When Good Employees Go Bad

Peter I. Dworsky Outcome Solutions

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Financial: None Opinions: Strictly those of the presenter (although based on research) and not of any single agency I have worked for or hope to work for someday.

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“People make errors, which lead to accidents.

Accidents lead to deaths. The standard solution is to blame the people involved. If we find out who made the errors and punish them, we solve the problem, right?

Wrong.

The problem is seldom the fault of an individual; it is the fault of the system.

Change the people without changing the system and the problems will continue.�

Don Norman Author, the Design of Everyday Things

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Hard worker Go-to person Doesn’t complain On time Professional look ? ? ?

One consistently fails to achieve the standard of performance or behavior as defined by management * ď ˝

What else?

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assumes a workplace where good management is in charge

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Human error – inadvertent action; inadvertently doing other than what should have been done; slip, lapse, mistake.

At-risk behavior – behavior 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.

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Unsafe acts Drug diversion Seat belt Hazing Pt abuse Theft Policy violation

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Cutting corners to save time Perception that rules are too restrictive Belief that rules no longer apply Lack of rule enforcement New workers see “routine violations”

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Think this is the “norm” Insufficient Staff to perform tasks Right equipment is not available Extreme conditions Perception that practice is safe

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Work load fluctuations Interruptions Multi-tasking Fatigue Poor hand off Ineffective communications Educational deficits Policy conflicts

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Bad Managers ◦ The rules don’t apply to me ◦ Unfair labor practice ◦ Deviance

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Bad work conditions ◦ Dented bumper theory

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Failure to check truck Uniform issues Blood borne pathogens PPE Extrication PPE … … …

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To err is human To drift is human Deviance is everywhere We are all accountable

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Observe actual process Draw steps as it actually happens Define steps and time stamps Review with staff Note gaps Develop plans to address gaps

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Before assigning tasks: ◦ Know the limits, strengths, and weaknesses of team members ◦ Capitalize on team members’ strengths

Courtesy of Sunstar Paramedics.

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Reportable Drug abuse Theft “Forced” resignation Discipline

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OT til replaced Interview time Pre-employment physical Orientation Uniforms Learning curve

Examines the fallibility of the system as well as inevitable human error and flawed behavioral choices   

System Human Error Flawed decisions

The Just Culture Model Human Error

At-Risk Behavior

Product of Our Current System Design and Behavioral Choices

A Choice: Risk Believed Insignificant or Justified

Manage through changes in:

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Choices Processes Procedures Training Design Environment

Console

Manage through:

• Removing incentives • •

for at-risk behaviors Creating incentives for healthy behaviors Increasing situational awareness

Coach

Reckless Behavior Conscious Disregard of Substantial and Unjustifiable Risk Manage through:

• Remedial action • Punitive action

Punish

The medic goes in the med box to get the Demerol for her patient. She reaches in and grabs the vial in the bottom right corner of the drawer.

She draws up the medication and administers it to the patient.

The Clinical Dept had made a change and placed Morphine in the slot where the Demerol used to be kept.

The Medic actually gave the patient Morphone and the patient had an allergic reaction and coded.

The Just Culture Model Human Error

At-Risk Behavior

Product of Our Current System Design and Behavioral Choices

A Choice: Risk Believed Insignificant or Justified

Manage through changes in:

• • • • • •

Choices Processes Procedures Training Design Environment

Console

Manage through:

• Removing incentives • •

for at-risk behaviors Creating incentives for healthy behaviors Increasing situational awareness

Coach

Reckless Behavior Conscious Disregard of Substantial and Unjustifiable Risk Manage through:

• Remedial action • Punitive action

Punish

The Just Culture Model Human Error

At-Risk Behavior

Product of Our Current System Design and Behavioral Choices

A Choice: Risk Believed Insignificant or Justified

Manage through changes in:

• • • • • •

Choices Processes Procedures Training Design Environment

Console

Manage through:

• Removing incentives • •

for at-risk behaviors Creating incentives for healthy behaviors Increasing situational awareness

Coach

Reckless Behavior Conscious Disregard of Substantial and Unjustifiable Risk Manage through:

• Remedial action • Punitive action

Punish

The Just Culture Model Human Error

At-Risk Behavior

Product of Our Current System Design and Behavioral Choices

A Choice: Risk Believed Insignificant or Justified

Manage through changes in:

• • • • • •

Choices Processes Procedures Training Design Environment

Console

Manage through:

• Removing incentives • •

for at-risk behaviors Creating incentives for healthy behaviors Increasing situational awareness

Coach

Reckless Behavior Conscious Disregard of Substantial and Unjustifiable Risk Manage through:

• Remedial action • Punitive action

Punish

The Just Culture Model Human Error

At-Risk Behavior

Product of Our Current System Design and Behavioral Choices

A Choice: Risk Believed Insignificant or Justified

Manage through changes in:

• • • • • •

Choices Processes Procedures Training Design Environment

Console

Manage through:

• Removing incentives • •

for at-risk behaviors Creating incentives for healthy behaviors Increasing situational awareness

Coach

Reckless Behavior Conscious Disregard of Substantial and Unjustifiable Risk Manage through:

• Remedial action • Punitive action

Punish

The Just Culture Model Human Error

At-Risk Behavior

Product of Our Current System Design and Behavioral Choices

A Choice: Risk Believed Insignificant or Justified

Manage through changes in:

• • • • • •

Choices Processes Procedures Training Design Environment

Console

Manage through:

• Removing incentives • •

for at-risk behaviors Creating incentives for healthy behaviors Increasing situational awareness

Coach

Reckless Behavior Conscious Disregard of Substantial and Unjustifiable Risk Manage through:

• Remedial action • Punitive action

Punish

Training for everyone Buy-in at the highest level of the organization Embed teamwork behavior in daily work Ongoing & refresher education Review of best practices Interaction of leadership Measurement of safety and team skills against established metrics ◦ Coaching when necessary ◦ ◦ ◦ ◦ ◦ ◦ ◦

◦ EMPOWER STAFF

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Based on the acceptance of the entire agency Laying a solid foundation includes: 

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Training personnel in open communication techniques Identifying and tracking errors Training personnel in conflict management Fostering an open learning environment

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Every team member has an appreciation of: 

The nature of the problem

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Team members’ strengths and weaknesses

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What is likely to happen based on taking no action

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What is likely to happen if a specific action is chosen

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A shared knowledge of the desired outcome

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A shared strategy

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Respectful and open communication

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Put together a learning lab Top recommendations from learning lab Design FMEA at each design stage Standardize location of equipment, supplies, vehicle schematics and care processes Cross reference P&P Use checklist for high risk / low frequency procedures Reduce noise

Questions?

Peter I. Dworsky Peter.Dworsky@OutcomeSolutions.org