CONSOLE, COACH, OR PUNISH? DAVID MARX MARCH 8, 2017 2017 Michigan Patient Safety and Quality Symposium
THE TOPIC
THE PROBLEM
US YOU, ME, THAT PERSON SITTING NEXT TO YOU We are inherently self-serving, occasionally altruistic, happinessseeking, inescapably fallible, pack animals blessed (or cursed) with free will and a mis-tuned ability to see and avoid hazards in the world around us
ACCOUNTABILITY?
AN EXAMPLE What does it take to inadvertently back over a child? What roles does accountability play?
THE DESIGN Child moves into harms way Driver does not walk around car Back up camera does not warn Child hit by car Three dice so why do we kill two kids a week?
CLOSER TO REALITY? What kid? Child hit by car
THE NEW YORK CITY SUBWAY
HEY YOU DON T FALL IN THE TRACKS!
HOW ABOUT BETTER SYSTEM DESIGN?
PERHAPS AN EXPECTATION As for me and my house We will, where possible, put ourselves three human errors from patient harm
BACK TO US We are inherently self-serving, occasionally altruistic, happinessseeking, inescapably fallible, pack animals blessed (or cursed) with free will and a mis-tuned ability to see and avoid hazards in the world around us
THE PROBLEM: CHOICE
HUMAN CHOICE I know, I know. I can t reach the top. Hey, do we have a third ladder? Hurry, Bob, the Cowboys play the Packers in 10 minutes
A SIMPLE MENTAL MODEL Sight Sound Smell Taste Touch Pursuit of the Mission The Risk Monitor (background process, harm focused) Perception Interpretation and Decision-Making Action
OUR RISK MONITORS
OUR RISK MONITORS
THE LIMITS OF NATURAL CONSEQUENCES Choice Desired and Undesired Outcomes The less likely the undesired outcome, the more distant the undesired outcome, the harder it is to see the link between a risky choice and the undesired outcome it may cause.
HOW WE MAKE CHOICES Life, Liberty, and the Pursuit of Happiness Pursue our individual mission, while trying to respect our shared values We are NOT inherently rule followers (we take them under advisement) We ARE hazard and threat avoiders Natural and man-made hazards Values-based threats Engineered threats
WE HUMANS PURSUE OUR INDIVIDUAL MISSIONS, WHILE TRYING TO AVOID HAZARDS Man-Made Hazard Values-Based Threat Engineered Threat
AN ORDER OF PREFERENCE? 1. I comply because I see the link between my deviation and the potential harm being managed by the rule. 2. I comply because it s a cultural expectation (peer condemnation). 3. I comply to avoid organizational sanction. I comply because it s the rule
CHOICES = CULTURE Culture: the degree to which human beings will, through their choices, be protective of a shared value. This often appears as the extra effort it takes to act in protection of a value, in the face of a belief that potential harm is uncertain, delayed, or will simply happen to someone else.
BACK TO US JUST WHO ARE WE?
WE MAKE MISTAKES
THE THREE BEHAVIORS HUMAN BEHAVIOR Human Error - inadvertent action; inadvertently doing other that what should have been done; slip, lapse, mistake.
WE DRIFT
THE THREE BEHAVIORS HUMAN BEHAVIOR Human Error - inadvertent action; inadvertently doing other that what should have been done; slip, lapse, mistake. At-Risk Behavior - behavioral choice that increases risk where risk is not recognized or is mistakenly believed to be justified.
WE GAMBLE
THE THREE BEHAVIORS HUMAN BEHAVIOR Human Error - At-Risk Behavior - inadvertent action; inadvertently doing other that what should have been done; slip, lapse, mistake. behavioral choice that increases risk where risk is not recognized or is mistakenly believed to be justified. Reckless Behavior - behavioral choice to consciously disregard a substantial and unjustifiable risk.
A MORE JUST CULTURE? Human Error At-Risk Behavior Reckless Behavior Product of Our Current System Design and Behavioral Choices Manage through changes in: Choices Processes Procedures Training Design Environment A Choice: Risk Believed Insignificant or Justified Manage through: Removing incentives for at-risk behaviors Creating incentives for healthy behaviors Increasing situational awareness Conscious Disregard of Substantial and Unjustifiable Risk Manage through: Remedial action Punitive action Console Coach Sanction
A MORE JUST CULTURE? Human Error Product of Our Current System Design and Behavioral Choices Manage through changes in: Choices Processes Procedures Training Design Environment At-Risk Behavior A Choice: Risk Believed Insignificant or Justified Manage through: Removing incentives for at-risk behaviors Creating incentives for healthy behaviors Increasing situational awareness Reckless Behavior Design systems to be tolerant of our inescapable human fallibility Conscious Disregard of Substantial and Unjustifiable Risk Manage through: Remedial action Punitive action Design systems that reduce the likelihood of human error Accept the error that Console Coach does occur: don t Sanction take it out on your employee
A MORE JUST CULTURE? Human Error Product of Our Current System Design and Behavioral Choices Manage through changes in: Choices Processes Procedures Training Design Environment At-Risk Behavior Use threat of sanction to deter self-interested choices A Choice: Risk Believed Insignificant or Justified Manage through: Remove those individuals who decide to gamble with others Removing incentives for at-risk behaviors Creating incentives for healthy behaviors Increasing situational awareness Reckless Behavior Conscious Disregard of Substantial and Unjustifiable Risk Manage through: Remedial action Punitive action Console Coach Sanction
A MORE JUST CULTURE? Human Error Product of Our Current System Design and Behavioral Choices Manage through changes in: Choices Processes Procedures Training Design Environment At-Risk Behavior A Choice: Risk Believed Insignificant or Justified Manage through: Removing incentives for at-risk behaviors Creating incentives for healthy behaviors Increasing situational awareness Reckless Behavior Good system design to deter human drift Conscious Disregard of Substantial and Unjustifiable Risk Managerial coaching Manage through: Remedial action Punitive action Peer to peer coaching Console Coach Sanction
SCENARIO 1 A housekeeping worker was waxing the floors around 10:00 pm. He could not find a wet floor sign and would have had to have gone to another building to search for one. Believing he was alone in the building, he did not search for a warning sign. An accountant slipped on the wet floor and severely damaged his knee. The housekeeping staff frequently had to search for the wet floor warning signs which caused them to get behind on their work. The housekeeping manager was aware of the unavailability of signs, but did not take any action to purchase more.
SCENARIO 2 The CNO has been a patient in the ICU for three days. It s rumored that she d acquired an infection here in the hospital. Strangely, Sally Burchimer, a charge nurse on 6 West seems to think she may have caused the CNO s illness. Sally had been out ill for a week. She knows that she met with the CNO directly upon her return, and is fearful that she is the cause. To alleviate here angst, she decided to look into the CNO s chart, in hopes that the CNO had fallen ill to another form of infection. An audit of those who accessed the CNO s record identified the breach in privacy.
SCENARIO 3 A brand new nurse to the OR (watching and learning the processes and practices of her new employer) storms out of the safety timeout ahead of surgery and right in the Director of the OR s office. She blurts out, Are you kidding me? The anesthesiologist is listened to his IPod with those little things in his ears. He s actually dancing a bit, you know, moving to the beat, nodding his lead when people look his way. I looked at everyone else in the timeout, and no one seemed to notice. They look like Zombies. Is this how we re going to treat patient s here? Do anesthesiologists get a pass? Does anyone care?
SCENARIO 4 The Engineering department has a large book in which the instructions for repairing equipment are located. Policy requires that these instructions be followed each time that a repair was performed. Last week a technician made a mistake on the repair of an infusion pump by omitting a required check upon re-assembly of the pump (relying on his memory to perform the task). This check, called out in the manual, would have confirmed that the infusion pump would not allow the free (unregulated) flow of medication under a particular failure mode of the pump. The inoperable pump safety device was caught when a patient received a free flow of heparin, leading to the death of the patient. Investigation reveals that the technician regularly performs this specific maintenance. Investigation also reveals that other technicians were performing this task by memory, without the aid of the procedure manual.
SCENARIO 5 An attending physician is about to perform minor surgery (removal of a cyst). Ahead of the surgery, the nurse comes in to have the consent signed by the patient. The patient states that the physician did not discuss the risks therefore it would be inappropriate to sign the disclosure form. The nurse said, Look, we can make a mistake and sometimes the outcome isn t that great. Given that, you re probably better off having the surgery. So, just sign the thing. The patient complains to the physician, who says well, did you sign the consent, or not?
PATIENT SAFETY AND WORKPLACE ACCOUNTABILITY?
UNDERSTAND WHAT WE CAN CONTROL Systems + Choices = Outcomes Reliable Systems + Good Choices = Good Outcomes
DO THE HARD WORK Articulate safety as an organizational value Design your systems to support safe choices Audit (look for safety supportive choices) Be a role model (resolve dilemmas in a manner that demonstrates your commitment to safety) Mentor (help others resolve dilemmas in the right way) Coach (call it out when you see choices that are unsafe) Hold everyone accountable for the right choices (unresponsive to coaching, or reckless -- go home)