Copyright 2011, Outcome Engineering, LLC. All rights reserved. The Just Culture Community THE JUST...

Copyright 2011, Outcome Engineering, LLC. All rights reserved.

The Just Culture

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PRESENTED TO:

Next Steps

THE JUST CULTURECHAMPIONS TRAINING


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Just CultureImplementation

Taking the Necessary Steps


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– 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

Our ExperienceIn Each Organization…


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• A Journey• A Transformation• An Intervention• A Program• A Set of Tools• A Model• A Lifestyle• A Foundation

Words to Describe Implementation


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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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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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Man

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Just Culture for Managers

Online & Classroom

Event Investigation

Safe Choices

Just Culture for

Physician Leaders

Coaching and Mentoring

Just Culture for Physicians

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Just Culture Certification

Training

Event Investigation

Training

Online Training

Champions Training –

Implementation Application


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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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Implementation Support Model

Fac 3 Champions travel to support Fac 1

Facility 3

Facility 2

Facility 1




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BANNER HEALTHSystem Wide

Implementation

Facility Application

Facility Application

Implementation vs Application


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Champions Setting the Course

Core Objectives

Roles

Expectations

http://www.indexstock.com/store/Chubby.asp?ImageNumber=640422


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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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Core Objectives

Manage Behavioral Choices

Design Safe Systems

Create a Learning Culture

Create an Open and Fair Culture


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• 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

Core Objectives

Create an Open and Fair Culture


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• 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.

Core Objectives

Manage Behavioral Choices


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Core Objectives

Design Safe Systems• 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

Design Safe Systems


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Core Objectives

• 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……

Create a Learning Culture


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ChampionsResponsibilities


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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 cross-department 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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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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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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Patient Safety, Risk/Quality and HR

• PSO/Risk/Quality– Helping improve

the effectiveness of the learning process

– Providing tools to line managers

– Helping to redesign systems

• HR– Protecting the

learning culture– Helping with

managerial competencies

• Consoling• Coaching• Punishing

HRPSO/Risk/Quality


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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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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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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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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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ManagersResponsibilities


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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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Identify Risk

• Informal interviews• Focus Groups• Walk-arounds• Occurrence reports/event reports• Collaborate with process owners and other

departmental managers to identify and monitor risk strategies

Proactively Identify Risk Through a Variety of Techniques:


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Assessments

• 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

Perform Assessments to Evaluate Risks


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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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Event Investigations

• 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

Event Investigation


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Coaching and Mentoring

–Staff–Peers/Champions–Internal transparency is a key marker of a Just Culture

–Proactive approach to education vs. waiting for an adverse event to occur before educating

Proactively Coach and Mentor

Educate Staff


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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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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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Responsibilities Owed to Manager

• 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

Champions Will:


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Responsibilities Owed to Manager

– 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

Staff Will:


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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: [email protected]

Participate in a one hour verbal debrief following your exam submission with an Outcome Engineering Consultant


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Thank You!Please visit us at:

Outcome Engineering, LLCCurators of the Just Culture Community

www.outcome-eng.comwww.justculture.org

214.778.2010

Copyright 2011, Outcome Engineering, LLC. All rights reserved. The Just Culture Community THE JUST...

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