ISMP Presents Lifetime Achievement Award to David Marx

David Marx Lifetime Achievement Award

David Marx Lifetime Achievement AwardAt its Annual Cheers Awards Dinner on December 6, 2016, ISMP presented a Lifetime Achievement Award to David Marx, CEO of Outcome Engenuity, for his ongoing contributions to healthcare patient safety initiatives and his significant impact on safe medication practices.  In a career spanning three decades, ISMP recognized David Marx as a true pioneer in the safety world.  Through the integration of systems engineering, human factors, and the law, David has built working environments that are more resistant to human error and changed the paradigm for how we manage individuals involved in medication errors and other types of failed outcomes.

David has authored a Patient Safety Guide for the National Institutes of Health, advised the US Agency for Healthcare Research and Quality on safety issues, created the Five Rules of Causation for the FAA, and led an external team benchmarking NASA’s Space Shuttle processing. Additionally, he has authored two books on workplace accountability: Whack-a-Mole: The Price We Pay For Expecting Perfection and Dave’s Subs: A Novel Story About Workplace Accountability. In 2005, ISMP awarded David an individual Cheers Award for his development of the Just Culture model. Incorporating lessons learned from aviation, aerospace, transportation, healthcare and other high-risk industries, David continues his efforts to help workplaces achieve highly reliable outcomes through his development of human factors risk modeling methods and as the father of the Just Culture accountability model.

imsp_cheers_awardOutcome Engenuity is honored to be recognized by Michael Cohen, founder, and CEO of ISMP, and his lifetime achievements of making medication practice safer for all through his tireless work at ISMP.

Pointing the Finger Is a Human Trait: We Must Learn to Do It Well

President Harry S. Truman is shown at his desk at the White House signing a proclamation declaring a national emergency. December 16, 1950. Acme. (USIA) NARA FILE #: 306-PS-50-16807 WAR & CONFLICT BOOK #: 1372
President Harry S. Truman is shown at his desk at the White House signing a proclamation declaring a national emergency. December 16, 1950. Acme. (USIA)
NARA FILE #: 306-PS-50-16807

Harry Truman famously kept a sign on his desk in the Oval Office reading “The Buck Stops Here.”  It was an overt declaration that he took ultimate responsibility for every choice his administration made, for everything they did or failed to do.  He assumed the blame.  And that’s an admirable trait in a leader—it builds trust and wins the respect of team members to know their leader is willing to take the blame for mistakes the team makes.  It goes back to justice: no one wants to be blamed for something for which they aren’t personally at fault.  Because whenever something goes wrong, there must be someone to blame, someone to be punished if necessary.  That’s a basic fact of human nature.  People think in terms of cause and effect: if something bad happened, someone or something must have screwed up to cause it.  But admirable as it is for a leader to assume responsibility for everything, blaming the person in charge isn’t enough.  Nor is just blaming the person at the point of failure, or picking a random scapegoat.  Simplistic ways of apportioning responsibility for mistakes, without in-depth analysis, allow us to gloss over the necessary response to failures: to figure out what actually went wrong, and how to fix it.  Pointing the finger is a human trait, but if leaders want their organizations to learn and improve, they must learn to do it well.

The key aspect of a learning culture is the ability to receive feedback that allows leaders to improve systems.  But the ability to improve systems is dependent entirely on the quality of the feedback leaders receive: they can only fix problems if they know what actually caused the problem in the first place.  Which means that they must have a system in place that allows them to gather accurate data and feedback.  Such a system, then, requires a delicate balance.  First, it must ensure that employees trust they will be treated fairly and justly, or they will not honestly report mistakes and areas for improvement.  If there is no sense of justice, there can be no learning culture, because information will not be reported for fear of being treated unjustly.  But the system must also be able to accurately identify the root causes of problems—to point the finger at the right person or people or systemic failure—and hold those responsible accountable.  A “no blame” culture is just as problematic as a strictly punitive culture in terms of learning and improvement.

Only when these two aspects are in place (accurate investigation and accountability combined with a sense of justice and fairness) can leaders learn from mistakes and improve the systems that bring them about.  Only if they can identify the person responsible for an error (pointing the finger accurately) can they then identify if it was indeed a simple error, or a risky choice due to an individual or systemic drift from procedural compliance, or reckless (or even intentionally harmful) action.  And only when that has been identified can they then determine if there were any systemic performance shaping factors that may have led to the error—factors that can be improved to reduce the likelihood of such an error in the future.  Or if the investigation reveals no such systemic factors were at play, they can decide the appropriate just response (consoling, coaching, retraining, punitive action, etc).  But this response—taking the appropriate reaction for the responsible individual(s) and possibly identifying and correcting systemic problems—can only occur if the leaders manage to get the first part right and point the finger well.  Letting the team leader take the blame may win him or her the respect of the team, but it does nothing for organizational learning and improvement.

Learning to point the finger accurately, to identify the root causes of problems and respond to them appropriately, is not only required for justice and employee trust and morale.  It is a sound business decision.  High-quality systems of investigation and accountability like the Just Culture (Workplace Accountability) Model are an investment in organizational learning and improvement.  When something goes wrong, it is natural to want to point the finger.  But leaders must learn to do it well if they want to make their organizations better.


Aaron Haskins, Outcome Engenuity Advisor.

Federal safety board foresees new role in era of driverless cars

View the original article here:

By Melanie Zanona - 06/30/16 03:24 PM EDT

As federal and state governments begin to develop policies surrounding autonomous vehicles, a federal safety board hopes regulators will call on the agency’s safety expertise to help bring more self-driving cars to the roads.

National Transportation Safety Board (NTSB) Chairman Christopher Hart, speaking at a National Press Club luncheon on Thursday, said the agency is stacked with a team of safety experts and accident investigators who can provide insight on the potential benefits — and risks — of autonomous vehicles.

“We could be a very valuable resource,” Hart said. “If people don’t take advantage of that experience … then they’re missing a valuable opportunity to miss the bumps in the road.”

Hart said that the NTSB’s most valuable asset comes in the form of recommendations. The independent federal agency oversees accidents in all modes of transportation by determining the cause of the incident and offering suggestions to prevent it from happening in the future.

“Our world-class investigators and analysts don’t like to give up until they have the answer,” he said.

Hart hailed the power of driverless cars to significantly reduce the 32,000 traffic deaths per year, which are mostly caused by human error.

But he also ticked off a list of lessons that the autonomous vehicle industry can learn from the NTSB’s experience with accidents in other modes of transportation.

“That experience has also demonstrated that there can be a downside,” Hart said.

One example is that automation can fail, as happened in a deadly Washington, D.C., Metro crash in 2009. Hart said it’s important to address what happens if the design fails and whether a human operator can take over in time.

He also said the agency has learned that not every crash is caused by human error and that challenges can arise when a transportation system is made up of both human operators and automation.

It’s unclear just how the NTSB’s role will change as the nation’s fleet of vehicles becomes more autonomous and accidents decrease. But Hart, who emphasized that there still will be accidents with driverless cars, said the agency will likely only investigate crashes with “systematic implications” — like it does with highway accidents.

The Department of Transportation is working to unveil guidance for states on autonomous vehicles this summer, as well as release a rule requiring all new cars to have vehicle-to-vehicle communication later this year.

Hart batted down concerns that the NTSB would be left out of the rule-making process, saying that the agency has been at the forefront of advocating for automation for two decades.

“I’m not concerned about us being left out. We’re already in the conversation,” he said. “For about 20 years we have been pushing something that is a collision-avoidance system.”

Sharpening the focus on medical errors

Hospital works to build culture where reporting mistakes is celebrated

This Article is a re-post. See the original article here.

— At 6:40 a.m. on a recent day, several dozen nurses, doctors, technicians and other workers gathered in the second-floor surgical center at Sharp Memorial Hospital in San Diego for the daily safety huddle.

All wearing scrubs, their heads covered with blue surgical caps, they held copies of the day’s schedule, listening as surgical care manager Sam Minero pointed out the patients whose circumstances called for a little more awareness.

There were patients with latex allergies in rooms one, five and 10.

“Anything we use to care for those patients must be latex free,” Minero reminded, drawing nods from the gathering.

The patient in room nine had a VRE infection. Over in 17, it was methicillin-resistant staphylococcus aureus.

Half an hour later, across the medical campus in the outpatient pavilion, Dr. Michael Keefe led his surgical team through a quick timeout, repeating his patient’s name and age and the specific procedure to be performed, noting an allergy to penicillin. All of these items and more had already been gone over with the patient and checked upon arrival in the operating room. But hospital policy calls for the surgeon to run through those items one more time before asking for the scalpel. Only after asking each member of the team if they had a question did the surgeon say “we are set to proceed.”

These procedures inside and outside the OR have been in place at Kearny Mesa facility for many years, but Sharp has been working over the last two years to make them more meaningful.

Focus on deepening the hospital’s safety culture tightened in 2012 when a surgical team mistakenly removed patient Paul Kibbett’s healthy left kidney though a cancerous tumor had been discovered on the right. Ultimately both organs were removed, and the patient was forced to rely on dialysis for the rest of his life. In addition to a lawsuit, Sharp received a $100,000 fine and bad publicity, courtesy of the state’s immediate jeopardy system.

The event caused Sharp, the region’s largest health system with four acute-care hospitals in San Diego County, to do some soul searching.

After all, it was not like the hospital was ignoring standard safety procedures. Hospitals across the nation have had an intense focus on error prevention for more than a decade, mandating new fail-safes often adopted from industries such as aviation and nuclear power where one slip-up can cost many lives.

Checklists, which pilots routinely use to make sure they don’t miss critical steps in the complex task of preparing an airplane for flight, have become common in operating rooms. Some, including Sharp, have now begun using wireless electronic tracking systems for surgical sponges that allow surgeons to detect a left-behind item even if it is not visible in a patient’s body cavity.

However, there are still plenty of ways things can go wrong. In the Sharp kidney case, the surgeon decided to move forward without having confirmatory X-rays, taken at another facility, up on the digital screen in the operating room for visualization by the whole team despite the fact that hospital policy clearly stated that X-ray verification is required in cases where there could be left-right confusion.

The incident highlighted a simple truth: Rules and procedures only work if all of the people involved actually follow them every single time.

Safety, then, is just as much about a hospital’s culture as it is about having the right policies, procedures, technology and personnel in place.

When someone decides to skip a step, someone else needs to spot that behavior and call it out.

Dr. Gerald Hickson, immediate past chair of the National Patient Safety Foundation and a quality and safety executive at Vanderbilt University Medical Center in Nashville, Tenn., said the true work in increasing hospital safety is changing culture.

“It requires people, process and technology. What has so often happened is, when somebody attempts to put in new procedures like checklists or universal timeouts, surgeon X looks up and says, ‘I’ve been operating for 20 years. I’ve never operated on the wrong side. We don’t have time for this. Move on,’” Hickson said. “That has been, in my view, one of the big factors slowing down the safety movement. Culture trumps everything.”

Sharp seems to agree.

Its latest moves, said hospital medical director Dr. Geoffrey Stiles, have been as much about the way workers collaborate and hold each other accountable as they have been about creating redundant safety policies for high-risk operations.

It has been important, he said, for doctors to understand that a sterling history of safety does not necessarily mean an error-free future.

“One of the big pieces to get them engaged was for them to realize their vulnerability. They were all, for the most part, saying, ‘Yeah, I’m safe, I’m good,’ but, when the American Academy of Orthopedics comes out and says that an orthopedic surgeon has a one-in-four chance of doing a wrong-site surgery sometime in their career, it’s like, ‘OK, I don’t want to be in that 25 percent,’” Stiles said.

Sharp has tried, the director added, to emphasize to its caregivers that reporting errors is a good thing, even creating a “great catch” award complete with a catcher’s mitt trophy and company-wide recognition.

Sharp has also implemented the TeamSTEPPS program created by the U.S. Department of Defense and the Agency for Healthcare Research and Quality, which is designed to improve teamwork.

Surgical nursing manager Michele McCluer went through the training and said its emphasis on encouraging all caregivers to speak up if they see a problem is its most valuable feature.

But encouragement, she noted, is actually not the most critical element of success. Employees, she said, need to know that the corner office has their backs.

“Knowing that we will be backed up by our leadership and our management team is very important,” McCluer said.

Changing culture can force some difficult conversations, and no one knows that better than Dr. Tom Karagianes, the soft-spoken medical director of Sharp Memorial’s outpatient surgery pavilion.

He said that, historically, hospital workers have made allowances for disruptive behavior by doctors. That, he said, is a mistake. Though it may be uncomfortable, it is important for management to back its staff by sharing with doctors that the way they talk to their coworkers has real safety implications. It is more likely, for example, that employees will rush through safety checks without paying proper attention if they feel uncomfortable, rushed or anxious.

“A physician who is borderline disruptive throws everybody’s game off,” Karagianes said.

So far Sharp says these changes to culture have had a positive effect. The health care system has not had a “wrong site” surgery since the kidney removal mixup.

Stiles said the new focus on speaking up has occasionally brought disagreements to his attention.

“We have had some that have said, ‘Yeah, yeah, let’s go,’ and we say, ‘No, we have to do the timeout.’ The staff won’t give them the knife. If need be, they’ll escalate it to me or Tom,” Stiles said.


The Just Culture Organizational Benchmark™ Survey

The Organizational Benchmark™ Survey is designed to measure critical behavioral markers that show an organization’s growth in culture around a particular organizational value, such as safety, privacy, compassion or cost control. The markers are the same for each value (safety or privacy) in that the basic elements of a learning and just culture are common.












The markers follow twelve areas of focus:

  1. Organizational Values
  2. System Design
  3. Management/Subordinate Coaching
  4. Peer/Peer Coaching
  5. Outcomes
  6. Open Reporting
  7. Search for Causes
  8. Internal Transparency
  9. Response to Human Error
  10. Response to Reckless Behavior
  11. Severity Bias
  12. Equity

An explanation of the 12 benchmarks:

1. Organizational Values

In this benchmark area, we ask employees if they believe their manager’s behaviors demonstrate that the particular value is supported by the organization. This provides a high-level view of how employees are interpreting their manager’s behaviors attached to a particular value.

2. System Design

In this benchmark area, we ask employees if they see systems being changed in response to adverse events and hazards identified by the employee group. This focus on system design is a key operational tool.

3. Management/Subordinate Coaching

In this benchmark area, we ask employees if they see their managers coaching when staff members make risky behavioral choices tied to the value being analyzed. Knowing that employees will drift into at-risk behaviors, this marker tells us whether managers are coaching employees onto better behavioral choices.

4. Peer/Peer Coaching

In this benchmark area, we ask if employees are willing to coach each other. This marker goes beyond merely offering help to another employee. We ask if employees are willing to challenge the behavioral choice of a peer that they see making risky choices.

5. Outcomes

In this benchmark area, we ask employees if they see outcomes tied to a particular value heading in the right direction (increasing or decreasing). This will assess employee perceptions of whether they believe organizational outcomes are improving. This is especially important where adverse events are hard to track in a quantitative manner (e.g., compassion).

6. Open Reporting

In this benchmark area, we ask employees if they are willing to report hazards or near misses that might detrimentally impact a particular organizational value. As opposed to reporting of adverse events, this behavioral marker looks at the near miss or hazard as the precursor to harm. Open reporting is essential to create a learning culture.

7. Search for Causes

In this benchmark area, we ask employees if they see managers investigating system precursors to potential harm. We focus on near misses that, if investigated and understood, would produce critical system learning.

8. Internal Transparency

In this benchmark area, we ask employees if they observe open dialogue concerning adverse events and lessons learned as related to the value under analysis.

9. Response to Human Error

In this benchmark area, we ask employees if they see employees being disciplined for inadvertent human errors. This marker ties directly to the Just Culture model for the proper response to human error.

10. Response to Reckless Behavior

In this benchmark area, we ask employees if disciplinary action is taken when an employee willfully chooses to recklessly endanger the value under analysis. This also ties directly to the Just Culture model in the response to reckless behavior.

11. Severity Bias

In this benchmark area, we ask employees if they believe that the severity of event outcomes play a significant role in whether the event will lead to positive change in systems or processes.

12. Equity

In this benchmark area, we ask employees if they believe that they are treated fairly across employee groups. Equity, the belief in the system being fairly applied across employees, is central to the notion of a Just Culture.

New Zealand agency identifies behaviors, others’ ‘Mistakes’

Last year, the New Zealand Transportation Agency (NZTA) launched their 'Mistakes' campaign, emphasizing the impact of behaviors and choices made on the road, and was directed at competent drivers who tend to drive above the speed limit. On the campaign's webpage, NZTA reported 83 deaths and 408 serious injuries from speeding accidents in 2013.

At the core of the campaign, the NZTA addresses the fact that to err is human: though drivers feel competent driving a fast speed, the drivers cannot control the mistakes of others on the road, leaving very little room for at-risk and reckless behaviors on the roads.

The NZTA identifies, emphasizes, and aims to re-frame the behavioral choices of those living in New Zealand through this campaign, an undeniable example of efforts being made in New Zealand to bring awareness to core "just culture" concepts, such as recognizing and investigating the root of behaviors.

Much like the NZTA, other New Zealand companies are seeking "just culture"--one such company being Air New Zealand, who has taken initiative to host a Just Culture Certification Course through Outcome Engenuity on May 13-15, 2015 in Auckland, New Zealand.

Over the three day certification course, key leaders from within companies will learn to improve their systems built around their employees, manage at-risk behaviors, create a more open reporting culture, learn how to properly use the Just Culture Algorithm and more.

Registration for the Auckland Just Culture Certification Course is currently open. The certification course is located at Air New Zealand Ltd. 185 Fanshawe St., Auckland 1010, New Zealand.

May 13-15, 2015

Auckland, New Zealand

Just Culture Certification Course

Hosted by Air New Zealand

Budget For Culture: How Investing In Your Team Drives Results – Forbes article recently posted an article addressing the the benefits an organization receives when it decides to invest in its culture and how that communicates its values. For your convenience we have posted it here so you may continue reading below.shutterstock_186067874

As a leader, every decision you make shapes your organizational culture, and when it comes to budgeting your limited resources, these decisions send powerful messages to your people about what’s most important. After all, money doesn’t just talk — it shouts your priorities through a bullhorn. You have to make budgeting decisions that drive your business’s strategy and goals. But too often, the technical aspects of your strategy are prioritized over the most important facet of your organization’s long-term performance: the people.

The best plan in the world won’t survive if your people aren’t on board. But if you support your employees and nurture their enthusiasm, they’ll take care of your business. In fact, investing in your people can reap rewards that ripple across your entire organization and beyond. According to Gallup, organizations with above-average levels of employee engagement reap 147 percent higher earnings per share. Furthermore, when they engage both customers and employees, organizations experience a 240 percent jump in performance-related business outcomes. Clearly, you need to start investing in culture.

The concept may still seem abstract, so here are six concrete aspects of organizational culture to focus on:

1. Recruitment, orientation, and the employee experience: A new team member’s impression of how you treat employees is set from the beginning. Even during the recruiting process, the way candidates are treated sends a clear message about your company culture. These messages about expectations and a person’s value are reinforced during the onboarding process. With this in mind, you need to be thoughtful about your employee experience throughout their tenure with you and make it as seamless and supportive as possible. This kind of investment will pay dividends down the road.

2. Professional and leadership development: It’s not uncommon for business leaders to create strategies that require a significant shift in employee behavior to succeed. However, if you’re asking employees to do things differently, you need to anticipate their apprehension.

By setting aside resources to train your employees in the knowledge, skills, and abilities they’ll need to implement your plan, they’ll see that you’re serious about your changes and are willing to support them through the transition.

3. Compensation and incentives: Compensation is a massive and complex topic in business — one that can’t be underestimated. As a professional services firm, the lion’s share of my company’s budget goes into compensation. Our team members are expected to dedicate a lot of time and energy to the success of our clients, and they’re paid as well as possible because we value and trust in their abilities.

People’s total compensation (not just their base salary) will drive all sorts of behaviors, but your plan must be designed thoughtfully. If it’s not, you may find yourself in a no-win situation with employees behaving in ways that maximize their personal gain but don’t move your organization forward.

4. Rewards and recognition: Like compensation, rewards and recognition require resources, but they also send clear messages to your people about what behaviors are acceptable and encouraged and which are not.

Finding creative ways to recognize people who are creating value in your business is worth its weight in gold. Rewards and recognition aren’t one-size-fits-all strategies, though. Different people value different things, so you must take the time to get to know your team members and develop an understanding of what incentives will be the most appreciated.

5. The physical environment: The space in which people work can promote desired behaviors, but it can also be used to reinforce what’s most important to you in less direct ways. Put careful thought into the design of your office space. If your strategy dictates significant changes in how people do their jobs, you may need to make extra room in the budget to align their workspaces with your expectations.

6. Tools and equipment: When you’re budgeting to drive your strategy, a final key consideration is whether your people have the proper tools and equipment to fulfill your expectations. Outfitting your team with the wrong equipment will lead to disaster. You can’t ask your team to get to the moon with a roll of duct tape and a spatula; it will only hold your team back from accomplishing your overarching goals.

If you fail to think more holistically about the “what” and the “how,” your perfect business strategy will be left on the launch pad, unable to take off. Don’t let all that planning go to waste by ignoring the needs of the people who make your strategy effective. Investing in ways that communicate how much you value team members will drive the behaviors you need to reach your goals this year.

Millitary hospitals looking to Just Culture for the answer?


Mass. hospitals show how to fix military medical care




Courtesy Boston Globe / Associated press
Army Surgeon General Lieutenant General Patricia Horoho speaks about military health care at the Pentagon in October.

Military hospitals charged with one of the country’s most important missions — serving active duty personnel — are roiled by dysfunction. As reported by The New York Times over the last several months, military hospitals suffer from chronic lapses in patient care and safety. Outgoing Secretary of Defense Chuck Hagel addressed the problem in October, when he ordered the military health system to reassess and revamp its procedures. But it might take nothing less than an act of Congress to change practices and procedures that are ingrained in military culture.

The command and control system that works well on the battlefield puts the military health care system out of touch with most modern medical institutions, where questioning of the system is a crucial component of everyday practice. The latest Times report described a system in which physicians and nurses who point out lapses in care are transferred or passed over for promotion, compromising patient safety and quality of care.

The Times report found that two areas of treatment in the military health system were particularly vulnerable — maternity care and surgery. A Pentagon review of the military’s hospitals found a systemwide problem: a reluctance by medical workers to identify problems, for fear of reprisal.

The reluctance to report errors is understandable. But in a medical setting, decision-making can literally be a matter of life or death — which is why civilian hospitals and medical centers have been working hard over the past 20 years to encourage “blame-free” reporting.

At three of Boston’s biggest hospitals, various high-tech systems for reporting errors are in place. Such a system is sometimes called a culture of safety or, after one model that was developed in the late 1990s, “just culture.” Massachusetts General Hospital, Brigham & Women’s, and Beth Israel Deaconess Medical Center all follow some version of the “just culture” model for reporting errors. Anyone from a janitor to a nurse to a surgeon is encouraged to report errors in a non-punitive environment, and there are active campaigns to encourage reporting. The principals of “just culture” defer blame from an individual to the system as a whole.

To gather these reports, hospitals establish websites available to all employees. The reports are vetted and analyzed, with protocols for followup. In some cases, individuals are held accountable for a decision that’s seen as reckless. But for the most part, “just culture,” says Karen Fiumara, director of patient safety at Brigham & Women’s, describes “a culture of trust and shared accountability.”

Such a reporting system sounds like common sense. But “just culture” is antithetical to the military hospital system for a very basic reason: chain of command. As hospital administrators point out, the “just culture model” won’t work unless leadership insists on it. The assistant secretary of defense for health affairs, Dr. John Woodson, an Obama appointee, has made strong statements about reforming the system, but his power is restricted to making policy recommendations. He cannot give orders to military commanders, and they’re the ones charged with running military hospitals.

One person who does have responsibility for change is the Army Surgeon General, Lieutenant General Patricia Horoho. Horoho has issued a statement demanding transparency regarding patient safety, and she has won praise from at least one member of a civilian agency in charge of inspecting and accrediting hospitals. “I applaud the way she’s handled the situation,” Dr. Ronald M. Wyatt said in an interview, adding that hers are the kind of actions “that resonate throughout the system.”

But the system, as it’s structured now, is working against Horoho, a decorated Army nurse. For one, commanders rotate out of assignments approximately every three years. And there’s no guarantee that Horoho herself, who has been Army surgeon general since 2011, will remain in her job much longer. “Imagine if the CEO at a civilian hospital changed every three or four years,” said Wyatt.

The problems in leadership stability are also compounded by the fact that the military hospital system is divided into three units for each branch of the armed services. What’s more, the system — whose primary mission is to train medical personnel for combat— is under strain after 12 years of war.

Clearly a system overhaul is required, one that at the very least involves the implementation of a stable leadership program in which just culture protocols are implemented. At best, the system would be streamlined, unifying all the branches of the military into one hospital system. Military service men and women put their lives at risk regularly overseas. They and their families shouldn’t be put in harm’s way when they seek medical help at home.

Healthcare Associations Can Offer Deep Discounts To It’s Members – Here’s How

Leaders around the world are supporting Just Culture initiatives

By being a Just Culture Connector, you can support your members in their initiatives and lead them in their journey by any of these three options:

  • Host a course for your hospitals and get 5 free seats
  • Promote a course with an exclusive member discount code for registrants
  • Support an OE Just Culture statewide initiative and offer discount Enterprise Licensing for all of your hospitals

Download “Whack-a-Mole” Digital Copy

David Marx says, "Give it away...". Whack-a-Mole: The Price We Pay For Expecting Perfection, by David Marx is now offered in a digital copy.



Whack-a-Mole: The Price We Pay For Expecting Perfection explores the role of human error in society, from aviation and healthcare, to driving and parenting—and where accountability rests for those errors, especially when they take the life of another. David Marx argues that regulatory and human resource prohibitions, along with the criminal prosecution of human error, have been counter-productive to helping society deal with the risks and consequences of human fallibility. Marx advocates a different approach to addressing our shared fallibility.

Scroll down to get your copy (digital download) of Whack-a-Mole: The Price We Pay For Expecting Perfection. by David Marx, JD, CEO of Outcome Engenuity and father of Just Culture and engineer of the The Just Culture Algorithm™ 

-Learn More About Just Culture-  -Just Culture Training Events-  -Event Investigation/Root Cause Analysis-

Safe Choices Training For Staff Online


Once your entire managerial team is proficient on Just Culture principles and the use of the Algorithm™, it’s time to get your front line employees on board. We recommend that you educate all front-line employees on their role in the organization’s learning culture, their ability to impact system design, and their ability to influence outcomes and organizational success through safe behavioral choices.

To better assist you, the one-hour online Safe Choices™ Training for staff is designed to provide your employees with a high level overview of the Just Culture concepts. The purpose of this course is to highlight the impact of an employee’s role in the Just Culture at your organization. Not only is this training about making choices that impact safety, but it is also about aligning values, designing better systems, and about how we communicate with each other.

The online training consists of:

  • Five minute introduction video that outlines some Just Culture basics
  • 23 minute movie that shows some everyday scenarios where staff can observe and apply Just Culture principles
  • Six modules that reference back to the movie, ending with a question or two that checks the employee’s learning progress
  • Upon completing the Safe Choices™ Training for staff, each employee will be on their way to making safer choices and having impact in the Just Culture of your organization.

The price of $29.00 is per online user. If you are interested in bulk "Enterprise Licensing" please feel free to contact our friendly Client Relations Team.

Provided below are a few screenshots of the basics of the online training materials. Click on the image for the full size view.