Governor Kitzhaber to Sign SB483, the Early Discussion & Resolution Bill

This is moving in the right direction! But is going to create a "Just Culture" for physicians to practice in? Development of the Just Culture Concept In 1997, John Reason wrote that a Just Culture creates an atmosphere of trust, encouraging and rewarding people for providing essential safety-related information. A Just Culture is also explicit about what constitutes acceptable and unacceptable behavior. Therefore a Just Culture is the middle component between patient safety and a safety culture (Reason, 1997). Marx argues that discipline needs to be tied to the behavior of individuals and the potential risks their behavior presents more than the actual outcome of their actions (Marx, 2001). The Just Culture model addresses two questions: 1) What is the role of punitive sanction in the safety of our health care system and 2) Does the threat and/or application of punitive sanction as a remedy for human error help or hurt our system safety efforts? The model acknowledges that humans are destined to make mistakes and because of this no system can be designed to produce perfect results. Given that premise, human error and adverse events should be considered outcomes to be measured and monitored with the goal being error reduction (rather than error concealment) and improved system design (Marx, 2001). In addition, the model describes three classes of human behavior that create predictability in error occurrence. The first is simple human error - inadvertently doing other than what should have been done. The second, at-risk behavior occurs when a behavioral choice is made that increases risk where risk is not recognized or is mistakenly believed to be justified. Finally, reckless behavior is action taken with conscious disregard for a substantial and unjustifiable risk. (Marx 2001) Intimidation and disruptive behaviors can foster medical errors, contribute to poor patient satisfaction and to preventable adverse outcomes, increase the cost of care, and cause qualified clinicians, administrators and managers to seek new positions in more professional environments. Safety and quality of patient care is dependent on teamwork, communication and a collaborative work environment. To ensure quality and promote a culture of safety, healthcare organizations must address the problem of behaviors that threaten the performance of the health care team. (Joint Commission, 2008). Simply put, every one of the IOM’s estimated 98,000 deaths caused by healthcare provider error is an opportunity to learn how the system may be modified, and how at- risk behaviors can be managed to significantly reduce the rate of harm.18 Our system has been too focused on blaming the individual provider, with too little emphasis on how we could have learned from the errors of the past. There need be no loss of accountability because of disciplinary system changes. It is instead a different type of accountability – one that requires an employee raise her hand in the interests of safety. Not reporting your error, preventing the system and others from learning – this is the greatest evil of all. Yes, there are obstacles within the tort system, within the criminal system, and within the regulatory environment that make re-design of your disciplinary system a tough job. Those who step up to this challenge, however, will serve the future safety of the health care system. In the final analysis, we must all be held accountable for our efforts to make the system safer. (Marx 2001) In the past this Governor used his OBME to punish, ravish and destroy Physicians life's and practices for very marginal and questionable errors. His gustapo Kathleen Haley would gather her bully's and charge and condemn. Never ever getting to an intelligent root cause and creating a " Just Cultue" so the system breakdown that involved the error could be reviewed and become learning experience so all could learn and avoid the error in the future. Like the aviation industry does. No, it was blame some one and punish, condemn and destroy. Marx, David, JD, Patient Safety and the “Just Culture”: A Primer for Health Care Executives, Columbia University New York, 2001

This is moving in the right direction! But is he going to create a "Just Culture" for physicians to practice in? Development of the Just Culture Concept In 1997, John Reason wrote that a Just Culture creates an atmosphere of trust, encouraging and rewarding people for providing essential safety-related information. A Just Culture is also explicit about what constitutes acceptable and unacceptable behavior. Therefore a Just Culture is the middle component between patient safety and a safety culture (Reason, 1997). Marx argues that discipline needs to be tied to the behavior of individuals and the potential risks their behavior presents more than the actual outcome of their actions (Marx, 2001). The Just Culture model addresses two questions: 1) What is the role of punitive sanction in the safety of our health care system and 2) Does the threat and/or application of punitive sanction as a remedy for human error help or hurt our system safety efforts? The model acknowledges that humans are destined to make mistakes and because of this no system can be designed to produce perfect results. Given that premise, human error and adverse events should be considered outcomes to be measured and monitored with the goal being error reduction (rather than error concealment) and improved system design (Marx, 2001). In addition, the model describes three classes of human behavior that create predictability in error occurrence. The first is simple human error - inadvertently doing other than what should have been done. The second, at-risk behavior occurs when a behavioral choice is made that increases risk where risk is not recognized or is mistakenly believed to be justified. Finally, reckless behavior is action taken with conscious disregard for a substantial and unjustifiable risk. (Marx 2001) Intimidation and disruptive behaviors can foster medical errors, contribute to poor patient satisfaction and to preventable adverse outcomes, increase the cost of care, and cause qualified clinicians, administrators and managers to seek new positions in more professional environments. Safety and quality of patient care is dependent on teamwork, communication and a collaborative work environment. To ensure quality and promote a culture of safety, healthcare organizations must address the problem of behaviors that threaten the performance of the health care team. (Joint Commission, 2008). Simply put, every one of the IOM’s estimated 98,000 deaths caused by healthcare provider error is an opportunity to learn how the system may be modified, and how at- risk behaviors can be managed to significantly reduce the rate of harm. Our system has been too focused on blaming the individual provider, with too little emphasis on how we could have learned from the errors of the past. There need be no loss of accountability because of disciplinary system changes. It is instead a different type of accountability – one that requires an employee raise her hand in the interests of safety. Not reporting your error, preventing the system and others from learning – this is the greatest evil of all. Yes, there are obstacles within the tort system, within the criminal system, and within the regulatory environment that make re-design of your disciplinary system a tough job. Those who step up to this challenge, however, will serve the future safety of the health care system. In the final analysis, we must all be held accountable for our efforts to make the system safer. (Marx 2001) In the past this Governor used his OBME to punish, ravish and destroy Physicians life's and practices for very marginal and questionable errors. His gustapo Kathleen Haley would gather her bully's and charge and condemn. Never ever getting to an intelligent root cause and creating a " Just Cultue" so the system breakdown that involved the error could be reviewed and become learning experience so all could learn and avoid the error in the future. Like the aviation industry does. No, it was blame some one and punish, condemn and destroy. Marx, David, JD, Patient Safety and the “Just Culture”: A Primer for Health Care Executives, Columbia University New York, 2001