When we think about how people deal with the daily work in their systems, we need to understand that they are trying to make sense of complicated systems, but also trying to get things done. There are many things in our systems that make it hard to balance efficiency with safety. The absolute rules they are held too with what makes sense to them as they try to do their daily work. Generally, the people who come to a healthcare system every day, and take care of patients are trying to do good things, but like every other person they also balance fatigue, stressors, hard choices, the list goes on. So let’s look at the choices people make before we make decisions about who they are.
The image above helps us breakdown the choices that people make. As you can see, human error happens and there is no choice on the part of the person who is involved. They cannot see the risk of what is happening and no choice is made. In these cases when an error happens the person who is involved may well be at the end of a series of systems issues for which they have little control or input.
In the case of “at risk” behavior the individual may choose a behavior that, in retrospect seems risky, but at the time may seem like a very reasonable choice to the person making the choice. They may or may not may not see the risk that they are taking. No one has the ability to see into the future, so the individual may not entirely feel that they are accepting a risk with a known outcome. Imagine if you are in a car and driving over the speed limit. You feel that you are a good driver and entirely in control. You have driven this route many times and done just fine at the speed you are moving, So you choose the risk, but don’t entirely see the risk you are taking, How much over the speed limit is OK? In hindsight if an accident happens it will be clear…..but in the moment, it seems very reasonable. You get home faster, you have things to do…. the risk you are taking in moving above the speed limit seems fine.
The final behavior is called “Reckless”. This may seem to be clearer that the choice an individual is making is out of bounds and worthy of blame. If you see someone on the highway weaving in and out of traffic at a speed of 85 MPH that may seem unreasonable. It is a choice and surely they see the risk! But what if someone is racing to the hospital with a loved one who is terribly ill. In such a case, that individual may choose the behavior and they even see the risk. But all of us might understand and be sympathetic to the terror that someone feels in that moment. In hindsight, if an accident occurs, this might seem like a ridiculous choice until we go back and fully understand why an individual was making that choice. Might all of us accept this risk ad make this choice in that moment…..
To be clear…a Just Culture does hold people accountable for actions that are truly blame worthy. Refusal to do certain things that are critical to safety must be managed and dealt with. I am an Emergency Medicine physician. If I wake up one day and decide that I can take out someone’s appendix, that is well beyond my scope of competency and practice. Of course, you would hold me accountable for such behavior (ok that’s an extreme and obvious example, but you get the point). The Just Culture is not about “no shame and no blame”, it is about holding people accountable for actions that are truly blame worthy. Yet we must try to understand the behaviors that people make under the various pressures to perform that they might face prior to holding them accountable. High Reliability Organizations seek to understand before they assign blame.
More to come on this as we dig deeper into how to think about a Just Culture. To be clear, this is hard. If it was easy to do this all health systems would have done it a long time ago.