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