CUSP: Understand “Just Culture”

Hi! I am Scott Griffith, the Chief Operating Officer of Outcome Engineering and I’d like to take a moment to talk about Just Culture and what it means for a healthcare institution. The term Just Culture refers to a value supportive system of accountability where healthcare institutions are accountable for the systems they design, and in turn, staff, patients, and visitors are accountable for the choices they make within those systems. In a Just Culture organization, there are three categories of behaviors that we must expect and learn how to manage. The first category is human error. We must predict that humans will make mistakes and occasionally drift into risky places. We define human error as the inadvertent action, inadvertently doing other than what should have been done. A psychologist will call it a slip, a lapse, or a mistake, but for our purposes the only thing that’s important is the understanding that it’s an inadvertent action, doing other than what was intended. The second category of behaviors is called at-risk behavior. At-risk behaviors are by contrast choices. These are not inadvertent actions. An at-risk behavior is defined as the choice that increases risk, where risk is either not recognized or mistakenly believed to be justified. And finally, the third category of behavior is called reckless behavior. Again, reckless behavior is a choice, much like at-risk behavior, but the distinction here is that the reckless choice is a conscious disregard of substantial and unjustifiable risk. Now, for a Just Culture organization, recognizing that each of these three behaviors should elicit a different response is very important. Our response to the human who makes a mistake or human error is to console the individual and then examine the system around them. Oftentimes human errors are contributed to or caused by risky system designs, that is, a system that might be pushing in an individual to make these types of mistakes. In addition to systems, we often see that human errors are caused by risky choices. A clear example of that is running a stop sign. If I come in and say that I ran the stop sign this morning on my way to work, the obvious next question is, what were you doing? How did it happen? Well, I might be just driving along and having a lapse in my mental state, which could cause me to run the stop sign. Or by contrast, I could be doing something risky, like talking on the cellphone or even text messaging, which you would say increases the likelihood of me one day running the stop sign. Again, human errors are caused by both risky systems and by the choices that we make that increase the likelihood that one day we will make a human error. Our response to the human is to console them and to examine the choices and the system around them. At-risk behavior is the most important category of behavior, because quite frankly, at-risk behaviors happen more frequently. Humans will make mistakes, but more frequently humans will make risky choices that usually result in positive outcomes. So when we see an at-risk behavior, the challenge is to examine how the individual believed the risk was worth taking and coach them around the choice to engage in the at-risk behavior. At-risk behaviors on the road are very common. You look around you and you see people text messaging, driving with one hand on the steering wheel, eating, or otherwise distracted as we drive down the road. These are behaviors that are common to most people, and usually when we engage in at-risk behaviors, we see positive outcomes, which often leads us to learn the wrong lesson from this risk taking behavior. In a Just Culture organization, we coach the individual and we examine the system around the individual. We look to what the incentives might have been for the risk taking behavior. If possible, we try to remove those incentives and create positive incentives for helpful behaviors. Systems and behaviors go hand in hand and we must examine the choices and the system around the individual who engages in an at-risk behavioral choice. And finally, the reckless behavior is the choice to consciously disregard a substantial and unjustifiable risk. You might think of intoxicated driving on the road. In those situations, our response is to punish the individual, to send a punitive deterrent signal to those engaged in the behavior. We have to go back and at times look at the system to understand the resiliency involved, but most of our response is tied to the punitive deterrent of punishment. Establishing where the line is drawn between at-risk behavior and reckless behavior is the most critical thing an individual organization can do around a particular risk. This is often challenging, but it can be done with the collaborative effort of the employees and the leadership alike.

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