Flashcards in Reading Deck (25):
What does Peter Brown see as the big ideas from Make it Stick?
1. Get it out to get it in
2. Some difficulties are desirable
3. Intuition misleads us
In Make it Stick, what is the effect of massed practice?
Can result in short term knowledge retention, but degrades rapidly
In Make it Stick, what is the effect of testing on memory?
Helps promote consolidation. Better long term retention that just reviewing. Even testing before teaching helps improve retention
What are the 3 habits to cultivate from Simple Habits for Complex Times?
1. Ask different questions
2. Take multiple perspectives
3. See systems
In a just culture, an account of failure can do these two things at the same time
1. Satisfy demands for accountability
2. Contribute to learning and improvement
What is the fundamental issue regarding explanations of failure in a just culture?
How can we produce explanations of failure that both satisfy demands for accountability and provide maximum opportunities for organizational learning?
In Just Culture, what was the effect of the scientific revolution on how misfortune was viewed?
Misfortune used to be viewed as uncontrollable, as acts of god, fate, predestination, etc.
Now, especially over the past 30 years, we have begun to use the term accidents, and view them as a failure to manage risk well enough.
What is the utilitarianism ethic, as described in Just Culture?
The right thing to do is to choose the option that results in the greatest good for the most people
What is the deontological ethic, as described in Just Culture?
The right thing to do is based on professional duty or obligation.
How does the utilitarianism and deontological ethics exist in unresolvable conflict for physicians, and other other service workers, in the book Just Culture?
Utilitarianism suggests that physicians should be compelled to do the greatest good for the most people, while deontological ethics, while applied to medicine, suggests that a physician is compelled do to the most fo the individual patient in from of them. Being a good professional means that physicians try to provide the maximally best care to all of their patients, and juggling time and resources as such. This is an resolvable conflict that physicians and healthcare providers feel on a daily basis.
In Just Culture, what are the criteria by which the ethical school of consequentialism indicates that a choice should be considered?
The consequences (especially unintended) of a decision should be considered. A decision may impact an individual, but more importantly, how other individuals might respond as well as the system.
Considering consequentialism, what types of things get "improved" when an individual is met with an unjust response? What does not typically get improved.
"Improvement" occurs with stuff that swirls around the primary processes - bureaucracy, involvement of the legal department, bookkeeping, micro-management. The primary processes are not typically improved.
In Just Culture, what are the two primary tradeoffs when considering sanctioning an individual versus supporting and learning?
Accountability (which can be seen by others) and learning from the event.
What are three things that a just culture would say about accounts of an incident?
1. A single account can not do justice to the complexity of events (analogies to Niels Bohr's work)
2. A just culture accepts nobodies account as "true" or "right"
3. A just culture pays attention to the "view from below" - i.e. the people closest to the work and the most powerless
How is justice achieved in a just culture?
By bargaining. A just culture is not about absolutes. The best outcome may be the one which allows for accountability and the organization to learn.
What does just culture say about punishment?
There should be a proportional and decent response to an action. To paraphrase, the punishment should fit the crime.
What are two things that a just culture say about disclosure
1. Disclosure is important. Not wanting to disclosure can make an honest mistake look dishonest.
2. Protecting those who disclose matters as much as disclosing itself
What is the difference between a technical error and a normative error?
A technical error is one that is results from an individual lacking the adequate training, knowledge, or role for the task or situation. In other words, they are performing their task diligently, but their present skills fall short. A normative error is one that would not be expected from someone with this level of training or knowledge. In other words, normative errors are about individuals not discharging their roles responsibly.
The interpretation of an error after the fact is considered to be "up for grab" in Just Culture. What type of bias is primarily responsible for this?
Hindsight bias. Once the outcome is known, an error will be interpreted more severely if the outcome is severe. This can cause a reasonable process to be viewed as problematic, or convert a technical error in to a normative error.
Do incident reporting systems and legal proceedings have a mechanism to protect against hindsight bias?
Basically, no. (I should challenge myself to do a better job of this on MSQC)
What are 5 ways hindsight bias can influence how we just past events? (just Culture)
1. Match the severity of the outcome to the severity of the error
2. More likely to see causal relationships where none exist
3. More likely to wrongly assume that a piece of critical information was recognized as such by the individual or team
4. Overestimate the likelihood of the outcome (because now we have it in hand)
5. Overrate the role of rule or procedure violations. There is almost always a gap between written or understood procedure, and the actual procedure.
Instead of matching consequences with outcome, what question should be asked in a Just Culture?
"Did the assessments and actions of the professionals at the time make sense, given their knowledge, their goals, their attentional demands, their organizational context?
When we find ourselves asking the question, "How could they have been so negligent, so reckless, so irresponsible?", what should we consider instead?
We should consider whether we have chosen the wrong frame of understanding their behavior. "The frame of reference of understanding people's behavior, and judging whether it made sense, is their own normal work context, the context they are embedded in." This must be one of the rationals for why people should be judged by their peers.
What are the arguments for reporting to safety staff versus line managers?
For safety staff: lack of immediate consequences, more able to have anonymity, promote organizational learning, avoid reporting to people that have skin in the game
For line managers: more immediate action is possible, they are knowledgeable about the area in question, are invested in improvement