part ii: an introduction to just culture - munson forum/hei leadership par… · title: microsoft...
TRANSCRIPT
Copyright © 2013
Presented by:K. Scott Griff ithPresident, Outcome Engenuity
Part II:An Introduction to Just Culture
Copyright © 2013
The Behaviors We Can Expect
• Inadvertent action; inadvertently doing other that what should have been done; slip, lapse, mistake.
• Behavioral choice that increases risk where risk is not recognized, or is mistakenly believed to be justified.
• Behavioral choice to consciously disregard a substantial and unjustifiable risk
Reckless Behavior
At-Risk Behavior
Human Error
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,
To Err is Human
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• 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
• Then examine the system for improvement opportunities
Managing Human Errors
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Managing Multiple Human Errors
What is the Source of a Pattern of Human Errors?
- In the system? If yes, address the system.- If no, can the repetitive errors be addressed
through non-disciplinary means?- Refer to Just Culture Algorithm - Repetitive Human
Errors
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To Drift is Human
View Video 2
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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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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 changingconsequences
– Examine the system for improvement opportunities
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Managing One Risk:Use of Seatbelts
Embrace Life
American vs. European Seatbelt
Australian Seatbelt PSA View Videos 3, 4, 5
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See Risk?
Want to Change Behavior?
Yes
No
NoYes
Receptive Disregarding
UnconvincedCompliant
Behavioral Change
Children See, Children Do
View Video 6
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In Each Organization…
Cooperation and Coaching Video
View Video 7
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• Examine your system(s)
• Begin education
• Change perceptions of risk
• Provide positive incentives
• Draw the bright line
• Enforce
Drawing the Bright Line
Around Behaviors to Support Our
Values
A Pattern for Success
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Reckless Behavior
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"The best car safety
device is a rear-view
mirror with a cop in it."
Dudley Moore
Managing Reckless Behavior
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Managing Reckless Behavior
A Part of the Game?
View Video 8
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• Reckless Behavior– Conscious Disregard of Substantial
and Unjustifiable Risk
• Manage through:– Disciplinary action– Punishment as a deterrent– How will you achieve the best outcome?
Managing Reckless Behavior
Note: Remediation is always available
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– Purpose– Knowledge– Reckless
– Negligence• At-Risk
Behavior• Human Error
Where Do You Draw the Line?
Intention
Action
Consequence of Action
Levels of Intention
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The Three Behaviors
At-RiskBehavior
RecklessBehavior
HumanError
Product of Our Current System Design and Behavioral Choices
Manage through changes in:
• Choices• Processes• Procedures• Training• Design• Environment
A Choice: Risk Believed Insignificant or Justified
Manage through:
• Removing incentives for at-risk behaviors
• Creating incentives for healthy behaviors
• Increasing situational awareness
Conscious Disregard of Substantial and Unjustifiable Risk
Manage through:
• Remedial action• Punitive action
HumanError
PunishCoachConsole
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A Single Event Repetitive Events
• Repetitive errors – yes, there is a process
• Repetitive at-risk behaviors – yes, there is a process
• Both may lead to disciplinary action…
Finding Justice (simplified)
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Exercise Scenarios
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A near-term pregnant patient is told by her doctor that sheneeds to return to the clinic within one week for her nextprenatal check up. The scheduler was new to the job andmade a mistake with the scheduling system. Flipping tothe wrong week, the scheduler inadvertently booked thepatient for an appointment in two weeks. Before herscheduled appointment, the mother goes into labor andthe baby is stillborn. The physician angrily tells the clinicmanager that the baby might have lived if the mother’sappointment had been scheduled correctly.
Scheduling Scenario
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Scheduling Scenario
Patient HarmWhy?
Scheduler flipped to
wrong page in appointment
book, scheduled
appointment too late
The Undesired Outcome Human ErrorA Cause of the Behavioral ChoiceA Cause of the Human Error
Behavioral Choice
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A new department manager is found to have lied on hisresume. He did not have the certification that he showedon his resume.
An investigation of why this oversight has occurred foundthat a human resources clerk did not do the requiredbackground check. The human resources manager hadnever had a candidate lie about their certification in their8 years of managing, and simply told his overworked clerkto skip the check. Corporate policies require that thecheck be completed. Both the clerk and the managerwere aware of the policy.
Resume Scenario
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Financial and
reputation harm to
company
Manager lied about having
certification
HR clerk did not confirm credentials
Why?
HR manager told HR clerk to
skip check
Resume Scenario
The Undesired Outcome Human ErrorA Cause of the Behavioral ChoiceA Cause of the Human Error
Behavioral Choice
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Housekeeping Scenario A housekeeping worker was waxing the floors around10:00 p.m. He could not find a wet floor sign and wouldhave had to go to another building to search for one.Believing he was alone in the building, he did not searchfor a warning sign.
The Chief Financial Officer slipped on the wet floor andseverely damaged his knee. The housekeeping stafffrequently had to search for the wet floor warning signswhich caused them to get behind on their work.
The manager was aware of the unavailability of signs, butdid not take any action to purchase more.
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CFO Slipped On
Floor
Wet FloorWhy?
Signs Far
Away
“Wet” Sign Not
Placed
Manager Did Not Buy More Signs
House Keeper
Thought He Was Alone
Severe Damage To Knee
The Undesired Outcome Human Error
A Cause of the Behavioral ChoiceA Cause of the Human Error
Behavioral Choice
Housekeeping Scenario
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NICU ScenarioA nurse is going to administer a medication to a baby in theneonatal 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 wherethe vial of medication is, confirms the blue cap on the vial, grabsthe medication and takes it to deliver the medication. At notime in the process did the nurse actually confirm themedication label, instead relied on location in the dispensingsystem and color of cap to confirm medication. In this case,pharmacy had put the wrong concentration in the dispensingsystem.
The nurse caught the error by glancing at the vial when drawingup the medication.
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NICU Scenario
Increased Risk Of Patient Harm
Pharmacy Mis-Stocks Dispensing
System
Relied On Color Of Cap, Did
Not See Risk
Nurse Does Not Confirm
Drug
Why?
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Summary
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– There will be a small population of the staff that will be openly opposed to most management initiatives
– There will be a larger population that believe that Just Culture is the key to future organizational success
– The remainder will believe the Just Culture will work, but likely will not buy into the program until they see leaders start to adhere to the principles
Our Experience
In Each Organization…
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Please visit us atwww.outcome-eng.com
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