To create a Fair and Just Culture (FJC) we have to begin to approach adverse events and errors differently. We need to try to imagine what was going on in the mind of the person who made the mistake. Why did it make sense to them in the moment that doing what they did was the right thing to do. This is how we begin to move from outcome or rule based decisions to risk based decisions.
Let’s review – a rules based decision is one in which an individual did not follow rules and there was a bad outcome. This might seem an easy one to decide on punishment, but consider this example. A social worker has been working with a patient for a few weeks. He has been pretty ill, but is finally doing better and is ready to be discharged. However, his family is on the east coast and he has been living on the west coast. His family wants to take him and have made it clear they are ready for him to come. The social worker is supposed to have the Medical al center director sign the form to allow transfer, but is unavailable that day and it is Friday. The family is waiting so the social worker allows the patent to leave and use the flight ticket she arranged. When the patient arrives on the east coast, it turns out that a critical bit of medical equipment (his hospital bed) had not arrived with the family. The patient needed up readmitted to a hospital on the east coast.
In looking at this case, it is clear that the social worker violated a rule and there was a bad outcome. Yet, before you decide to fire her, ask one question. Why did she violate this rule? She thought everything was set up for this patient and the family very much wanted to help care for the patient. Had the facility director been there and signed the rule-based form, the outcome would have been identical. The facility director was unlikely to have some mystical power to know that the expected medical equipment was not going to arrive. Had everything worked out well, no one would care that the rule had been violated.
We have previously discussed outcome based decisions making as well. But the above example also has an element of outcome based thinking. As stated, if the outcome had been fine and the medical equipment had arrived, no one would be upset.
So now we get to the idea of risk based decision making. The social worker in the above example tried to weigh the risks of not having one last signature against a patient who wanted to leave and had a family that wanted to care for him. The medical equipment was supposed to arrive but it didn’t. Had the medical director signed the transfer forms the outcome would have been similarly disappointing.
Do you still want to punish the social worker? Would the outcome be just and fair if you punish her? A just culture tries to focus on the risks that people are trying to balance not just the outcomes. It’s hard to think this way and it is different than the way many of us were trained. But punishing people for mistakes is a great way to make them hide those mistakes. And we cannot fix what we do not know about.