WHA Partners for Patients
Just Culture Implementation Guide
ASSESSING READINESS
GETTING STARTED WITH A FAIR AND JUST CULTURE
Convene a Steering Team
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Determine who will be part of the team
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Identify Leadership Lead
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Identify Management/Project Lead
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Develop Project Charter
ASSESSING READINESS - CULTURE
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Perform organizational gap analysis and/or organizational safety culture baseline survey o Readiness Assessment components
 Develop process to complete the assessments
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Identify target audience
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Survey tool o Paper/electronic o Distribution, compilation, sharing of results o Review results gap analysis & determine next steps o Conduct walk rounds o Create awareness & set a vision
 Mission and Primary Values should be designed around what the organization values that it wants to protect
 Build a Business Case and present to targeted audiences (e.g., Board of Directors, Leadership )
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Assess the level of severity bias in your organization – “no harm, no foul” thinking o Survey staff to find out their level of severity bias by using the examples of professional accountability slides that were shared in the
WHA Just Culture Implementation – Incident Reporting webinar slides
( http://www.whaqualitycenter.org/PartnersforPatients/JustCulture/JustCultureWebinars/JCWebinarsImplementationNov.aspx
) o Determine if an education component for severity bias needs to be developed

WHA Partners for Patients
Just Culture Implementation Guide
ASSESSING READINESS - PROCESSES
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Review existing HR policies, incident reporting practices, and disciplinary processes to determine how they align with a fair and just culture o Query staff, managers, and physicians regarding their current perceptions of the use of discipline in response to a person’s behavior
– depending on whether or not the behavior resulted in harm o Is there a process in place to routinely assess risk? o Does the incident reporting system allow for staff to report risk/events (e.g., a good catch/near miss reporting system)? o Is there a process in place to routinely assess risk? o Embed principles into system policies
 Policies:
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Corrective action
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Performance appraisal
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Problem resolution process
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Management rights and responsibilities
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Incident/occurrence reporting
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Patient safety event/error reporting
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Sentinel event investigation policy and process
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Job descriptions
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Discipline policies
 Wording changes to incorporate “a fair and just culture” language
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Categorize behavior – error, at-risk or reckless
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Management response – console, coach or punish
 Develop a timeline to revise policies and procedures to incorporate fair and just culture language and behaviors
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Duties of managers are explicit (this is about seeing risk, designing safe systems and coaching/mentoring staff)
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Duties of staff are explicit (the processes, but also looking for risk, reporting hazards and making safe behavioral choices
IMPLEMENTATION
IMPLEMENTATION – PHASE ONE

WHA Partners for Patients
Just Culture Implementation Guide
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Engagement on all levels – Develop education materials and communication plan for a fair and just culture o All levels of management o All staff o Patients/families
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Convene an implementation team o Determine who will be part of the team o Identify implementation lead o Develop Implementation Plan
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Review current practices – determine if a “fair and just culture” are imbedded practices within the system o Incorporate into system wide initiatives
 Hand washing
 Medication reconciliation
 Patient identification
 Team training
 Safe patient handling o Routinely use in root cause analysis process o Perform routine employee safety rounds o Ensure there is a process in place for staff to report risk/events, such as a good catch/near miss reporting system o Ensure there is a process in place to routinely assess risk
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Designing an effective Just Culture system – How will you do the following in your organization: o Barriers - Prevent the error from occurring and/or prevents the hazard from touching target
 Examples: Personal protective equipment; Covers/Shields; Interlocks; Control limits (preventing excess movement) o Redundancy – Allows the error to occur, but is caught by 2 nd or 3 rd strategy that is in place before the event occurs; Relies on parallel system elements to perform function of failed system component
 Examples: Second person performing task, Backup supplies, Backup power, Parallel tests o Recovery – Allows the error to occur, but is captured before it becomes critical
 Examples: Downstream checks; Downstream tests; Making the error visible thru feedback o Perception of High Risk – Acts to limit at-risk behaviors by fostering focus on specific tasks being worked
IMPLEMENTATION – PHASE TWO – THE JUST CULTURE ALGORITHM

WHA Partners for Patients
Just Culture Implementation Guide
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The Just Culture Algorithm is designed to evaluate individual behaviors, regardless of the outcome and can be used both pre and post event o Managing behavioral choices in a way that allows the organization to achieve the outcomes they desire o Provides a mechanism to better understand “near misses” and degree of risk o Ability to clearly distinguish between Human Error, At-Risk Behavior, and Reckless Behavior o Utilize algorithm consistently to determine the actions taken as a result of an investigation
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Understanding the algorithm o Request copies of the Just Culture algorithm from WHA o Review existing event investigation process to ensure it is addressing the following questions:
 What happened?
 What normally happens?
 What does procedure require?
 Why did it happen?
 How were we managing it? o Revise existing event investigation processes to align with what was found during the review period
 What training protocols will also need to be updated to accommodate this?
 How will this change be shared with management and staff?
 Who will be responsible for ensuring this will happen? o Practice using the Just Culture algorithm with actual event investigation cases
 As you walk thru the cases using the algorithm be thinking about:
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How easy is the algorithm to follow (i.e., level of severity bias)?
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How will levels of severity bias be addressed for management? Staff?
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How will managers be educated on how to use the algorithm?
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How will staff be educated on using the algorithm?
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Determine system-wide expectations of when and how to use the algorithm o Develop education component for the Just Culture Algorithm (see phase three – training) and revised event investigation practices
IMPLEMENTATION – PHASE THREE - TRAINING
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Fair and Just Culture training incorporated into, accountability is established and communicated via: o Organizational-wide training for all employees as appropriate to their functions

WHA Partners for Patients
Just Culture Implementation Guide o Accountability is established and communicated (leader, staff, and management) o Revised policies and procedures are communicated to leaders, management and staff o New employee orientation
 Educate on current reporting system
 Demonstrate how staff are held accountable for behaviors versus outcomes o Management and new manager training
 Hold organizational-wide training for all applicable management
 Establish a process for managers to consistently work with human resources prior to any disciplinary action o Medical leadership training
 Training on creating a safety-supportive culture, supporting an open reporting environment while holding employees accountable for their choices o Staff training
 Hold organizational-wide introductory training for clinical staff
 Educate staff on their role in a fair and just culture environment – looking for risk, reporting hazards and making safe behavioral choices o Patients/Families
 Establish process to educate patients and families on patient safety and their ability/role with patient safety, including asking questions and speaking up with any safety questions or concerns
IMPLEMENTATION – PHASE FOUR – EMBEDDING FAIR AND JUST PRACTICES INTO THE ORGANIZATION
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Fair and just culture concepts are infused and embedded in regular routines/practices throughout the organization o Concepts are routinely used in the root cause analysis process (e.g., drifting, coaching) o Becomes a regular management meeting agenda o Concepts are routinely used in the peer review process o Principles are incorporated into performance improvement o Principles match with employment/practice agreements (e.g., physician code of ethics/behaviors)
IMPLEMENTATION EVALUATION
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Conduct periodic gap analysis and/or organizational safety culture tool review
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Identify and review work done for safe systems design

WHA Partners for Patients
Just Culture Implementation Guide o What’s working? o How is patient care impacted?
 o Future goals?
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Analyze safe behavioral choices by reviewing HR discipline issues, good-catch reporting system, unsafe choices in RCAs
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Utilize algorithm with event investigations on a routine basis
Establish and review error rate and other leading process improvement indicators (e.g., good-catch system)
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Measure outcomes associated with improvement projects