The Just Culture
Community
THE JUST CULTURE
CHAMPIONS TRAINING
Next Steps
PRESENTED TO:
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The Just Culture
Community
Just Culture
Implementation
Taking the
Necessary Steps
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The Just Culture
Community
Our Experience
In Each Organization…
– There will be a small population of the staff that will be
openly opposed to most management initiatives
– There will be a larger population that believe that Just
Culture is the key to future organizational success
– The remainder will believe the Just Culture will work, but
likely will not buy into the program until they see
leadership start to adhere to the philosophy
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The Just Culture
Community
Words to Describe Implementation
•
•
•
•
•
•
•
•
A Journey
A Transformation
An Intervention
A Program
A Set of Tools
A Model
A Lifestyle
A Foundation
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The Just Culture
Community
Key Implementation Steps
• Take the First Steps
• Gap Analysis, Disciplinary Policy Alignment,
• HR Actions
• Event Investigations Review
• Educate Senior Leadership
• Identify, Educate, and Mentor Champions Team
• Initial Champions Classroom Training
• Just Culture Certification Course (selected attendees)
• Event Investigation Course (selected attendees)
• 12 Monthly Webinars: Coaching and Mentoring,
• Combined with Organizational Self-Assessments
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The Just Culture
Community
Key Implementation Steps
• Educate Managers
• One-Day Just Culture Classroom Instruction plus Online Training
• Event Investigation Online Training
• Coaching and Mentoring Online Training
• Train Managers and Staff – Whole of Organization
– Featuring the Safe Choices ™ Movie and the Producer’s
Commentary
– Ongoing training – 12 month program
• Measure Success
– Benchmarking Surveys
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The Just Culture
Online
Training
All
Staff
Physicians
Managers
Champions
Community
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Just Culture
Certification
Training
Champions
Training –
Implementation
Application
Event
Investigation
Training
Event Investigation
Just Culture for
Managers
Online & Classroom
Coaching and Mentoring
Just Culture
for
Physician
Leaders
Just Culture for
Physicians
Safe Choices
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The Just Culture
Community
Leadership Responsibilities
•
Provides the vision—demonstrates a commitment to safe, reliable
delivery of high quality care
•
Establishes a sense of urgency around managing risks
•
Creates an environment of internal transparency around risk
•
Demonstrates an open, fair and learning culture, including
response to behaviors, errors, and events
•
Encourages trust and participation to improve safety and other
core values
•
Uses data and information to measure performance and build
both unit and organizational models for risk and the allocation of
resources
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The Just Culture
Community
Implementation Support Model
Fac 1 Champions
travel to support Fac 2
Fac 2 Champions
travel to support Fac 3
Facility
1
Facility
2
Facility 3
Fac 3 Champions
travel to support Fac 1
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The Just Culture
Community
Implementation vs Application
Facility
Application
BANNER HEALTH
System Wide
Implementation
Facility
Application
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The Just Culture
Community
Champions Setting the Course
Core Objectives
Roles
Expectations
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The Just Culture
Community
Champions Team
• President/CEO
• Chief Operating Officer
• Executive Sponsorship
______________________________
•
•
•
•
Chief Medical and Nursing Officers (CMO, CNO)
HR Officer/Director
Patient Safety/Risk Management/Quality Officers/Directors
Other Respected Leaders
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The Just Culture
Community
Core Objectives
Create an Open and Fair Culture
Manage Behavioral Choices
Design Safe Systems
Create a Learning Culture
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The Just Culture
Community
Core Objectives
Create an Open and Fair Culture
• Move away from an overly punitive culture
and strike a middle ground between punitive
and blame free
• Recognize human fallibility
• Humans will make mistakes
• Humans will drift away from what we have been
taught
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The Just Culture
Community
Core Objectives
Manage Behavioral Choices
• Humans will make mistakes.
Console.
• People and Cultures will drift into unsafe places.
Coach.
• People will make choices that consciously
disregard substantial and unjustifiable risk.
Consider Discipline.
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The Just Culture
Community
Core Objectives
DesignSafe
SafeSystems
Systems
Design
• Reduce opportunity for human error
• Capture errors before they become critical
• Allow recovery when the consequences of
our error reaches the patient
• Facilitate our employees making good
choices
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The Just Culture
Community
Core Objectives
Create a Learning Culture
• A culture that is hungry to learn
• Eager to recognize risk at both the individual
and organizational level
• Risk is seen through events, near misses, and
observations of system design and behavioral
choices
• Without learning we are destined to make the
same mistakes……
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The Just Culture
Community
Champions
Responsibilities
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The Just Culture
Community
Chief Nursing Officer and Physician
Leaders
• Leaders of Champions team
• Role models for both managers and staff at the facility
• Articulate priorities, establish and coordinate crossdepartment risk reduction initiatives
• Recognize and reward managers actively implementing
Just Culture
• Advocate for program at department meetings and at the
executive level
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The Just Culture
Community
Director of Human Resources
• Aligns HR policies and practices with Just Culture
• Ensures that HR investigations and actions are
consistent with Just Culture principles
• Incorporates Just Culture principles into manager
training and development
• Coaches and mentors managers applying Just
Culture principles and tools
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The Just Culture
Community
Director of Risk Management
• Reviews and coordinates event investigations
for team, reporting if investigation and follow-up
meets organizational Just Culture standards
• Determines if managerial actions are addressing
the components of the system that are under
their control so team can take appropriate action
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The Just Culture
Community
Patient Safety, Risk/Quality and HR
PSO/Risk/Quality
• PSO/Risk/Quality
– Helping improve
the effectiveness
of the learning
process
– Providing tools to
line managers
– Helping to
redesign systems
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HR
• HR
– Protecting the
learning culture
– Helping with
managerial
competencies
• Consoling
• Coaching
• Punishing
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The Just Culture
Community
At the Champions Meetings:
•
•
Recent event investigations are considered, including
HR cases:
– to identify errors,
– assure that timely and appropriate follow-up happens,
– the necessary actions have been taken, and
– Team monitors for trends/clusters/repetitive errors or
events
“Major,” “Catastrophic,” “Moderate” and “Never” events
are discussed by this group during the investigation
stage to ensure consistent response
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The Just Culture
Community
Barriers to Team Effectiveness
• Lack of structure:
meetings aren’t
scheduled or spotty
attendance by members
• Do SILOs exist?
• Personality issues?
• Manager resistance?
• Other issues?
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The Just Culture
Community
Potential Challenges
• Difficult to overcome the tendency to coach
human error
• Severity of the outcome of the event will
influence response in some cases
• Managers value consistent disciplinary
standards but vary in their ability to apply the
standards in their units
• Managers to do good event investigations and
follow-up
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The Just Culture
Community
Bottom Line for Champions
•
Champions are responsible for driving culture change
within the organization and are accountable to the CEO
•
It is recommend that Champions meet at least monthly
and more frequently, if needed.
•
Discuss what is going well and what is not. Sample
topics include barriers to implementation, education,
scheduling, coaching, and additional tools/topics as
needed
•
Outcome Engineering is available to Coach and Mentor
Champions remotely to guide the implementation plan
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The Just Culture
Community
Managers
Responsibilities
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The Just Culture
Community
Getting Started
• Complete Classroom and Online Training
• Meet With Other Managers and Gain Proficiency in:
– Conducting Just Culture Event Investigations
– Use of the Just Culture Algorithm™
– Applying Coaching and Mentoring Skills
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The Just Culture
Community
Identify Risk
Proactively Identify Risk Through a Variety
of Techniques:
•
•
•
•
•
Informal interviews
Focus Groups
Walk-arounds
Occurrence reports/event reports
Collaborate with process owners and other
departmental managers to identify and
monitor risk strategies
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The Just Culture
Community
Assessments
Perform Assessments to Evaluate Risks
• Review contributing factors to events to
determine whether existing systems and
processes sustain an acceptable level of risk
• Adopt a predictive model for human
behaviors….where will people err, drift and
make the reckless choice…and what is
justifiable in the context of organizational
values and risk management
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The Just Culture
Community
Visibility of Top Risks
• Maintain Visibility Of “Top 3” Departmental Risks
– System Design
– Human Behavior
• Develop intervention strategies
• Monitor the effectiveness of these strategies
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The Just Culture
Community
Event Investigations
Event Investigation
• Perform thorough, fair, and consistent
investigations
• Identify contributing systems and human
failures
• Severity of outcome will not dictate
discipline
• Learn from the behavioral choice that
contributed to the event
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The Just Culture
Community
Coaching and Mentoring
Proactively Coach and Mentor
–Staff
–Peers/Champions
–Internal transparency is a key marker of a Just Culture
Educate Staff
–Proactive approach to education vs. waiting for an
adverse event to occur before educating
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The Just Culture
Community
Risk Reduction
• Motivate Staff By Adopting Innovative, Effective,
Efficient Methods To Reduce Risk
– Implement timely system changes necessary to
reduce risk
– Provide feedback on why error at at-risk
behaviors occur in the workplace
– Incentivize the desired behaviors to manage the
risk
• Owed to Staff
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The Just Culture
Community
Measure Effectiveness
• Create Metrics and Methods to Track and
Analyze Risk and Risk Reduction Strategies
– Share data and progress
• Owed to the Champions
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The Just Culture
Community
Responsibilities Owed to Manager
Champions Will:
• Provide the resources needed for management to
build safe processes to apply Just Culture principles
• Monitor and assess the new processes and systems
• Endorse manager’s responses to events in
accordance with Just Culture principles
• Align organizational and departmental HR and
discipline policies to support a Just Culture
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The Just Culture
Community
Responsibilities Owed to Manager
Staff Will:
– Work together with managers and other staff to
identify and manage risk
– Report operational hazards/risks that may affect the
safety of patients or colleagues, and holds
management accountable for a response in the
handling of those reports
– Support management efforts to encourage staff in
making safe behavioral choices to minimize potential
risk to patients or colleagues
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The Just Culture
Community
Just Culture Certification Checklist
 Complete Just Culture Certification Training
 Complete Just Culture Online Training
 Just Culture Managers Training
 Just Culture Event Investigation
 Just Culture Coaching and Mentoring
 Just Culture Physician Algorithm (Optional alternative to
Managers Training)
 Submit Certification Proficiency Exam to:
exams@outcome−eng.com
 Participate in a one hour verbal debrief following your
exam submission with an Outcome Engineering
Consultant
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The Just Culture
Community
Thank You!
Please visit us at:
Outcome Engineering, LLC
Curators of the Just Culture Community
www.outcome-eng.com
www.justculture.org
214.778.2010
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