting errors and hazards
 Helping to design safe systems
 Making safe choices
 Following procedure
 Making choices that align with
organizational values
 Maintaining situational awareness
 A Shared Conceptual Model

Human At-Risk Reckless

Error Behavior Behavior

Product of our current Unintentional Risk-Taking Intentional Risk-Taking

system design

Manage through changes in: Manage through: Manage through:

• Processes • Removing incentives for
• Procedures • Remedial action
at-risk behaviors
• Training • Disciplinary action
• Creating incentives for
• Design healthy behaviors
• Environment • Increasing situational
awareness

Console Coach Punish

 An Algorithm to Follow

 Common
language

 Common
conversation
 The Just Culture Algorithm
The analytical heart of the Just Culture is the Just Culture Algorithm™. It
will serve as a guide when managers address employees whose
behaviors do not align with organizational values or procedural rules.
Developed around the Three Duties, the Algorithm provides both the
organization and the employee a method to ensure that breaches in the
system will be dealt with in a consistent manner throughout the
organization. The Algorithm is the answer key for what to do when
things go wrong.

Available at: https://www.justculture.org/store

 We need…..

 A culture that truly supports learning

 A common understanding about how to treat people

when things happen
 The Chain of Effect in Improving Health Care Quality

Patient and Community Experience Aims: Safe, timely,

effective, efficient, equitable,
and patient-centered

Microsystem Process Simple rules/Design concepts:

(e.g. cardiac team) (e.g. knowledge-based,
customized, cooperation)

Organizational Context Facilitator Design Concepts:

(e.g. hospital) of Processes (e.g HR, IT, Leadership)

Environmental Context Facilitator Design Concepts:

(e.g. legislature) of facilitators (e.g. Legistaion, regulation,
accreditation, education)
 The Minnesota Agenda
 Formation of a stakeholder group - The Minnesota
Alliance for Patient Safety
 Change state law
 Developed principles of justice, learning and
accountability
 Change the policies and practices of:
 The Boards

 The Dept of Health

 Delivery systems
 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
 Minnesota Statement of
Support
Given that:
 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.
 A punitive environment does not fully take
into account system issues, and a blame-free
environment does not hold individuals
appropriately accountable
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.
 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.
 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
 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.