I want to return to the topic of a Just Culture. Recall that the idea here was to not punish people for making mistakes or causing adverse events. A Just Culture also requires that you don’t punish people or get frustrated with them when they bring up concerns that they see as safety issues. It is fair to say that sometimes people overuse the “safety card”, not because something is really unsafe, but because they don’t want to make a change or do things that are asked of them. They then claim that the requested change is unsafe, when they just want to continue to do things their preferred way. But we should try to start with the premise that people who raise safety concerns are truly concerned until proven otherwise.
When people make a decision and the outcome of that decision appears to lead to a mistake we often look back at the decision and since we now know the outcome was bad, we leap to the conclusion that the initial decision was also bad (Monday morning quarterbacking anyone??). Yet, in many cases, the decision that the individual was making in the moment made a lot of sense to them. They thought that good things would result from that decision. Only with the beauty of hindsight do we see that the decision was a bad one. I hope at this point you might feel that judging people in this way, particularly if there is possible punishment isn’t fair and will tend to make people hide their mistakes. Since some mistakes are very much the result of systems issues, if people hide their mistakes then the system cannot learn and cannot get better. This is why we try to encourage people to be transparent and bring their mistakes forward even in the cases that no one notices. Certainly, when errors cause significant and public errors, we still hope that people will be willing to talk about what happened and that their leadership will support them rather than punish them.
So what do I mean when I say we should try to think about decisions as rules based versus value based? A decision that is rules based, is pretty much like it sounds. If you violate a rule/policy/directive and something bad happens you should always be punished. This might seem like the right thing to do, but what should we do with people who violate the same rule and everything turns out swell? Still punish them? The point of course is that we like to judge things by the outcomes rather than the process.
In a Just Culture, we like to approach things differently. Rather than focusing only on rules, we try to focus more on what people were trying to do at the time they made a decision. They may bend or even break a rule, but if you can pause for long enough to ask them “why” they made the decision they made, you may find that it was very reasonable and very focused on doing good things for a patient. That things did not go as they planned or hoped and something bad happened, may not completely override the good that the employee was trying to do.
It would be fair at this point for people to have concerns that I am suggesting that rules and policies don’t matter and that people can just do what they want. I want to put those concerns to rest. A Just Culture does not allow for people to do whatever they want. Yet, it does try to force leaders to step away from the outcome they see, and try to look back in time to what people were doing and thinking before the bad outcome occurred.
More to come next time.