A Learning, Just, and Accountable Culture Timeline
March 2005 Initial Training led by David Marx of Outcome Engineering, held at
United Hospital in St. Paul. Attended by several DST members, Quality
Consultant, Managers from Pharmacy, HR, Occupational Health (Safety),
Acute Care and In-Patient Mental Health.
Summer 2005 Decision made to be part of the Minnesota Collaborative – a group of
hospitals that would implement A Learning, Just, and Accountable Culture
and work with Outcome Engineering on incorporating Learning, Just, and
Accountable Culture principles within the member organizations.
Hospitals involved included HAHC, Fairview-University Health Systems
and St. Lukes Hospital in Duluth.
October 2005 Additional training for collaborative hospital members. Interdisciplinary
team formed.
December 2005 – December 2007
Monthly phone call meetings with Learning, Just, and Accountable
Culture collaborative members, MN Hospital Association representative
and Outcome Engineering (David Marx and Sharon Comden) for
consultation, sharing of processes used for training and implementation
and future planning.
February 2006
Leadership training began with a two hour orientation and overview.
Leadership attended this portion as well.
A Learning, Just, and Accountable Culture algorithm used to deal with
review of incidents and for situations involving disciplinary action.
February-April 2006
Leadership completed on-line training modules via the Learning, Just, and
Accountable Culture website.
August 2006 Incident reporting form revised to include Learning, Just, and Accountable
Culture principles.
September 2006 – April 2007
Team continued to meet to plan means of continuing to move Learning,
Just, and Accountable Culture principles into organizational policies and
procedures, as appropriate.
October 2006 -Ongoing
a Learning, Just, and Accountable Culture topic included at monthly
leadership meetings, with team members scheduled to facilitate the
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monthly topic (review of incidents, some component of a Learning, Just,
and Accountable Culture principles, etc.) a Learning, Just, and
Accountable Culture newsletter sent out to leadership as new editions are
published.
February 2007
Procedure for training new leaders developed and implemented. All new
organizational leaders receive a Learning, Just, and Accountable Culture
training orientation at the time of Leadership Orientation.
Summer 2007 Learning, Just, and Accountable Culture principles discussed with
Medical Executive Committee and peer review process use of the
principles reviewed.
Learning, Just, and Accountable Culture principles included in employee
handbook for distribution to new employees.
Learning, Just, and Accountable Culture principles included in revised
employee standards of behavior.
Participated on Minnesota Alliance for Patient Safety (MAPS) Learning,
Just, and Accountable Culture Work Group, to work with health care
licensing boards, and Minnesota Department of Health to incorporate
principles into their investigation and disciplinary review processes.
November 2007
Reinforced Learning, Just, and Accountable Culture principles with the
All Medical Staff quarterly meeting and explained that principles are now
included in the peer review process.
Root Cause Analysis process under review for revision to include
Learning, Just, and Accountable Culture principles and change form to
include the “three behavioral errors”.
January 2008
New leader orientation process changed – using Outcome Engineering’s
revised training manual and online training resource. Leader’s Learning,
Just, and Accountable Culture orientation is part of the Human Resource’s
New Leader training process.
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