Another dissatisfied customer? Another safety event? That’s easy, let’s just write a new rule. Articulate the expectation. Our employees are good people, they’ll follow the rule.
Maybe.
It could be that there is no more troublesome safety rule than that of hand hygiene upon entering a patient’s room. We’re told that at any one time, 1.4 million of us have an infection we picked up in a hospital.1 And we’re told that basic hand hygiene, 15 seconds with alcohol rub, is the single most important thing healthcare providers can do. Yet, our worldwide rate within hospitals still hovers around 40%. Can any current workplace safety rule be more critical? Or more ignored?
Still, the World Health Organization, Centers for Disease Control, and individual hospital leaders continue to write rules and simply expect us humans to comply. This is not how we work. We are NOT inherently rule followers; we ARE hazard and threat avoiders. Therein lies the problem.
Humans are mission-focused creatures. You hop in your car to drive to the local mini-mart to buy a gallon of milk. At that moment, milk is the mission. Driving the speed limit, wearing a seat belt – those are just things we do to be safe along the way. Safety, like privacy, dignity, or punctuality, is simply a value to be respected. The mission, in contrast, is what we’re trying to accomplish.
For a nurse entering a patient’s room, the mission is to serve the patient in some way: to administer a medication, refresh a bandage, or perhaps only to answer a patient’s question. What is not part of that service is hand hygiene. After all, no one ever hears, “Bob, we need a hand hygiene in room 212.” Washing hands is what we do along the way in order to avoid harm. It is never itself the mission at hand.
We humans follow rules for three simplified reasons: 1) to avoid the harm prevented by compliance, 2) our shared values dictate the need, and 3) to avoid an engineered threat. The most noble of reasons to comply with any rule is to believe in the purpose of the rule. We love liberty, but we’re willing to constrain that liberty if it’s for a good reason. If we see non-compliance as a threat to something we value (such as life or property), we’ll likely comply. The problem, however, is that the more rare or hidden the potential harm, the harder it is for us to see the link between our decision to violate the rule and the harm that might someday result.
The second reason to comply is that we’d suffer the condemnation of our peers if we didn’t follow the rule. Here in Texas, we like to speed on our freeways, but speed in a school zone and you’re likely to get honked at, or be victim of a particularly offensive gesture. Shared values dictate much of our societal conduct – even when we don’t individually see the potential harm.
The third reason to comply is to avoid an engineered threat created specifically to steer human behavior. This is the police officer parked up ahead. We engineered him right into the system to act as a deterrent against your choice to speed on the road. In fact, a recent article suggests that budget cuts reducing police enforcement is the real reason we’ve seen a spike in automobile fatalities.2 Drinking and driving, speeding, and failure to wear a seat belt all tie into the effectiveness of the engineered threat.
Three reasons we follow rules, none of which is the rule itself. Merely articulating a rule is a poor strategy for enticing compliance. We humans are too focused on the localized mission to let a mere rule get in our way. To be effective, we must properly use hazards and threats (hazards being static – like a hazardous material, threats being dynamic like a threatening storm). That’s what we try to do in the Just Culture model – when we “coach” an employee around an at-risk behavior. Coaching is a discussion about the first two reasons – the importance of the harm to be avoided by compliance with the rule, and the shared value we put on the behavior itself.
Give me a rule with no reason to deviate and I will likely follow your rule. Give me a mission that in the slightest of ways is in conflict with the rule, and I will likely consider non-compliance. This is the strength of the mission. Give me a compelling reason to deviate from the rule, such as strong production pressure, or a troublesome rule to follow, and I’m overwhelmingly motivated to deviate. If we are good system designers, we should be able to see and address these incentives at the time we write the rule.
Bottom line – if we want to create compliance around a rule, we need to get beyond the mere articulation of the rule itself. It is about how systems incentivize non-compliance, and it is about how us humans perceive the hazards and threats attached to non-compliance.
David Marx
CEO Outcome Engenuity
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This is an excellent article – an often overlooked part of the Just culture discussion