Creating a Just

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A physician fails to detect a rare, life-threatening illness…A pharmacist pulls the wrong drug fr om the shelf…A unit clerk misreads an order…A nurse delivers the correct medication but to the wrong patient…A healthcare worker inserting a catheter doesn’t follow hand hygiene protocol…

In the high-pressure, high-risk healthcare environment, numerous things can go wrong on a daily basis – and they do. From surgical errors and the

administration of confl icting medications to infected IV lines, mistakes happen, and as a result, patients may get worse or even die.

Across the United States, medical errors are grossly under-reported. It’s estimated that only 2% to 3% of major mistakes are reported, according to David Marx, a thought leader at APIC’s 2008 Futures Summit, and author of a new book on process improvement called Whack-a-Mole: Th e Price We Pay for Expecting Perfection. Why? Because when errors are reported, the person responsible is oft en suspended, severely reprimanded, or even fi red – but that outcome off ers little opportunity to learn from the mistake and prevent it from happening again.

Th is type of situation is not confi ned to healthcare, but has been seen in other high-consequence sectors. Th anks to the punitive nature of our society, Marx says, when something goes seriously wrong, the fi rst instinct of those in charge is oft en to assign blame and dole out punishment, even if the error was unintentional.

“As adults, we push our need for ‘justice’ to the point that every adverse outcome in life must have an accompanying blameworthy human behind it,” he says.

In healthcare, as in other industries, that approach has taken its toll.PH

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CulturePunitive and blame-free discipline systems don’t reduce healthcare errors. But an alternative system offers effectiveness … and justice.BY CAROL LATTER

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Marx notes that in an eff ort to ensure patient safety, health regulators have drawn up, and hospital administrators have enforced, strict practice guidelines aimed at preventing medical errors – and the consequences for breaching them can be severe. But that has created a culture of fear, where those who make mistakes or have “near misses” are afraid to report them. Colleagues who observe these incidents may be bound by an unspoken “code of silence,” knowing that they could have just as easily made the same type of mistake.

Th e problem with most corporate disciplinary systems, he says, is that they “literally prohibit human error,” which is not only unrealistic but doesn’t take into account the fact that many mistakes are due to system failures that make errors far more likely.

Yet a blame-free culture is not the answer, either. According to Marx, most medical errors fall under the category of negligence – either “human error” by people who were trying their best but were tripped up by lack of knowledge, distraction or fatigue, or “at-risk behavior” by people who took

shortcuts as they tried to accomplish more with fewer resources and less time. But occasionally, people act recklessly without regard for patient safety, or even intentionally cause patients harm. In the last two cases, a strong disciplinary or punitive response is appropriate.

Enter Just Culture

Marx believes there’s a better way to ensure patient safety – one founded on the right mix of fairness and accountability. An international consultant in human error to industries ranging from aviation to nuclear power, he’s been traveling around the world to promote “Just Culture,” an approach that involves a major shift in thinking from the current “culture of blame.”

First developed 15 years ago by British psychology professor James Reason, Just Culture is based on the premise that humans are fallible, and no operating or business system is perfect. It’s predicated on treating people fairly and encouraging open communication so that “near misses” can serve as

David Marx says a “Just Culture” approach could reduce errors, and costs, in the healthcare industry.

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learning tools to prevent future problems. Actual errors can be used to identify root causes that can then be corrected, whether they’re honest mistakes, at-risk behaviors on the part of providers, or problems with the system.

“I think of Just Culture as being the middle ground between a punitive culture, where every mistake gets you in hot water, and the blame-free scenario, where it’s assumed nobody intends to make a mistake,” Marx says. “We don’t have to go

all the way to the blame-free culture. Just Culture is short for fi nding workplace justice.”

Finding a solution, he insists, is imperative. Each year in the United States, “200,000 people die from medical error or hospital infection. Th at would be the number one place where we as humans create the greatest amount of harm.”

While numerous patient safety initiatives have been implemented in recent years, they have tended to focus on more detailed issues, like procedural

guidelines to prevent healthcare-associated infections and wrong site surgery. Marx believes – and several statewide initiatives are proving his claim – that a broader culture shift is necessary if healthcare outcomes are ever to improve.

Unlike a culture of blame, Just Culture is a system of shared accountability whereby healthcare institutions are accountable for the safety of their systems, and for supporting the safe choices of staff , patients and visitors. Staff members are accountable for the quality of their choices, knowing that while they may not always be perfect, they can strive to make the best possible choices when providing care.

“We want to raise the bar,” Marx says. “We want to make a safer system, but you don’t do it by having a more punitive system. You do it by expecting more, based around good system design and the behavioral choices of individuals in the system.”

Making Change

Just Culture is being embraced by a growing number of states across the U.S. Many healthcare organizations, in states like California, North Carolina and Missouri, have invited Marx to provide training so that they can create their own Just Culture environments. Several of these organizations have already launched statewide initiatives to engage everyone – from regulators and healthcare leadership to individual physicians and nurses – in this alternate approach to promoting patient safety and improving the tone of the workplace environment.

As part of the training, participants learn to use the Just Culture Algorithm, an assessment tool developed by Marx’s Texas-based company, Outcome Engineering.

In an environment of Just Culture, when a mistake is made or a “near miss” occurs, the healthcare facility uses the algorithm to determine the following: What happened? What normally happens? What does procedure require (if applicable)? Why did it happen? How was the organization managing the risk?

Th e algorithm provides a series of fl ow charts whereby management can decide whether the provider in question made a human error, engaged in at-risk behavior or showed reckless disregard for the patient’s wellbeing. Th e chart suggests a suitable response, based on the outcome.

“We start with the premise that humans make

JUST CULTURE DEFINITIONSAt-risk behavior: Behavioral choice that increases risk where the risk is not recognized, or is mistakenly believed to be justifi ed.

Coaching: Supportive discussion with the employee on the need to engage in safe behavioral choices.

Counseling: A fi rst step disciplinary action; putting the employee on notice that his or her performance is unacceptable.

Disciplinary action: Actions beyond the remedial, up to and including punitive action or termination.

Human error: Inadvertently doing other than what should have been done; a slip, lapse, or mistake.

Impossibility: A condition outside of the employee’s control that prevents a duty from being fulfi lled.

Knowingly: Having knowledge that harm is practically certain to occur.

Performance shaping factors: Attributes that impact the likelihood of human errors or behavioral drift.

Punitive action: Punitive deterrent to cause an individual or group to refrain from undesired behavioral choices.

Purpose: A conscious objective to cause harm.

Reckless behavior: Behavioral choices to consciously disregard a substantial and unjustifi able risk.

Remedial action: Actions taken to aid an employee, including education, training, or assignment to a task appropriate to that employee’s knowledge and skill.

Substantial and unjustifi able risk: A behavior where the risk of harm outweighs the social benefi t attached to the behavior.

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errors in two ways. Number one, they simply make a mistake, or two, they drift into at-risk behavior. A healthcare worker who chooses to distribute medications without practicing adequate hand hygiene, for example, might think to himself or herself, ‘I’ve got a lot to do and don’t see the link

between my choice and a negative outcome,’ ” he explains.

“We have to work around behavioral choices to keep people from drift ing into riskier and riskier behaviors. Because when a mistake is made, all of a sudden, people are saying, ‘Where is the medical board? Where are the tort lawyers?’ ”

While reckless or intentional behavior calls for punitive actions, Marx says, human error or at-risk behavior is best managed by consoling the person who made the mistake, or by coaching the at-risk employee into safer patterns of behavior. Th is goes hand-in-hand with an investigation into why the incident took place.

“And we say you should do this independent of the harm [to the patient]. Today, the single biggest indicator of whether we will hold the person accountable is the extent of the harm. It becomes a ‘no harm, no foul’ system of justice. Th e penalty depends on the severity of the outcome, not the riskiness of the behavior.”

Th at approach, he insists, puts the emphasis in the wrong place. Taking a risk with someone’s health – or life – is never acceptable.

Preventive Strategies

Another big piece of the puzzle, he says, is heading off trouble before it takes place. A proactive process involves “fi nding ways to get managers out to help employees, and spot the risks before they lead to harm. Th e [current] system is very reactive.”

Th is proactive approach is extremely critical in the fi eld of infection prevention, he notes, because “healthcare-associated infections are less visible than a wrong site surgery. Th ere’s something about a wrong site surgery that shocks the average person because that kind of thing is not supposed to happen.”

At the same time, “healthcare-associated infection has a much more signifi cant toll on human life. Yet it’s almost as if we have a tolerance for it. We see extraordinarily low levels of hand hygiene compliance because it’s hard to associate the behavior with the bad outcomes. You can’t see the bugs.”

He adds, “I recently talked to a CEO of a hospital about this. I think it’s been an expectation that someone gets an infection when they come into the hospital. It’s become normalized.”

Eff ective infection prevention “requires safe procedural routines. If they [nurses] begin to drift from what they were taught, we need to be able to spot it and get that person back to a safe place. Every hospital struggles with protocols around infection prevention. We can do what we do to design the system, but we have to get employees to really see the link between the behavior and the outcomes.”

PHOTO COURTESY OF DAVID MARX

Don’t miss the presentation by author and risk assessment expert David Marx at the APIC 2009 Annual Conference. His session, on Just Culture, will be held Thursday, June 11 at 10 a.m., with an 11:30 a.m. book signing to follow at the APIC Book Store on the third level of the convention center for his new release, Whack-a-Mole: The Price We Pay for Expecting Perfection.

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Involving the staff in a positive rather than fear-based process, and getting the proper buy-in has proven to be extremely eff ective. By using a Just Culture collaborative process, Marx says, “North Carolina raised its hand hygiene compliance level from 60% to 90%.”

He says in a consequence-based environment, nurses who have the responsibility of passing a couple of hundred meds a day may feel hard-pressed to do all of the hand hygiene they should,

and human nature being what it is, they may be more careful about it in view of the nursing station, for example. Some hospitals have tried programs whereby those observed failing to perform hand hygiene are reported, which leads to an unwelcome feeling that Big Brother is watching.

“We’ve got to get beyond the fact that your compliance is high when you’re being watched, but how do you get a group of human beings to change their collective view about the risk?”

he asks rhetorically. “It’s important to raise the awareness of risk so we have them believe – each and every practitioner – that to deviate is to take an unreasonable risk with our patients. Th ere are system contributors that we have to address, but beyond that, we have to get our staff to collectively believe that this is important. It’s not that they don’t believe infection prevention is important, but they have to believe that compliance is important.”

Th at goes for doctors as well. “We can say to a surgeon, ‘If you choose not to participate in Just Culture and the safety protocol around it, maybe you shouldn’t have privileges here.’ We are trying to be more assertive. Th ere are choices you make at your own peril. So we’re asking institutions to have higher expectations in that regard.”

Getting physicians’ buy-in is also critical. “When a physician takes a lead and says, ‘I will begin to model good behavior,’ it makes a huge diff erence. If you and I [as nurses and other healthcare workers] are asked to be pretty strongly compliant with a protocol but I don’t see physicians and visitors complying, then how important can it be? If you have physicians saying, ‘We’re going to be as compliant as we expect our nurses to be,’ then it becomes clear that everyone is on the same team.”

But all change, Marx says, must begin at the top. “When we do this in an organization, we end up doing it from the top down. We have to get leaders modeling it, because their reaction to the big events is what drives the employees’ behavior on the fl oor. Th e leaders who integrate this change successfully are the ones who believe in it.”

Culture shift s do take time, and in order for them to be eff ective, participants must be open to new ways of thinking, he says. “What I would say to healthcare staff is, ‘Don’t sweat the errors. Sweat the choices, and periodically critically review whether you’re making good choices to prevent drift ing. Don’t feel like you’re infallible.’ To management, I would say that the organizations without a good learning culture live in the blindness that everyone’s doing what they’re supposed to be doing. People really do drift , and you’ve got to be out there, helping employees get back on the safe path.”

He adds, “the lessons we teach a nurse around hand hygiene are no diff erent than what parents teach their kids when they hand their 16-year-old the keys to the car: ‘You can drive safely, or you can drive recklessly. It’s the choices you make that will dictate the outcome.’ ”

There are four cornerstones of a strong safety culture in healthcare, according to risk management expert David Marx. These cornerstones are outlined by a pamphlet being distributed to healthcare providers by his company, Outcome Engineering, which has been spreading the Just Culture message for more than 10 years.

1. Create a Learning Culture. “In the case of patient safety, it is a culture that is eager to understand risk at both the individual and organizational level. We can see risk through events and near misses. We can see risk by observing the design of the systems in which we work, [as well as] our behaviors and the behaviors of those around us. We must all be willing to learn from our mistakes and to share this learning in a manner that supports system design and continued safe choices.”

2. Create an Open and Fair Culture. “Organizations must move away from an overly punitive reaction to events and errors. We must ask the erring provider to report the event so that others may not be denied the learning opportunity. That being said, a strong safety culture is one that reinforces accountability for safety across all levels of the organization, from CEO to staff. It is a system of accountability that does not focus on the human error or the unintended consequences but rather focuses on the quality of our decisions.”

3. Design Safe Systems. “It is the system in which we work that has the greatest overall infl uence on the safety of the patient. We must design healthcare delivery systems that anticipate human error, capture errors before they become critical, and permit recovery when errors do reach the patient.”

4. Manage 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. A strong safety culture puts a premium on critical decision-making skills and asks every healthcare provider to continuously evaluate the risks inherent in the choices they make.”

David Marx will speak on these cornerstones and other aspects of Just Culture at the APIC 2009 Annual Conference.

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Thinking Outside the Box

Marx and his team are also taking the Just Culture message outside of healthcare facilities, to regional and state nursing and medical boards, to regulatory agencies and now, to the public.

Government is infl uenced by the public, he says, and many people believe that when something goes wrong in healthcare, government should revoke licenses, doctors or nurses should be fi red, or someone should sue.

By educating the public about Just Culture, Marx hopes the average person won’t be so quick to point fi ngers and call for someone’s job – or their arrest.

He points out that healthcare facilities can use Just Culture to try to create a safe haven for their staff members, but when it comes to regulators and government, “the public is the tail on the dog, and if the public is clamoring for more accountability, the government is going to react.”

When medical errors occur in a particular state,

“it’s not unusual to hear the governor say, ‘We’ve got to get tough.’ Th e biggest challenge and opportunity is to change the public view around accountability so that the public can change the regulator. We’d like the public to say to the regulator, ‘We don’t want you to instinctively and punitively react, no matter what the situation.’ ”

When a patient decides to sue a physician, he explains, the doctor understandably reacts by being less open about what really went wrong, and why. “We have to present a better approach that is less cat-and-mouse, and more focused on fi nding the right models and expectations for our healthcare providers.”

Th rough the publication of his book, Whack-a-Mole, Marx hopes to get the message out to the public that there is a better way, and it’s called Just Culture.

“Healthcare should not be like a child’s Whack-a-Mole game,” he concludes. “We’ve got to let go of that notion, embrace our fallibility and fi nd ways to design around it.”

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