HR Pulse - Winter 2007 - (Page 17) Given the extraordinarily high stakes, those in the healthcare field—and in the communities they serve—have a very low tolerance for errors, and when they do occur, there is a tendency to place blame and mete out punishment. But does that approach make the systems any safer or the employees any better at making safer choices? Not really. A Change in Perspective “We have to get away from the ‘{Hurricane} Katrina effect,’ where we point to how bad things are and then ask who is to blame,” says David Marx, a system safety engineer with a law degree. Marx has been working with high-risk industries— including aviation and healthcare—for more than a decade to improve safety and performance. “We need to ask different questions,” says Marx. “How do we help employees be as reliable as they can be? How do we work through human resources and risk management to help line managers coach employees on choices that make patients safer?” He believes the answers can be found in the Just Culture Model. As the “father of Just Culture” and the founder of the Just Culture Community (www.justculture. org), Marx believes that improving patient safety requires a shift away from the traditional focus on errors and outcomes to one that concentrates on system design and behavioral choices. “The Just Culture Model is about redefining accountability to create a more effective system of safety and determine what we can reasonably expect from a fallible human being, especially one who is working in a complex system. We have to accept that we cannot eliminate errors. So, what can we manage? We can design better systems in which employees work, and we can coach employees to make safer behavioral choices,” he says. In Marx’s view, a “just” culture occupies the middle ground, somewhere between one that is penalizing and one that is blame-free. It operates with a nonpunitive reporting system while still holding employees accountable for their actions. He advocates for a definition of accountability that requires employees to raise their hands and report their own errors and those of their colleagues in the interest of patient safety. The goal is to manage risk and prevent adverse outcomes more effectively by creating environments of open learning, where errors get reported and everyone has a chance to learn from them. The question of accountability is a tricky one, he admits. How can a manager hold an employee accountable for her choices and encourage open learning at the same time? The answer, Marx believes, depends on creating reasonable expectations and a clear path to deciding how to handle breaches when they occur, as they inevitably will. The Model The Just Culture Model framework includes four areas of focus: 1. Creation of a learning culture–The culture must be hungry for knowledge at both the local/departmental level and organizational level to identify solutions that will have the greatest impact. 2. Creation of an open and fair culture–Organizations must move away from overly punitive reactions to foster a culture where human fallibility is recognized and all employees are held accountable for their behavior. 3. Design of safe systems–Organizations must design systems that are reliable and facilitate good decision making on the part of employees. 4. Management of behavioral choices–Managers must be able to coach employees when appropriate and recognize when remedial, disciplinary or punitive measures are necessary. An important step in shifting to a new view of accountability is to recognize that there are different types of behavioral choices. “The quality of your choice counts, regardless of outcomes,” says Marx. “That means we have to differentiate between levels of culpability.” When something bad happens, the Just Culture Model distinguishes between: • Human error • At-risk behavior • Reckless behavior. Traditional policies—written by attorneys with input from risk managers—are generally extremely strict and tend to treat the three types of behavior the same way. Marx suggests that, in a just culture, each behavior requires a different response. In other words, an employee who makes a mistake should not be treated the same as an employee who is reckless. “Just Culture is a new language to talk about human fallibility—language that didn’t come from the legal department,” explains Marx. “It’s about getting away from the mentality of figuring who was the last guy to touch something and blaming him.” Marx likes to use driving analogies when talking about accountability. “Human error is when a person doesn’t realize he’s driving over the speed 17 HR Pulse Winter 2007 >>
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