Medical University of South Carolina Grads Certified in Just Culture

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Some CHP grads go through pilot workforce accountability program

By: Heather Woolwine
May 24, 2017

CHARLESTON, SC – Health care administration professionals, who must carefully consider how they evaluate human errors and at-risk behaviors in health care practice by those they manage, often struggle with knowing the best way to encourage transparency and accountability for those errors. To address this knowledge gap in training for health administrators about to hit the workforce, the MUSC College of Health Professions (CHP) piloted a new curriculum approach for this year’s Master in Health Administration (MHA) graduating class that incorporated the Just Culture system of workplace accountability for high-consequence industries. It is the only program in the country to date to offer this additional training and research opportunity to its MHA students.

“Over the years, I have asked former graduate students what they felt unprepared for when they got into the real world of leading individuals within a health care entity,” said Tom Crawford, Ph.D., MHA program assistant professor.  “The answer was the delicate interaction with their employees when things did not go as planned.” To that end, Crawford and his colleagues constructed a curriculum using “Dave’s Subs: A Novel Story About Workplace Accountability” and partnered with the book’s author and Outcome Engenuity principal, David Marx, for a research and education project to develop and refine academic materials and testing related to Just Culture.

Recognized by industry leaders as the “father of the Just Culture movement,” Marx said that Just Culture is about differentiating human errors and at-risk behaviors from more culpable and reckless choices that providers may make in the course of caring for patients. “It works to move away from judging employees based upon an unfortunate outcome, putting more emphasis on the quality of their choices.  In doing this, we create a more accountable, open, learning culture within an organization – which in turn leads to better outcomes,” he said.

MHA students were provided an opportunity to take the Just Culture Certification exam, and provided feedback on the exam and curriculum throughout the educational partnership. Student Parker Rhoden, who recently passed the exam, said, “The Just Culture certification provided me with a framework to effectively handle difficult human resources decisions, and will be extremely valuable to my career in health administration. This really is an immediate benefit for those of us entering the workplace.”

Jami DelliFraine, Ph.D., CHP Department of Healthcare Leadership and Management chairwoman, echoed Rhoden’s comments. “We see this as an opportunity to bring the incredibly important message of Just Culture to tomorrow’s health care leaders, and through our continuing education program to leaders within the broader community,” she said.

A Call to Action for Every Healthcare Leader in America

Joint Commission Sentinel Event 57By Stephen G. Jones, MD

Strange. Our healthcare profession has among its ranks some of the brightest, most talented, highly-trained individuals to be found. We work in an environment utilizing cutting-edge science and technologies. Yet, we continue to fail at an alarming level in our pledged sacred mission to do no harm. Why?

As a profession, healthcare is often compared to the so-called high-reliability professions of aviation and nuclear power; then the question posed is, why we in the healthcare profession aren’t as good? Could it be that those industries were lucky enough to recruit all the exceptionally talented and gifted people, leaving healthcare with the B-list professionals? Of course not. Perhaps the individuals that work in aviation and nuclear power just care more about their work? Not a chance.

So why, 18 years after the release of the Institute for Medicine’s report To Err is Human, do we find ourselves as healthcare leaders asking the same questions?

Part of the answer may lie in the Joint Commission’s most recent Sentinel Event Alert, “The Essential Role of Leadership in Developing a Safety Culture” (Issue 57, March 1, 2017).

As a practicing physician with more years of experience than I care to admit, I have been witness to some remarkable changes in our field – many good, some not so good. The Joint Commission most certainly falls into the good category. Over the years, the Joint Commission has continued to evolve as an organization and build on its mission.

The Joint Commission has endeavored to work as more of a supportive partner to hospitals as opposed to regulatory policemen. More than ever, they seek best practices over citations, learning over blame, transparency over hiding. It can be argued that the Joint Commission now holds healthcare organizations to an even higher standard than it did in the past. The goal did not change, the approach did. Is there a lesson here for us?

The Joint Commission chose to build on their own success. In other words, the leadership of the Joint Commission did exactly what they are now fervently pleading with our own healthcare leadership to do:

• Develop and embed a culture of openness that is accountable and just

• Stop punishing well-intentioned employees who make an error. Instead, supporting them, and seeing the error not as an opportunity to blame, but rather to learn (partner vs. police)

• Foster an open and safe reporting system where everyone is encouraged to speak up without fear of reprisal

• Create an environment of shared learning that focuses on good system design and helping employees make better behavioral choices in a challenging environment

To be sure, the vast majority of very capable and gifted hospital leaders in our country don’t need a lesson from anyone, and certainly not me, on what’s important when it comes to patient care. And to be fair, hospital leaders today, unlike any time in the past, are faced with seemingly insurmountable and never-ending challenges. They operate in a volatile, uncertain, litigious environment often driven by external forces outside their control: hospital boards that expect (among other things) a beautiful environment, near perfect outcomes, a positive operating margin, and wonderful patient and employee satisfaction scores.

Nevertheless, this pivotal release by the Joint Commission is calling upon every healthcare leader to prioritize their efforts on developing a culture of safety, and utilize resources that drive, support, and maintain such a culture.

Building a true culture of safety, a Just Culture, is not easy. In fact it’s downright hard. It doesn’t happen overnight and doesn’t happen without passion and commitment from the very top leadership of any organization. And it certainly doesn’t happen by simply declaring you have a Just Culture and writing a policy around it. A Just Culture needs to be built from the ground up, with a model of systematic learning, and in an environment that wraps itself in the right system of justice.

I urge every hospital leader in America to read, share, and discuss this important Sentinel Event Alert with their extended leadership and embrace its recommendations. I encourage you to reach out to the many resources available to help you on this important journey.

The Joint Commission has provided a clear direction, but more importantly, a compelling challenge for establishing a culture of safety. More than ever, our patients, their families, our staff, all of us, need our top healthcare leaders to embrace this challenge. This country needs our healthcare leaders to lead.

Stephen G. Jones, MD

Medical Director of Safety

Yale New Haven Health System

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.

Federal safety board foresees new role in era of driverless cars

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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.


Just culture can improve safety

Analysis published by International Air Transport Association (IATA) - Airlines International.

February 3 2016

"It is only natural that people and organizations would be less willing to report their errors and other safety issues if they are afraid of punishment or even prosecution"

Just Culture achieved prominent recognition in the European Union (EU) last month, and there are new provisions calling for the protection of safety-related information anticipated to be adopted by the ICAO Council very soon. But, it is what you do with the tremendous amount of data that a just culture enables to be captured, through various mandatory and voluntary reporting systems, that magnifies its positive effect.

“The new EU regulation is about encouraging aviation personnel to tell their employer when things aren’t working well. It isn’t always that someone has made a mistake, it’s that something hasn’t worked out as expected on this occasion. They need to feel that they are being supported by their employer and that this information is useful and will be used to improve things,” said U.K. Civil Aviation Authority’s Performance Based Regulation Safety Data Lead, Sean Parker.

Beyond Europe, global standards beckon for Just Culture [See box Explaining Just Culture]. In October, ICAO member states filed their responses to proposals that include the addition of Safety Culture to Annex 19 of the Chicago Convention. Safety Culture is a broader concept, in which Just Culture is part. Just Culture enables a Safety Culture to exist. Following the anticipated final approval in March 2016, ICAO member states could be required to adopt Safety Culture through the amended Annex in November. Experts foresee a 2018-2020 timeframe for Safety Culture’s incorporation into the domestic regulation of the 190 ICAO member states.

Safety Culture and the need to protect safety data and safety information, collected for the purpose of maintaining or improving safety, was a notable theme at the second ICAO High Level Safety Conference, held earlier in 2015 in Montréal. It was agreed that quick progress in this regard is critical for the improvement of aviation safety.

“It is only natural that people and organizations would be less willing to report their errors and other safety issues if they are afraid of punishment or even prosecution,” noted Gilberto Lopez Meyer, IATA Senior Vice President, Safety and Flight Operations. “These protections are essential for the ongoing availability of safety data and safety information, and forms the basis of a Just Culture.”

The adoption of Just Culture will not only widen the array of data sources that can feed into a company or industry-wide predictive tool, but also increase the quality of the data provided. It is the predictive data analysis that can deliver more than simply local improvement at an airport or maintenance hangar, which a conventional mandatory reporting system for the immediate line managers may do.

Such predictive analysis can also be useful for accident prevention and investigation. A diversity of data to analyse is good because accidents are, “always a confluence of a variety of different factors, which nobody would ever have guessed would have come together at the same time,” IATA General Counsel Jeffrey Shane said.

The quantity of data produced from mandatory and voluntary reporting systems cannot be understated. Legal firm Pillsbury Winthrop Shaw Pittman Partner and Head of its aviation practice, Kenneth Quinn said: “You’re getting 10,000 bits of data from the widest possible variety of sources from airlines, as well as voluntary occurrence reports, [and] your getting it from repair stations.” And all of that can go into powerful computers.

“A big benefit is you can benchmark against other people,” Quinn said. “If you have five engine shutdowns over the course of a year and airline B has none then you have a higher than normal average of in-flight shutdowns, how are you monitoring things?”

Quinn points to the work the United States’ Federal Aviation Administration has done. All of that occurrence data, Quinn said, “goes into very powerful computers…and you take that and implement mitigation strategies to correct that, its having demonstrable safety benefits.” Because of the FAA’s work, Quinn explained that other authorities are examining the potential for such mass data reporting based predictive technology.

At the European Commission’s Aerodays 2015 conference in London in October, the European Aviation Safety Agency talked about its big data safety project that will spend about 31 million euros from 2015 to 2017. The project will seek to demonstrate an ability to predict an unsafe situation.

The adoption of Safety Culture, and by default Just Culture, by ICAO, will, however, present a challenge to some member states and access to all the diverse data that could make a difference could be hindered.  “We recognize there are sovereign legal systems that regard an accident as, in the first instance, something that is a potential criminal act,” said Australia’s Civil Aviation Safety Authority’s Associate Director of Aviation Safety, Jonathan Aleck.

Australia is not a country that begins with a criminal investigation, Aleck highlighted. Its airlines have adopted Just Cultures and in its latest annual review for 2015, Qantas said: “We are proud of our strong, ‘just culture’ of reporting and our dedication to learning from our experiences. And we strive to maintain an environment that encourages trust and confidence in our people to report hazards and incidents and suggest safety improvements.”

Nations whose airlines do face a criminal investigation team, whether they have Just Cultures or not, according to Aleck. He said: “In some jurisdictions there is a strict program [of aviation regulation]. The idea of just culture doesn’t fit well with those kinds of regimes, where the first people on the scene are often criminal investigators.”

Before the likely cause of the 31 October crash of Metrojet flight 9268 had been identified as a bomb, the Russian authorities initial announcement regarding its investigation was the start of a criminal one. The concern is that people who know what led to an accident will say nothing for fear of prosecution, when their information could help stop potentially fatal incidents from occurring again.

Shane is positive about changes to national legislation where Just Culture is not already codified following the expected ICAO March decision. He said: “The benefits can be demonstrated so powerfully that I expect [legislatures to adopt it in the next few years].”

The expansion of Just Culture has grown momentum. For those that have or are employing it, they find that it delivers new insights into how things go wrong. But, questions remain as to how far nations, whose instinct is to investigate possible criminal action first, can succeed in gaining all the possible benefits from the additional information that becomes available.

IATA Member & External Relations, ICAO, Director, Michael Comber sums it up simply. “It’s a tremendous advantage to have people come forward and speak because it’s the best way to prevent as well as figure out how [accidents] happened.” And that points us in the direction of improving safety.

Explaining Just Culture
The definition of Just Culture is an open way of working in which employees are not punished for decisions taken in good faith and commensurate with their experience and training. The employees can report mistakes, by them or others, and know that that information will feed into the safety management system.

However, gross negligence, willful violations and destructive acts are not tolerated.

Just Culture has been required within the EU since November under its regulation 376/2014 that also renews earlier mandatory reporting law. For Just Culture, the EU is requiring that organizations have protection for the reporting staff member, and for persons mentioned in the report, rules for confidentiality, and protection from an employer.

Prior to the European law coming into effect, a European declaration in favor of Just Culture was published in October. The declaration is supported by the Airports Council International, European regions airline association, European Cockpit Association, Aircraft Engineers International, IATA, and other aviation organizations.

As well as European efforts to implement Just Culture, this non-punitive reporting system was included in the Australian Civil Aviation Safety Authority’s new regulatory philosophy published in 2015. Prior to Australia’s CASA action, the United States, New Zealand and the UK had their own rules in place.


UPenn Law’s Quattrone Center receives $350,000 for deep just culture reviews

The Quattrone Center for the Fair Administration of Justice at the University of Pennsylvania Law School was recently awarded $350,000 in funding from the National Institute of Justice to conduct extensive reviews of error in Philadelphia’s criminal system using a just culture approach, according to a recent article from the University of Pennsylvania Law School. The funding will go toward the Philadelphia Event Review Team (PERT), which will be launched early 2016. PERT will assemble major criminal justice agencies to deeply analyze cases with unintended outcomes in Philadelphia’s criminal justice system in order to identify, prioritize and implement reforms across the various criminal justice agencies. Read the entire Penn Law article below:

Watch John Hollway discuss the Philadelphia Event Review Team below. See Full Article Here.

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Bringing Just Culture to the Streets


Making judgments without an understanding of the root cause(s) of the situation quenches both growth and learning culture. It is absolutely necessary for us to remain impartial in our judgments until we can adequately discern the root cause(s) of the event.

Recently, a pastor who played a major role in the Boston Miracle, Jeffrey Brown, presented a Ted talk testifying to the power of this.

In the late 1980s, violence on the streets of Boston was increasing at alarming rates, and by 1990 Boston’s homicide rate reached a peak of 152. But by 1999, that number dropped down to 31 thanks to the key leaders within the Boston community. The Boston Miracle, simply stated, was this unprecedented 79 percent drop in the city’s homicides over the span of 10 years from 1990–1999.

In his Ted Talk, Brown shared that after a multitude of tragic events, he realized that it was not enough for him to build programs for the at-risk youth. He began to search for the youth actively involved in violence. He soon found himself walking the streets of Boston during the hours of the night, and by 1992 he and other area pastors had formed the Ten Point Coalition to combat youth violence in the streets of Boston.

Over time, these pastors began developing relationships on the streets of Boston during the night hours. They discovered that the individuals, who many dismissed as cold and heartless, were the exact opposite of their labels, and were simply trying to “make it on the streets.”  By not rushing to judgment, the pastors were able to engage with the youth and partnered with them to change the culture on the streets.

But this journey took time. It was only when these youths viewed the Ten Point Coalition and the law-enforcement as legitimate, fair and just that the culture on the streets began to change. This meant the Ten Point Coalition and law enforcement had to consistently take the time to discern what justice meant for each person involved, determining who needed to be helped, who needed to be coached and who needed to be punished. In turn, the Boston area pastors were able to help the Boston police focus on the truly reckless and intentionally harmful behaviors.

This began the transformation of the street culture, and cultivated a cultural atmosphere ripe for justice. With cooperation at all levels, the Boston Miracle occurred, becoming a powerful testimony to the fruit of not rushing into judgment over a situation. Even now, others are inspired by the result of Boston’s street transformation in the 1990’s. In fact, a group of Baltimore pastors have decided to devote the summer of 2015 to walking the streets of Baltimore at night in hopes of the cultural transformation of the streets of Baltimore.

Monica Lewinsky addresses the culture of shame

Culture is shaped by our behaviors, and both repetitive human errors and at-risk behaviors can be detrimental to the direction of an organization. For leaders, this is critical to note.

Why? It is simple. Leaders have the authority to shape the system and culture, ultimately determining the direction of an organization. What is allowed and voiced within the workplace either gives room for learning and growth, or squashes learning and growth.

In March 2015, Monica Lewinsky presented the Ted Talk message “The Price of Shame,” which focused on the effects of cyber bullying. Out of respect for Lewinsky, it was Ted’s aim to provide a safe place for her because it was among her first public appearances in 10 years. However, comments derailing Lewinsky began almost immediately upon the posting of the message (before the public would have time to watch the full 20 minute Ted Talk).

The very thing that Lewinsky was speaking up about was happening.

With that, three Ted employees immediately took control of the situation through aggressively monitoring the comments being made: they would purge the negative comments and reply to the positive comments, bringing the good to the top of the feed. After much deliberate work, the Ted employees saw a shift within the public forum—the voices that uplifted, empowered and encouraged Lewinsky were prevailing, changing the forum content and culture altogether.

The public began to see what was clearly accepted and what was not acceptable for the forum.

During Lewinsky’s message, she encouraged the listeners to become “upstanders,” defending those who are victims in the world’s steep culture of shame. Interestingly, the very call-to-action given by Lewinsky during her message was manifesting within the forum—people were becoming “upstanders” for Lewinsky in the midst of a culture of shame.

One commenter wrote: “I am so inspired by her wisdom and courage. I cannot imagine the depths of despair she went through and wow look at the incredible message she is bringing to us now because she survived and is now thriving.”

Clearly, through this case, we see the way that the Ted employees shaped—and ultimately shifted—the culture of the forum, helping to redefine the norm within the forum. The Ted employees victoriously encouraged the voices that silenced the shame and silenced the voices that encouraged shame.

For leaders within the workplace, it is important to understand that through empowering individuals who are giving voice to desired outcomes within the workplace, we shape the culture of the workplace in a positive manner, creating an open atmosphere encouraging the desired outcome, and thus, discouraging the undesired outcome.

It is evident through the Lewinsky case, the power of unity to shift a culture--and within the workplace voices that uplift, encourage, and empower each other to learn and grow--can eventually impact the culture of the organization as a whole.

Australian aviation agency implements Just Culture

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It’s simple: mistakes occur—and our response (or lack of response) to mistakes can either propel an organization forward or fully divert its direction. If a mistake remains neglected, that mistake could develop into at-risk—and even reckless—behavior. Yet again, if a mistake is brought forth and is properly investigated, there remains an opportunity for learning and growth.

In an effort to develop a culture where mistakes are genuinely recognized as opportunities to learn and improve from, Australia’s Civil Aviation Safety Authority (CASA) recently announced its decision to implement a “just culture” approach to aviation regulation.

"The advantage of a Just Culture approach is that it encourages people to be open and accountable about their mistakes, so there is a better reporting of errors and the ability to learn from them is enhanced,” CASA Director of Aviation Safety, Mark Skidmore, said in an interview with Australian Flying.

Skidmore stated that through this initiative, CASA’s desire is for individuals and organizations to understand the root cause of mistakes and how to reduce the likelihood of the same mistake from occurring in the future. Even more, through the implementation of Just Culture, CASA’s hope is to better improve aviation systems altogether through commitment to accountability and transparency.

He further emphasized in a later article from Australian Flying the need for cooperation and accountability throughout the aviation community. Without it, the implementation of Just Culture will not impact Australian aviation.

In the latter article, Skidmore also emphasized the need for a structured system such as Just Culture. He explained that such structure creates an atmosphere for open reporting, helping to establish a culture of accountability and workplace transparency.

CASA’s decision to encourage and implement Just Culture throughout Australian aviation reveals the need for industry and organizational cooperation for effective implementation of Just Culture. Even more, through this, it is clear how important it is for organizational leaders to take action through committing to understand how to properly manage and investigate the root of events, in order to establish a culture of accountability and workplace transparency.

Learn how to implement Just Culture in your organization by visiting our Live Just Culture Course training page for upcoming Just Culture Certification Course dates and information, or search our Online training page for more resources.

Hospital duties hindered by lack of nursing staff safety

All too often nurses and other hospital staff are harmed at work while diligently performing their duty of providing care for patients. Last week, NPR News released the first of a series of four investigative pieces addressing this failure to protect employee safety within hospitals.

Every day, nurses are repeatedly faced with circumstances that hinder their ability to adequately meet the need of their patients without harming themselves—specifically when it comes to their everyday duty of moving and lifting patients.

According to the NPR article, it is clear that the extent to which hospitals are emphasizing a “culture of safety” for nurses is incomparable to the way it is emphasized for patients—and understandably so being that the patient is the one who is ill or injured.

However, with nurses put in such fragile situations daily, the risks are high. In fact, the Bureau of Labor Statistics (BLS) reported more than 35,000 back and other injuries among nursing employees.  In 2013 the BLS reported that orderlies and nursing assistants experience nearly triple the amount of musculoskeletal injuries causing them to miss work as police officers, correctional officers and construction laborers.

The article also notes that there is little to no aggressive action being taken by hospitals to address this and to protect their staff from lifting injuries—potentially leading to employees missing work or attempt to work through the pain, hindering patient care quality. According to American Nurses Association (ANA), 10 states within the country “require a comprehensive program in health care facilities” promoting nursing staff safety.

It seems there is a correlation between the lack of protection of nursing staff safety and the duty nursing staff have to produce an outcome--is the fix to the problem Just Culture?

For more information on establishing Just Culture, see our Live Training Courses page or our Online Course Training page.

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.

Risk Analysis – Blast Door Incident

AP Photo/Eric Draper

AP Photo/Eric DraperYahoo News reported recently that Air Force officers have been caught disregarding certain safety protocols in active nuclear missile facilities. Here’s a link to the article.

The rule is that the blast door must be closed while one of the officers is napping; two officers operate on a 24-hour shift on this duty. On multiple occasions the blast door has been left open during these naps. This is clearly a violation of the rules laid out for this job function. In Just Culture terms, this falls under the banner of at-risk behavior; safety rules have been violated here because the officers are beginning to fail to see the risk, or are seeing it differently than it has been explained to them.

Perhaps the long work shift is affecting their perception of the job; in combination with the inherent stress of the job and the confined space in which it is performed, a good officer’s perception could become skewed.

Or perhaps the fact that there are always two officers on duty, a built-in redundancy for safety purposes, is affecting their sense of safety. In addition, there are several other safety checks required to get into the missile control area. A false sense of security could easily emerge, causing the officers to see the risks differently.

Or perhaps the lack of a consistent threat to their safety has skewed their view of the risk. The procedures used today are the ones designed during the Cold War, when there was a constant threat of a nuclear attack (or at least the belief of said threat). The threat was consistent and obvious, but now the primary threat is terrorist activity, which is much less consistent and less predictable. This can make it easier to let one’s guard down, to engage in risky choices.

It’s easy to fall into the mindset that military personnel are somehow more apt to follow procedure than civilians, but people are people, really, and all people are subject to human fallibility. They are certainly trained specifically in regard to discipline, but even the most disciplined person can feel secure behind half a dozen redundant security systems.

According to the article, punishments for this violation range from docked pay to potential discharge from the service. In Just Culture terms, the message that this sends is that violating this rule will be considered reckless behavior, which is a more drastic offense than an at-risk behavior. We should believe that there is no possible justification for violating this rule, which makes sense in terms of the potential for catastrophic outcome. But the perception of the risk is a much more slippery slope; even with training and discipline, people’s perception of risk can drift, especially if it’s been a long time since there was a perceived threat.


How does your organization handle major threats? Do you have security issues? What kind of training do you provide your people to handle them? There are no clear cut answers here, so please continue the discussion in the comments below. We would enjoy talking further with you about this.