The Just Culture
Community
THE JUST CULTURE
CERTIFICATION TRAINING
Presented by Outcome Engineering
David Marx
Chief Executive Officer
Fiona Lawton
Manager, Consulting Services
PRESENTED TO:
Copyright 2011, Outcome Engineering, LLC. All rights reserved.
The Just Culture
Community
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
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Page 2
The Just Culture
Community
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
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Page 3
The Just Culture
Community
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
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Page 4
The Just Culture
Community
The Downside of Life –
Producing Undesired
Outcomes
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The Just Culture
Community
Jacqueline Saburido
http://www.youtube.com/watch?v=5OBBqe6Wo1c
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Page 6
The Just Culture
Community
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.
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Page 7
The Just Culture
Community
16 Design Laws
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The Just Culture
Community
Design Laws
Rule 1
Pursuit of individual happiness drives the
human condition; it is the mission.
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Page 9
The Just Culture
Community
Design Laws
Rule 2
We are endowed with a free will to pursue
our individual happiness.
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Page 10
The Just Culture
Community
Design Laws
Rule 3
We pursue our happiness as inescapably
fallible creatures. We will do things, that in
hindsight, we never intended to do.
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Page 11
The Just Culture
Community
Design Laws
Rule 4
We live in a world of limited resources. This
drives the competitive nature of human
beings.
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Page 12
The Just Culture
Community
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.
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The Just Culture
Community
Design Laws
Rule 6
One person’s pursuit of happiness will
inevitably conflict with someone else’s
pursuit of happiness.
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The Just Culture
Community
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.
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The Just Culture
Community
Design Laws
Rule 8
When more than two humans exist,
coalitions will inevitably form to work to the
benefit of the subgroup.
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The Just Culture
Community
Design Laws
Rule 9
Collective happiness is important to our
individual happiness.
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The Just Culture
Community
Design Laws
Rule 10
Because we humans are imperfect and
resources are limited, systems are
necessarily imperfect.
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The Just Culture
Community
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.
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Page 19
The Just Culture
Community
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.
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Page 20
The Just Culture
Community
Design Laws
Rule 13
Feedback (learning) systems are essential in
our stewardship of limited resources,
whether it be for our personal or collective
happiness.
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Page 21
The Just Culture
Community
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.
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The Just Culture
Community
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.
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Page 23
The Just Culture
Community
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.
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The Just Culture
Community
The Five Skills
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The Just Culture
Community
The Five Skills
The Mission
2
System
Design
1
Values and
Expectations
Errors &
Outcomes
3
Behavioral
Choices
4
5
Learning
Systems
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Justice &
Accountability
Page 26
The Just Culture
Community
Missions, Values, and
Expectations
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The Just Culture
Community
Mission and Values
Our Mission
Our reason for
acting
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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?
Page 28
The Just Culture
Community
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.
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The Just Culture
Community
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.
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Page 30
The Just Culture
Community
Mission and Values
Our Mission
Our Primary Values
Our reason for
acting
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What do you
value that you
want to protect?
Values that are in play - that
can be threatened by a
overly zealous commitment
to the mission
Page 31
The Just Culture
Community
Mission and Values
Our Mission
Our Primary Values
Our reason for
acting
Our Supporting Values
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?
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Values that are a
means to an end –
needed to support
the mission and the
primary values
Page 32
The Just Culture
Community
For Each Value: Inputs and Outputs
System
Design
Values and
Expectations
Behavioral
Choices
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Errors &
Outcomes
Page 33
The Just Culture
Community
The Constraints
System
Design
Values and
Expectations
Behavioral
Choices
• Competing Values
• Limited Resources
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Errors &
Outcomes
• Fallible Human Beings
• and, the Laws of Physics
Page 34
The Just Culture
Community
Our Values
• Overlapping Duties?
Yes
• Competing Duties?
Customer
Safety
Capacity
Efficiency
Yes
• We Must Prioritize and
Balance in Support of Our
Values
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Employee
Privacy
Safety
Cost Control
Page 35
The Just Culture
Community
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)
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The Just Culture
Community
Setting System Expectations
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The Just Culture
Community
Setting System Expectations
• What level of reliability do we want?
– Relative to the mission
– Relative to the most critical value
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The Just Culture
Community
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
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The Just Culture
Community
A Range of Reliability
Commercial aviation design standard – one in a billion
10-9
One in a
Billion
10-6
One in a
Million
10-3
One in a
Thousand
Current fatal aviation accident rate – 1 in 6 million
Six Sigma – 3 defects per million
Current wrong site surgery rates – 1 in 30,000
Current rate of hospital iatrogenic death – 1 in 500
Current rate of space shuttle accident – 1 in 60
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The Just Culture
Community
Managing System Reliability
System Reliability
100%
100%
System
Failure
Design for
system reliability…
•
•
Successful
Operation
Human factors
design to reduce the
rate of error
0%
Barriers to prevent
failure
•
Recovery to capture
failures before they
become critical
•
Redundancy to limit
the effects of failure
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Poor
Good
Good
Factors Affecting System Performance
… knowing that systems will never be perfect
Page 41
The Just Culture
Community
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
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The Just Culture
Community
Managing Human Reliability
Human Reliability
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
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Successful
Operation
0%
Poor
Good
Factors Affecting Human Performance
… knowing humans will never be perfect
Page 43
The Just Culture
Community
Designing Effective Systems
• Controlling
Contributing Factors
– Changing the rate of
human error and atrisk behavior
• Adding Barriers
– Trying to prevent
individual errors
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• Adding Recovery
– Trying to catch errors
downstream
• Adding Redundancy
– Trying to add parallel
elements
Page 44
The Just Culture
Community
The Five Skills
The Mission
2
System
Design
1
Values and
Expectations
Errors &
Outcomes
3
Behavioral
Choices
4
5
Learning
Systems
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Justice &
Accountability
Page 45
The Just Culture
Community
Human Fallibility
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The Just Culture
Community
Fallibility
Main Entry: fal·li·bil·i·ty
Pronunciation: \ˌfa-lə-ˈbi-lə-tē\
Function: noun
Date: 1634
: liability to err
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Page 47
The Just Culture
Community
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.”
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The Just Culture
Community
How about something a little easier?
5+3+2÷2=?
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The Just Culture
Community
The Behaviors We Can Expect
Human Error
• Inadvertent action; inadvertently doing other that what
should have been done; slip, lapse, mistake.
At-Risk Behavior
• Behavioral choice 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
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Page 50
The Just Culture
Community
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.
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Page 51
The Just Culture
Community
The Just Culture Algorithm
• One method
that works
across all
values
• One method
that works
both pre- and
post-event
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Page 52
The Just Culture
Community
Life, Liberty, and the Pursuit
of Happiness –
Rejection of the King
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The Just Culture
Community
Rejection of the King
• The Declaration of
Independence
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• The Constitution
The Just Culture
Community
Helen Palsgraf v.
The Long Island Railroad
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The Just Culture
Community
Imposers – Their Role in
Society
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The Just Culture
Community
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
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The Just Culture
Community
Government as Imposer
Who are the Imposers?
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What are their tools?
Page 58
The Just Culture
Community
Broad Areas of Gov’t Imposition
• Criminal Law
• Regulation
• Tort
• Contracts
• Property
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The Just Culture
Community
Workplace Controls
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The Just Culture
Community
Employers
Who are the Imposers?
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What are their tools?
Page 61
The Just Culture
Community
Fiduciary Controls
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The Just Culture
Community
Fiduciaries
Who are the Imposers?
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What are their tools?
Page 63
The Just Culture
Community
Clubs, Gangs, Homeowner’s
Associations
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The Just Culture
Community
Clubs, Gangs, and Homeowners Asso.
Who are the Imposers?
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What are their tools?
Page 65
The Just Culture
Community
Oddball Imposers
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The Just Culture
Community
Oddball Imposers
Who are the Imposers?
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What are their tools?
Page 67
The Just Culture
Community
Today’s Imposers?
What Do They Do
With Human Fallibility?
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The Just Culture
Community
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
§ 91.13 Careless or Reckless Operation
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The Just Culture
Community
Governmental Imposers
“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
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The Just Culture
Community
Governmental Imposers
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 § 18.130.180 Unprofessional Conduct
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The Just Culture
Community
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
Also, Gross Carelessness /
• Fraud
Negligence – any action or failure
• Assault
to act which threatens the health or
• Sexual Harassment
safety of patient, members of public
or other staff
• Malicious Damage
• Corruption
• Being Unfit for Duty
Norfolk and Norwich Community Hospital
• Serious Breach of Confidentiality
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The Just Culture
Community
Society as Imposers
http://www.click2houston.com/video/25319441/
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The Just Culture
Community
All in the name of the game….
• You are the imposer
• What say you?
http://www.youtube.co
m/watch?v=ITdPTKpG
HuI
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Page 74
The Just Culture
Community
All in the name of the game….
• You are the imposer
• What say you?
http://www.youtube.co
m/watch?v=UvEobeNf
Gcc
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Page 75
The Just Culture
Community
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
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Page 76
The Just Culture
Community
Thinking About Human Intention
Action
Four
Options
Intention
Do Not Intend
Consequences
Intend
Action
Consequence
of Action
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Intend
Consequences
Do Not
Intend
Action
Page 77
The Just Culture
Community
Thinking about Human Intention
• Levels of
Intention
–
–
–
–
Purpose
Knowledge
Reckless
Negligence
– At-Risk Behavior
– Human Error
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Action
Intention
Consequence
of Action
Page 78
The Just Culture
Community
The Model Penal Code
1. Purposefully
Conscious objective to engage in conduct to cause such a result
2. Knowingly
Practically certain that his conduct will cause such a result
3. 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
4. Negligently
Should be aware of a substantial and unjustifiable risk that will
result form conduct
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Page 79
The Just Culture
Community
US v. Morrisette
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Page 80
The Just Culture
Community
Justice Versus Safety
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The Just Culture
Community
Justice Versus Safety:
A Look at Two Programs
• The Aviation Safety
Reporting System
– Why build the
program?
– What are the ground
rules?
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• Aviation Safety Action
Programs
– Why build the
program?
– What are the ground
rules?
Page 82
The Just Culture
Community
The Reasonable Person
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The Just Culture
Community
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”
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The Just Culture
Community
The Reasonable Man (circa 1837)
• 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”
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The Just Culture
Community
The Reasonable Man (circa 1933)
• Hall v. Brooklands
Auto-Racing Club
– Did racetrack take
reasonable caution in
it design of the track?
– What would the baldheaded man at the
back of the Clapham
omnibus do?
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The Just Culture
Community
The Reasonable Man (circa 2008)
• Wears all the right gear
• Looks both ways
before crossing the
street
• Never puts others at
risk
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The Just Culture
Community
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
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Page 88
The Just Culture
Community
The Duty to Save?
“Thirty Eight Who
Saw Murder Didn’t
Call Police”
NY Times
http://www.strimoo.com/video/17042338/
Kitty-Genovese-MySpaceVideos.html
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The Just Culture
Community
What About A Duty to Self?
“Thirty Eight Who
Saw Murder Didn’t
Call Police”
NY Times
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The Just Culture
Community
Outcome-Based Duties
System
Design
Values and
Expectations
Behavioral
Choices
Errors &
Outcomes
• Under what circumstances will we stand in
judgment of the outcome?
• Under what criteria will we consider
disciplinary action?
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Page 91
The Just Culture
Community
Procedure-Based Duties
System
Design
Values and
Expectations
Behavioral
Choices
Errors &
Outcomes
• Under what circumstances will we stand in
judgment of procedural compliance?
• Under what criteria will we consider
disciplinary action?
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Page 92
The Just Culture
Community
Kitchie’s Ice Cream Parlor
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Page 93
The Just Culture
Community
Kitchie’s Ice Cream Parlor
Target five areas of possible imposition:
1. Employee safety (exposure to bacteria, sharp edges)
2. Customer safety (tainted food, salmonella)
3. Employee work hour/salary requirements (working teenagers beyond
reasonable hours, not paying overtime)
4. Customer satisfaction (varieties of flavors, taste)
5. Fashion patrol (offensive, suggestive, or tacky clothing)
A. Identify the Imposers (e.g., employer, department of health)
B. Which classes of duty (avoid unjustifiable risk or harm, procedural, outcome)
you would have each imposer use.
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Page 94
The Just Culture
Community
The Just Culture
Algorithm™
Copyright 2011, Outcome Engineering, LLC. All rights reserved.
The Just Culture
Community
The Basis for the Tool
Science
Law
– 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)
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Page 96
The Just Culture
Community
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
Console
Copyright 2011, Outcome Engineering, LLC. All rights reserved.
Manage through:
• Removing incentives for
•
•
at-risk behaviors
Creating incentives for
healthy behaviors
Increasing situational
awareness
Coach
Manage through:
• Remedial action
• Punitive action
Punish
Page 97
The Just Culture
Community
The Just Culture Algorithms
• One method that
works across all
values
• One method that
works both preand post-event
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Page 98
The Just Culture
Community
The Five Skills
The Mission
2
System
Design
1
Values and
Expectations
Better
Outcomes
3
Human Behavior
4
5
Learning
Systems
Copyright 2011, Outcome Engineering, LLC. All rights reserved.
Justice &
Accountability
The Just Culture
Community
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
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The Just Culture
Community
The Role of
Event
Investigation
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Page 101
The Just Culture
Community
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.
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Page 102
The Just Culture
Community
The Basics of Event Investigation
What happened?
What normally happens?
What does procedure require?
Why did it happen?
How were we managing it?
Copyright 2011, Outcome Engineering, LLC. All rights reserved.
Increasing
value
The Just Culture
Community
Five Rules of Causation
1.
Causal statements should clearly show the “cause
and effect” relationship
2.
Negative descriptors should not be used in causal
statements (i.e., poorly, inadequately, etc…)
3.
Each human error should have a preceding cause
4.
Each “at risk” behavior/procedural deviation
should have a preceding cause
5.
Failure to act is only causal when there was a preexisting duty to act
Copyright 2011, Outcome Engineering, LLC. All rights reserved.
The Just Culture
Community
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
3–4
each
Rule
– each
human
error must
violation
must
have
a
have
a preceding
preceding
cause cause
Copyright 2011, Outcome Engineering, LLC. All rights reserved.
The Just Culture
Community
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.
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Page 106
The Just Culture
Community
Understanding Causation
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Page 107
The Just Culture
Community
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.
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Page 108
The Just Culture
Community
The Diagram Decode
The Undesired
Outcome
A Cause of the Human
Error
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Human
Error
Behavioral
Choice
A Cause of the Behavioral
Choice
Page 109
The Just Culture
Community
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
Copyright 2011, Outcome Engineering, LLC. All rights reserved.
The Just Culture
Community
The Basic Structure
Condition
Condition
A
B
The causal link
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The Just Culture
Community
“Cause and Effect”
(IV pump not started)
Patient distracted the nurse with a
personal request while the nurse was
hanging an IV Piggyback
The Undesired Outcome
IV pump not
set for the
piggyback
Human Error
A Cause of the Human Error
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Patient did not
receive ordered
medication
Behavioral Choice
A Cause of the Behavioral Choice
Page 112
The Just Culture
Community
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.
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Page 113
The Just Culture
Community
Housekeeping Scenario
Signs Far
Away
Manager Did
Not Buy More
Signs
Housekeeper
Thought He Was
Alone
“Wet” Sign
Not Placed
Accountant
Slips On
Floor
Severe
Damage To
Knee
Wet Floor
Why?
The Undesired Outcome
Human Error
A Cause of the Human Error
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Behavioral Choice
A Cause of the Behavioral Choice
Page 114
The Just Culture
Community
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Page 115
The Just Culture
Community
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?
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Page 116
The Just Culture
Community
Finishing the Review:
Are the Right Actions Being Taken to
Address the Risks Identified?
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The Just Culture
Community
The One Stop Rule:
Leave Systemic Causes to Multiple Event
Analysis
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The Just Culture
Community
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
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Page 119
The Just Culture
Community
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.
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Page 120
The Just Culture
Community
Resume Scenario
Staff member
lied about
having a
college
degree
Why?
HR
manager
told HR
clerk to
skip
check
The Undesired Outcome
HR clerk did
not confirm
with school
Human Error
A Cause of the Human Error
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Financial
and
reputation
harm to
company
Behavioral Choice
A Cause of the Behavioral Choice
Page 121
The Just Culture
Community
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.
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Page 122
The Just Culture
Community
Probabilistic Cause
What is the
organizational
culture?
Did the surgeon
understand his role
in the time out?
Group Norm vs.
Individual Norm???
What usually
happens?
Direct Cause(s)
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
The RN assumed the
patient nodding her
head indicated she
was the right patient
The Undesired Outcome
Human Error
A Cause of the Human Error
Copyright 2011, Outcome Engineering, LLC. All rights reserved.
RN did not do two
patient identifiers in
the pre-op area
Behavioral Choice
A Cause of the Behavioral Choice
123
Page 123
The Just Culture
Community
Day 4 – Gaining Proficiency
Gaining Proficiency in the Algorithm™
Coaching & Mentoring
The Big Healthcare Event
Other Just Culture Algorithms
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Page 124
The Just Culture
Community
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.
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Outcome
Engineering,
LLC. All rights reserved.
Copyright
2007,
Outcome
Engineering,
LLC. All rights reserved.
Page 125
The Just Culture
Community
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
Copyright 2011,
Outcome
Engineering,
LLC. All rights reserved.
Copyright
2007,
Outcome
Engineering,
LLC. All rights reserved.
The Just Culture
Community
Managing At-Risk Behavior
• 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
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Outcome
Engineering,
LLC. All rights reserved.
Copyright
2007,
Outcome
Engineering,
LLC. All rights reserved.
Page 127
The Just Culture
Community
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
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Page 128
The Just Culture
Community
Managing Reckless Behavior
• Reckless Behavior
– Conscious Disregard of Substantial and
Unjustifiable Risk
• Manage through:
– Disciplinary action
– Punishment as a deterrent
Note: Remediation is always available
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Page 129
The Just Culture
Community
Coaching & Mentoring
in a Just Culture
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The Just Culture
Community
What Is the Difference Between…
• Role-Modeling?
• Mentoring?
• Consoling?
• Coaching?
• Counseling?
• Punishing?
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Page 131
The Just Culture
Community
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
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The Just Culture
Community
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
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The Just Culture
Community
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
Copyright 2011, Outcome Engineering, LLC. All rights reserved.
The Just Culture
Community
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
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The Just Culture
Community
The PIDA Model
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The Just Culture
Community
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!
Copyright 2011, Outcome Engineering, LLC. All rights reserved.
The Just Culture
Community
Peer-to-Peer Coaching
Source: BC Hydro
Copyright 2011, Outcome Engineering, LLC. All rights reserved.
The Just Culture
Community
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
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The Just Culture
Community
Counseling
(Repetitive Human Error or At-Risk Behavior)
A first step disciplinary action: putting the
employee on notice that performance is
unacceptable
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The Just Culture
Community
Discipline
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The Just Culture
Community
Punishing
(The Response to Reckless Behavior)
• Behavioral choice to consciously disregard a
substantial and unjustifiable risk
• Manage through
– Remedial action
– Punitive action
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The Just Culture
Community
The Three Duties
The Duty to Avoid
Causing Unjustifiable
Risk or Harm
The Duty to Produce
an Outcome
Copyright 2011, Outcome Engineering, LLC. All rights reserved.
OR
The Duty to follow a
Procedural Rule
Page 143
The Just Culture
Community
The Duty to Produce an Outcome
Meet me at 7:00 pm at
410 Chestnut Street
The Duty to Produce
an Outcome
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Page 144
The Just Culture
Community
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
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Discipline
Page 145
The Just Culture
Community
Categories of Possible Physician Breach
A. Insufficient prevention, diagnosis or
treatment of patient disease or
condition
B. Iatrogenic harm – caused by the
physician incidental to the practice
of medicine
C. Inappropriate conduct not directly
related to the delivery of care
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Clinical
Review
Administrative
Review
Page 146
The Just Culture
Community
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:
A. High patient return rate to the emergency department
B. High prescription error rate
C. 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.
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Page 147
The Just Culture
Community
Two Specific Classes of Duty
Meet me at 7:00 pm at
410 Chestnut Street
The Duty to Produce
an Outcome
Copyright 2011, Outcome Engineering, LLC. All rights reserved.
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.
The Duty to Follow a
Procedural Rule
Page 148
The Just Culture
Community
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
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Page 149
The Just Culture
Community
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
Console
Copyright 2011, Outcome Engineering, LLC. All rights reserved.
Manage through:
• Removing incentives for
•
•
at-risk behaviors
Creating incentives for
healthy behaviors
Increasing situational
awareness
Coach
Manage through:
• Remedial action
• Punitive action
Punish
Page 150
The Just Culture
Community
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:
A. Failure to use medical staff approved order sets for
community acquired pneumonia
B. Not participating in a required pre-procedural time-out
C. Not completing date and time documentation according to
policy
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Page 151
The Just Culture
Community
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
Console
Copyright 2011, Outcome Engineering, LLC. All rights reserved.
Manage through:
• Removing incentives for
•
•
at-risk behaviors
Creating incentives for
healthy behaviors
Increasing situational
awareness
Coach
Manage through:
• Remedial action
• Punitive action
Punish
Page 152
The Just Culture
Community
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:
A. Not ordering an indicated diagnostic test
B. Writing a contraindicated prescription
C. 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
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Page 153
The Just Culture
Community
The Just Culture
Algorithm
Copyright 2011, Outcome Engineering, LLC. All rights reserved.
The Just Culture
Community
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
•
•
•
•
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
Copyright 2011, Outcome Engineering, LLC. All rights reserved.
The Duty to follow a
Procedural Rule
•
•
•
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
Page 155
The Just Culture
Community
Working
in the
Algorithm
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Page 156
The Just Culture
Community
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.
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Page 157
The Just Culture
Community
Scheduling Scenario
Why?
The Undesired Outcome
Scheduler
flipped to
wrong page in
appointment
book,
scheduled
appointment
too late
Human Error
A Cause of the Human Error
Copyright 2011, Outcome Engineering, LLC. All rights reserved.
Patient
Harm
Behavioral Choice
A Cause of the Behavioral Choice
Page 158
The Just Culture
Community
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.
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Page 159
The Just Culture
Community
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.
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Page 160
The Just Culture
Community
NICU Scenario
Relied On Color
Of Cap, Did Not
See Risk
Nurse Does
Not Confirm
Drug
Increased Risk
Of Patient
Harm
Why?
The Undesired Outcome
Pharmacy MisStocks
Dispensing
System
Human Error
A Cause of the Human Error
Copyright 2011, Outcome Engineering, LLC. All rights reserved.
Behavioral Choice
A Cause of the Behavioral Choice
Page 161
The Just Culture
Community
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.
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The Just Culture
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Fire Safety: Near Miss
Holster
repeatedly
dislodged;
ES lines
were
tangled
Scrub Nurse
anchored ES
pencil/holster to
sterile drape
Surgeon
requested ES
pencil/holster be
re-positioned
Increased
Risk of
Surgical Fire
OR staff did not
object to
physician’s
request
Why?
The Undesired Outcome
Human Error
A Cause of the Human Error
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Behavioral Choice
A Cause of the Behavioral Choice
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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.
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The Just Culture
Community
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
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The Big Healthcare Event
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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
?
Chg Nurse
instructed other
nurses not to
replace it
?
Other nurses
chose to breach
the rule
?
Other nurses did
not report the
breach
Nurse F assumed
Nurse C had
checked the blood
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Nurse F asked
only patient name
and not DOB
Mr Delta did not
have wristband on
as he had been
agitated by it
Nurse C assumed it
was the overdue blood
for her patient
Nurse F did not
have second
nurse present
when hanging
blood
Nurse C did not
check blood when
picking it up at
nurse’s station
Nurse F did not
check blood when
she went to hang
the blood
Patient given
other patient’s
blood
Nurse C selects
wrong bag at
nurse’s station
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Community
Banner Policy Review
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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.”
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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?
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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.
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Alternative Models of
Accountability
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The Just Culture
Community
Jim Reason’s Unsafe Acts
Algorithm
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The Just Culture
Community
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The NHS Incident Decision
Tree
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The Just Culture
Community
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
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The Just Culture
Community
16 Design Laws
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The Just Culture
Community
Design Laws
Rule 1
Pursuit of individual happiness drives the
human condition; it is the mission.
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The Just Culture
Community
Design Laws
Rule 2
We are endowed with a free will to pursue
our individual happiness.
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The Just Culture
Community
Design Laws
Rule 3
We pursue our happiness as inescapably
fallible creatures. We will do things, that in
hindsight, we never intended to do.
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The Just Culture
Community
Design Laws
Rule 4
We live in a world of limited resources. This
drives the competitive nature of human
beings.
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The Just Culture
Community
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.
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The Just Culture
Community
Design Laws
Rule 6
One person’s pursuit of happiness will
inevitably conflict with someone else’s
pursuit of happiness.
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The Just Culture
Community
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.
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The Just Culture
Community
Design Laws
Rule 8
When more than two humans exist,
coalitions will inevitably form to work to the
benefit of the subgroup.
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The Just Culture
Community
Design Laws
Rule 9
Collective happiness is important to our
individual happiness.
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The Just Culture
Community
Design Laws
Rule 10
Because we humans are imperfect and
resources are limited, systems are
necessarily imperfect.
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The Just Culture
Community
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.
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The Just Culture
Community
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.
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The Just Culture
Community
Design Laws
Rule 13
Feedback (learning) systems are essential in
our stewardship of limited resources,
whether it be for our personal or collective
happiness.
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The Just Culture
Community
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.
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The Just Culture
Community
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.
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The Just Culture
Community
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.
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The Just Culture
Community
The Five Skills
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The Just Culture
Community
The Five Skills
The Mission
2
System
Design
1
Values and
Expectations
Errors &
Outcomes
3
Behavioral
Choices
4
5
Learning
Systems
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Justice &
Accountability
Page 196
The Just Culture
Community
Thank You!
Please visit us at:
Outcome Engineering, LLC
Curators of the Just Culture Community
www.outcome-eng.com
www.justculture.org
214.778.2010
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