Outcome Engenuity to Exhibit at the AONE 2016 Annual Meeting

aone2016-logoAre you and your colleagues planning to join the thousands of nursing leaders at the American Organization of Nursing Executives (AONE) Annual Meeting 2016? We are. Outcome Engenuity (Oe) is set to be a part of the Exhibition at the AONE 2016 Annual Meeting. Visit our exhibition booth for more on David Marx's latest book, Dave's Subs: A Novel Story about Workplace Accountability. We will have copies on hand to give away. We will also be available for more information on Just Culture training and products.

The AONE 2016 Annual Meeting is scheduled to run March 30 - April 2, 2016, with the Exhibition being from March 31 - April 1. For more information, visit: http://www.aone.org/annual-meeting/.

We hope to see you there!

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. http://www.bostonglobe.com/opinion/editorials/2015/01/05/mass-hospitals-show-how-fix-military-medical-care/2IWh1zeNGC2goyYXho0KeP/story.html

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.

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-

Announcement: Just Culture for Critical Access Hospitals Program

Outcome Engenuity has created a program to help 1,331 Critical Access Hospitals across the country bring Just Culture to their organizations, which until now have been limited by resources and isolation. The program seeks to leverage a network of 1500 certified trainers and offer substantial discounts in order to broaden the reach of Just Culture to these rural facilities.

Plano, TX (PRWEB) February 25, 2013Doctor Comfort Holding Hand

Outcome Engenuity is pleased to announce the Just Culture Critical Access Hospital Program. This program will give smaller Critical Access Hospitals better and more ready access to Just Culture materials and training.

Critical Access Hospitals are a specific type of facility which have 25 or fewer beds and are generally located more than 35 miles away from another hospital. Their isolation and small size tend to limit their resources and access to Just Culture training and support. The Just Culture Critical Access Hospital Program will take an active role in helping to educate in these smaller markets by giving Just Culture Certified Champions the opportunity to serve as regional trainers. This allows Just Culture training to become available at a reduced cost to the facility; it will also give the facility more flexible options for scheduling the training.

As part of the program, Outcome Engenuity is offering an exclusive pricing package that will include the Just Culture training program for 17 managers and 10 physicians, a training license for the Safe Choices™ film 'No Small Consequence,' and 20 seats for an exclusive webinar. The cost for this package is discounted 45% off the regular price for these products. In addition, on-site training will be available through a network of certified Just Culture Champions. (Read the letter to Champions here)

“We have 1,500 Certified Champions throughout the country,” said David Marx, Outcome Engenuity CEO. “We seek their help in bringing these important patient safety tools to the doorstep of every critical access hospital."

For more information, visit JustCulture.org, email info(at)outcome-eng(dot)com or call 866-785-0204.

About Just Culture

“Just Culture” is a process to implement organizational improvement, presenting a set of design laws that influence the ability to create desired societal outcomes. The five-skill model is designed to help change an organization’s culture by placing less focus on events, errors and outcomes, and more focus on risk, system design and the management of behavioral choices. The model identifies three manageable behaviors—human error, at-risk behavior and reckless behavior—each of which has its own causes and appropriate managerial responses. Knowing how to manage each helps an organization to build a culture which encourages coaching and honesty at all levels. Just Culture has been implemented by various organizations in such high-risk industries as healthcare, aviation and nuclear power to name a few.

About Outcome Engenuity

For 50 collective years, Outcome Engenuity has been working to help high-consequence industries, including aviation, healthcare, space flight and nuclear power, to become safer. Outcome Engenuity integrates systems engineering, human factors science, and even the law into unique strategies that are among the best in the world. The company creates some of the most complex socio-technical risk models the world has ever seen, teaches industries how to investigate events, and pioneers modern notions of values-supportive justice and learning. For more information on Outcome Engenuity please visit outcome-eng.com or call 866-785-0204.

North and South Carolina Hospitals Announce Outcome Engenuity’s Just Culture as Statewide Standard

CEO David Marx, announces today that Outcome Engenuity's materials have been selected as the statewide standard for all Just Culture products, training, and resources across both North Carolina and South Carolina. As the curators of The Just Culture Community, Outcome Engenuity continues to bring culture change to the forefront of many risk management and patient safety initiatives.

Plano, Tx (PRWEB) November 02, 2012

How do we respond when a physician, nurse, or pharmacist makes a mistake that injures or kills a patient? How do we create an open learning culture that promotes the reporting and learning from errors that are the precursors to harm? A concept called “Just Culture” attempts to answer these questions – when to console a provider, when to coach a provider, and when to sanction a provider. Hospitals across the country are embracing Just Culture as a critical step in their patient safety efforts.

Today, both the North and South Carolina Hospital Associations announce that they have chosen Outcome Engenuity’s Just Culture model as their statewide standard. Both states have positioned certified trainers, from the associations and member hospitals, throughout the state to act as champions for this substantial culture change initiative. Both associations have also purchased statewide enterprise licenses for Outcome Engenuity’s training materials, at a fraction of the retail prices. “We partnered 5 years ago with Outcome Engenuity to build Just Culture competency within our state,” said Dr. Carol Koeble, Executive Director of the North Carolina Center for Hospital Quality and Patient Safety. “Having achieved success with four rounds of Just Culture collaboratives and gained experience as certified Just Culture trainers, we made Just Culture training for all member hospitals across our state part of our strategic plan. We are ensuring North Carolina hospitals have a solid infrastructure to proactively reduce harm to patients.” Lorri Gibbons, Vice President of Patient Safety at the South Carolina Hospital Association, said, “Outcome Engenuity’s Just Culture model is the industry standard – it is a foundation of our patient safety effort. Our funding through the Duke Endowment and the CMS Hospital Engagement Network has allowed us to take Just Culture to every hospital in our state. This is a great step forward in patient safety for South Carolina Hospitals.”

To learn more about Just Culture, please visit The Just Culture Community at https://store.justculture.org or contact Outcome Engenuity at 866-785-0204.

About Outcome Engenuity:

For 50 collective years, Outcome Engenuity has been working to help high consequence industries, including aviation, healthcare, space flight and nuclear power, to become safer and safer. Outcome Engenuity has integrated systems engineering, human factors science, and even the law into unique strategies that are truly world-class. The company created some of the most complex socio-technical risk models the world has ever seen, taught industries how to investigate events, and pioneered modern notions of values-supportive justice and learning. For more information on Outcome Engenuity please visit http://www.outcome-eng.com or call 866-785-0204.