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Patient Safety Awareness Month

The Missouri Center for Patient Safety (MOCPS) is committed to raising patient safety awareness within the health care industry, for the media and the general public. MCOPS intensifies their awareness and educational efforts each year in the month of April to further increase the use of patient safety language and cultural practices professionally and publicly. In April 2011 MCOPS invited David Marx to participate in a Patient Safety Tele-Forum with Host, Nick Haines from KCPT-TV. David introduced the audience to Just Culture concepts while Becky Miller, Executive Director of MOCPS spoke about the programs of patient safety improvement that they have been able to put in place using the framework of the Just Culture.

Listen to David and Becky share their Just Culture experiences and knowledge

Just Policy - AeroSafety World

Just Policy - AeroSafety World On June 15, the American Airlines Maintenance and Engineering Organization (known as M&E) implemented a new policy designed to enhance the company’s ability to learn from errors and violations in the workplace, and to identify the most effective actions to take to prevent their reoccurrence. The approach applies just culture philosophy and tools, and standardizes previously diverse investigative processes into one cooperative investigation that considers errors and violations as learning opportunities for everyone. The resulting document is titled Just Policy for Maintenance Errors and Violations. American Airlines M&E have trained up a cadre of Just Culture Certified Champions to guide this implementation and provide assistance and practical internal support to easily identify system deficiencies and to objectively assess the quality of choices made by individuals.

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Missouri State Board of Nursing – Just Culture Champions

Missouri State Board of Nursing – Just Culture Champions Missouri State Board of Nursing Executive Director, Lori Scheidt, and Practice Administrator, Debra Funk, recently completed the much acclaimed Outcome Engenuity Just Culture Certification Training. This certification enhances the Board’s ability to protect the citizens of Missouri through a more effective and “just” enforcement of the state laws governing the safe practice of nursing.

The Board of Nursing is charged with protecting the public. More disciplinary actions does not equate to safer healthcare. We must understand the behavioral choices of the nurse and the system in which the nurse was working in order to make just decisions. – Lori Schedit, Executive Director, Missouri State Board of Nursing.

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American Airline's Leading Edge Magazine Focuses On Just Culture

American Airline's Leading Edge Magazine Focuses On Just Culture The publication for the maintenance and engineering division of American Airlines, Leading Edge, devoted its entire July issue to M&E’s Just Culture implementation. Click to read why a Just Policy for Maintenance Errors and Violations offers benefits to managers and staff by creating a safer and more accountable work environment.

Read the magazine

Incorporating a Just Culture in Maintenance and Engineering

The Transport Workers Union that maintains American Airlines in parts of the South also supports Just Culture. TWU Local 514 explained the benefits of a Just Culture in a recent newsletter.

Visit the web site

Manage Risk, Build a Just Culture

Manage Risk, Build a Just Culture This article from the July – August 2011 Health Progress outlines some of the parallels between the Just Culture model and the Catholic moral tradition and show that Catholic health care presents fer tile ground for the approach. Both the Just Culture and the culture of the Catholic health care are about "doing the right thing" in the treatment of caregivers.

Read the article

Scott Griffith on EMS Culture of Safety Improvements

Scott Griffith on EMS Culture of Safety Improvements Caramanis O’Brien from BaselineVitals.com interviews Scott Griffith from Outcome Engenuity. Scott brings experience from other “higher risk” industries including airlines to talk about building a “Culture of Safety” from the ground up.

View the video

The Importance of Coaching

The Importance of Coaching William Voss, President and CEO, of the Flight Safety Foundation highlights the importance of Coaching in the May issue of AeroSafety World. The Flight Safety Foundation mission is to pursue the continuous improvement of global aviation safety and the prevention of accidents.

Learn more about Coaching and Mentoring within the context of a Just Culture.

On the Scene: Just Culture staff training for EMS

On the Scene Outcome Engenuity, with the assistance of the Missouri Ambulance Association and the Missouri Center for Patient Safety, proudly announces the soon to be released Just Culture staff training for EMS entitled On the Scene.  As EMS organizations bring the Just Culture message to their staff, On the Scene will help staff understand Just Culture concepts and assist them with the everyday choices that they make.

Watch the trailer

Part Three in ‘Joint Commission’ Series: Scott Griffith Addresses Error Prevention in a Just Culture

The Joint Commission Perspectives on Patient Safety Continuing his five-part series in The Joint Commission Perspectives on Patient Safety, Scott Griffith examines the interplay of human behaviors and system designs in an organization that implements the Just Culture. Scott discusses human error, at-risk behavior and reckless behavior, and how organizational values should inform an institution’s understanding of and approach toward error prevention.

Click here to read the article.

American Nurses Association: Just Culture an "ideal fit for health care systems"

The American Nurses Association
The American Nurses Association cited David Marx’s Healthcare Primer, the Just Culture Algorithm and also highlighted the far-reaching success that several statewide initiatives in Minnesota, Missouri, North Carolina and California have experienced. ANA formally endorsed Just Culture in its January 28 statement, saying, “By promoting system improvements over individual punishment, a Just Culture in healthcare does much to improve patient safety, reduce errors, and give nurses and other health care workers a major stake in the improvement process.”

To read the full document, please click here. © 2010 American Nurses Association, All rights reserved.

In the News: The Wall Street Journal addresses system and human behavior accountability in health care, quotes David Marx

The Wall Street Journal
Errors made by doctors, nurses and other medical caregivers cause 44,000 to 98,000 deaths a year. Hospital infections, many considered preventable, take another 100,000 lives. And mistakes involving medications injure 1.3 million patients annually in the U.S., according to the Food and Drug Administration.

Hospitals are taking what might seem like a surprising approach to confronting the problem: Not only are they trying to improve safety and reduce malpractice claims, they're also coming up with procedures for handling—and even consoling—staffers who make inadvertent mistakes. The National Quality Forum, a government-advisory body that sets voluntary safety standards for hospitals, has developed a Care of the Caregiver standard, calling on hospitals to treat traumatized staffers involved in errors as patients requiring care, then involving them in the investigation of what went wrong if their behavior was not found to be reckless or intentional. Just Culture, a model developed by engineer David Marx, stresses finding a middle ground between a blame-free culture, which attributes all errors to system failure and says no individual is held accountable, and overly punitive culture, where individuals are blamed for all mistakes.

Click here to read the WSJ article.

Part Two in ‘Joint Commission’ Series: Scott Griffith Addresses the Severity Bias

The Joint Commission Perspectives on Patient Safety Scott Griffith’s second installment in a five-part series on Just Culture was published in the Feb. 2009 edition of The Joint Commission Perspectives on Patient Safety. He discusses the three different ways that we often respond to the Severity Bias: either by punishing someone for a mistake, regardless of the outcome; by ignoring harmful behaviors because there are no adverse outcomes; or by addressing the behavior in a non-punitive fashion. Scott includes a hospital survey that reflects where the Severity Bias can be found in most hospitals, noting that a true Just Culture resists “the urge to say ‘no harm, no foul’ and will treat a risky choice as a precursor to a bad outcome.” Stay tuned for future installments of his bi-monthly column.

Click here to read the article.

Scott Griffith Outlines Just Culture Basics in ‘Joint Commission’ Column

The Joint Commission Perspectives on Patient Safety Scott Griffith’s first installment in a five-part series on Just Culture was published in the Dec. 2009 edition of The Joint Commission Perspectives on Patient Safety. He introduces basic Just Culture concepts like fostering a learning environment, recognizing risk and managing the “severity bias” in health care environments. Scott highlights goals for Just Culture organizations, pointing out that though an organization can’t guarantee perfect outcomes, it “can commit to maximizing its reliability around each of its core values and being the best steward of the limited resources it has.” Stay tuned for future installments of his bi-monthly column.

Click here to read the article.

David Marx featured in Prevention Strategist

Prevention Strategist The Winter 2009 edition of Prevention Strategist includes an article profiling David Marx’s work as curator of the Just Culture community and its guiding principles. Carol Latter takes a closer look at the North Carolina, Missouri and California statewide initiatives specifically to see how Just Culture has changed their healthcare environments. Theresa Manley, the chair of the California Patient Safety Action Coalition, points out in the article that Just Culture is conducive to healthcare because it influences people to do the right thing even when a supervisor isn’t present. Manley says that Just Culture “speaks to the intelligence and integrity of healthcare providers.”

Click here to read more from Prevention Strategist.


The Price We Pay For Expecting Perfection

Whack a Mole the book

We’re going to hurt each other--it’s a fact of life, a cost of doing business. On the bright side, we can reduce the odds. We can design better systems, and we can make better choices. Along the way, we could abandon our “no harm, no foul” approach to personal accountability, we could rewrite regulations and corporate policies that outlaw human error, and we could rethink how we respond to our children’s mistakes.

David Marx addresses regulators, attorneys, CEOs, public policy makers, the media, and even parents to show that our current social perspectives toward our inherent human fallibility have substantially hindered efforts to make the world a safer place to live. While his observations are primarily about American culture, the lessons are universal. Insightful, bold, and told through often humorous tales, Whack-a-Mole pushes readers to rethink what it means to be accountable--at work, at home, and at play.

Read more about the book here. Buy the book here.

North Carolina Video Released

Starting in 2006, a group of North Carolina hospitals, with the support of the North Carolina Board of Nursing and the North Carolina Hospital Association, launched their Just Culture journey. Their story has been documented in the video “The North Carolina Just Culture Journey.” Click below to watch a 20 minute version of this video. Should you desire to watch the full 30 minute version with more hospital testimonials, please click on the link for the longer version.

The North Carolina Just Culture Journey "20 Minute Version."

The North Carolina Just Culture Journey "Full Version."

California Healthcare Organizations Adopt Just Culture

The California Patient Safety Action Coalition (CAPSAC) introduces regional Just Culture training at 15 locations throughout California in October and November. Following a successful July conference with 200+ California healthcare leaders in attendance, CAPSAC and its member organizations are moving full steam ahead with implementation of Just Culture across all healthcare sectors – from acute care to long-term care, ambulatory surgical centers to group practices. To receive more information and register for California Just Culture training, visit the CAPSAC site at www.capsac.org. Outcome Engenuity and the Just Culture Community are proud to support CAPSAC in the very important journey.

Click here to view the full CAPSAC press release.

Safe Choices: Training for Staff

Featuring the film No Small Consequence

“Justice demands both organizational accountability and personal accountability. Non-punitive safety reporting is only one aspect of safety, and only one goal of the Just Culture. While we live with human fallibility, we must demand that executives, managers, and staff be accountable for the quality of their choices. Those we serve should expect nothing less.”

- K. Scott Griffith, Chief Operating Officer, Outcome Engenuity, LLC

Safe Choices Training for Staff

Outcome Engenuity is proud to announce the release of Just Culture training for staff. We call it Safe Choices™ – a year-long training program to bring the message of Just Culture to your entire staff, including executives, champions, managers, and front-line employees. Safe Choices™ is two hours of initial training with six bi-monthly multimedia vignettes.

We introduce the training with a dramatic 28 minute film entitled No Small Consequence, a By Your Side Studios production designed specifically to demonstrate the message and principles of Just Culture and Safe Choices™.

After more than a year in development, we’re excited to be able to offer the Safe Choices™ training program for staff. We’re confident it will be a great addition to your Just Culture journey.

The Outcome Engenuity Behavioral Benchmark™ Survey

Outcome Engenuity introduces the Outcome Engenuity Behavioral Benchmarking™ Survey. Measuring progress in the Just Culture journey is an important key to the success of an organization. Traditional culture surveys do not measure the real markers important to a just and learning culture. Surveys that only look for a non-punitive culture will miss critical elements of personal accountability that are needed to maintain peak organizational performance. Surveys and measurement tools that only look at outcomes will miss the important measures involving systems design and behavioral choices. Better measures than those available today are needed. Values to measure are:

Behavioral Benchmark Survey
  • Organizational Values
  • System Design
  • Management/Subordinate Coaching
  • Peer/Peer Coaching
  • Outcomes
  • Open Reporting
  • Search for Causes
  • Internal Transparency
  • Response to Human Error
  • Response to Reckless Behavior
  • Severity Bias
  • Equity

It’s called the Outcome Engenuity Behavioral Benchmark™ Survey. Click here to learn more.

Interview with Julie George - North Carolina Board of Nursing

Ms. George has been a registered nurse for more than 30 years and has been involved in nursing regulation since 1996 when she was employed with the North Carolina Board of Nursing as an Investigator.

Julie George

In 2001, Ms. George became involved in efforts to re-frame how the NC Board of Nursing addressed practice errors and discipline. She was instrumental in developing policies and programs that focused on patient safety and quality improvement. North Carolina was the first Board of Nursing to partner with Citizen Advocacy Center and implement the Practitioner Remediation and Enhancement Partnership (PREP), a non-punitive, early intervention program for nurses.

She has been actively involved in the work of the National Council of State Boards of Nursing and has championed integrating Just Culture into regulator’s day-to-day practices. The following interview describes Julie George’s and the Board’s pioneering work implementing Just Culture in a regulatory environment, in concert with the North Carolina provider community.


An Examination of Red Rules in a Just Culture

red rules

In recent months, several members of the Just Culture Community have questioned whether implementing “red rules” is a desirable strategy in a Just Culture. Many high-consequence organizations have considered the option of implementing red rules to improve organizational safety performance.

To assess the effectiveness of red rules, we must first understand the outcome we desire once we implement them. According to the Agency for Healthcare Research and Quality (AHRQ), “red rules should foster a culture of safety” within the organization. In the context of Just Culture, this infers added value to an organization’s ability to improve system design and influence the behavioral choices of staff.


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