JUST CULTURE - SMALL GROUP DISCUSSION
Session Description: In testimony before congress, Lucian Leape, MD, member of the Quality of Health Care in America Committee at the Institute of Medicine and adjunct professor of the Harvard School of Public Health, noted that “Approaches that focus on punishing individuals instead of changing systems provide strong incentives for people to report only those errors they cannot hide. Thus, a punitive approach shuts off the information that is needed to identify faulty systems and create safer ones. In a punitive system, no one learns from their mistakes” (Leape, 2000). In this session, you will hear an alternative to a punitive system - the Just Culture model which seeks to create an environment that encourages individuals to report mistakes so that the precursors to errors can be better understood in order to fix the system issues.
Small Group Preceptors: Various. See Small Group Assignment Sheet
Location: Various. See Small Group Assignment Sheet
Learning Objectives: At the end of this session, the student learners will:
- Differentiate errors and outcomes from culture
- List elements of a safety culture
- Distinguish three types of behavior in Just Culture- human error, at risk behavior and reckless behavior
- Define system 1 (subconscious reasoning) from system 2 (conscious reasoning) thinking and how this relates to when humans fail
- Apply these to cases to determine who to coach, console or punish
Pre-Session Assignment: NONE