Professional Documents
Culture Documents
Community
Copyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.
The Just Culture
Community
Agenda
Copyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.
The Just Culture
Community
Copyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.
The Just Culture
Community
Copyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.
The Just Culture
Community
Copyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.
The Just Culture
Community
Your Options
• Take no action
• Warn against doing it again
• Encourage different behavior/coach
• Discipline/punish
Copyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.
The Just Culture
Community
Copyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.
The Just Culture
Community
Copyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.
The Just Culture
Community
MGH Credo
• As a member of the MGH community and in service of our mission, I believe
that:
– The first priority at MGH is the well-being of our patients, and all our work, including research, teaching and
improving the health of the community, should contribute to that goal.
– Our primary focus is to give the highest quality of care to each patient delivered in a culturally sensitive,
compassionate and respectful manner.
– My colleagues and I are MGH’s greatest assets.
– Teamwork and clear communication are essential to providing exceptional care.
Copyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.
The Just Culture
Community
MGH Boundaries
As a member of the MGH community and in service of our
mission, I will never:
Copyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.
The Just Culture
Community
Bo’s Law
• 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
Copyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.
The Just Culture
Community
Copyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.
The Just Culture
Community
Lord Denning
English Judge
Copyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.
The Just Culture
Community
Copyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.
The Just Culture
Community
Copyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.
The Just Culture
Community
A Balanced Accountability
What system of
accountability
best supports our
values?
Support
of System
Safety As applied to:
and Other • Providers
Values • Managers
• Institutions
• Regulators
Blame-Free Punitive
Culture Culture
Copyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.
Copyright 2007, Outcome Engineering, LLC. All rights reserved.
The Just Culture
Community
• Engineering
• Human Factors
• Legal
Copyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.
The Just Culture
Community
System
Design
Behavioral
Choices
Copyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.
The Just Culture
Community
System
Design
Values and
Expectations
Behavioral
Choices
Copyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.
The Just Culture
Community
Copyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.
The Just Culture
Community
Successful
• Human factors Operation
design to reduce the
rate of error
0%
• Barriers to prevent Poor Good
failure
Factors Affecting System Performance
• Recovery to capture
failures before they
become critical
• Redundancy to limit … knowing that systems will never be perfect
the effects of failure
Copyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.
Copyright 2007, Outcome Engineering, LLC. All rights reserved.
The Just Culture
Community
• Information Successful
• Equipment/tools Operation
• Design/configuration
• Job/task
0%
• Qualifications/skills Poor Good
• Perception of risk
Factors Affecting Human Performance
• Individual factors*
• Environment/facilities … knowing humans will never be
• Organizational perfect
environment
• Supervision *80 hour work week for residents tradeoff
• Communication* with handoffs
Copyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.
Copyright 2007, Outcome Engineering, LLC. All rights reserved.
The Just Culture
Community
Copyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.
The Just Culture
Community
To Err is Human
Copyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.
Copyright 2007, Outcome Engineering, LLC. All rights reserved.
The Just Culture
Community
Copyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.
The Just Culture
Community
Our Response –
Human Error
Learn
Copyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.
The Just Culture
Community
To Drift is Human
Copyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.
The Just Culture
Community
To Drift is Human
Copyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.
Copyright 2007, Outcome Engineering, LLC. All rights reserved.
The Just Culture
Community
Our Response -
At-Risk Behavior
Learn
Copyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.
The Just Culture
Community
Copyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.
The Just Culture
Community
Reckless is Reckless
Copyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.
The Just Culture
Community
Our Response –
Reckless Behavior
Punish
Copyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.
The Just Culture
Community
Copyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.
The Just Culture
Community
Copyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.
The Just Culture
Community
Copyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.
The Just Culture
Community
Summary
• Takes focus off of errors and outcomes
– And puts focus on the quality of system design
and the quality behavioral choices puts it on
systems and behavioral choices
• Systematic and uniform process designed
to support practice
• A More “Just” Culture for Providers
Copyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.
The Just Culture
Community
Thank You!
www.justculture.org
Copyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.