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THE JUST CULTURE CHAMPIONS TRAINING. THE JUST CULTURE CERTIFICATION TRAINING. Next Steps . PRESENTED TO:. Just Culture Implementation Taking the Necessary Steps. There will be a small population of the staff that will be openly opposed to most management initiatives

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The just culture certification training



Next Steps


The just culture certification training

Just Culture


Taking the

Necessary Steps

The just culture certification training

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 Experience

In Each Organization…

The just culture certification training

A Journey

A Transformation

An Intervention

A Program

A Set of Tools

A Model

A Lifestyle

A Foundation

Words to Describe Implementation

Key implementation steps

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

Key implementation steps1

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 ™ Movieand the Producer’s Commentary

Ongoing training – 12 month program

Measure Success

Benchmarking Surveys

The just culture certification training

Just Culture Certification Training

Event Investigation Training

Champions Training –



Online Training


Just Culture for Managers

Online & Classroom

Event Investigation


Coaching and Mentoring

Just Culture for Physician Leaders

Just Culture for Physicians




Safe Choices

Leadership responsibilities

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

Implementation support model

Implementation Support Model

Fac1 Champions

travel to support Fac2

Fac2 Champions

travel to support Fac3

Fac 3 Champions

travel to support Fac 1

Implementation vs application

Implementation vs Application

Champions setting the course

Champions Setting the Course

Core Objectives



Champions team

Champions Team


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

Core objectives

Core Objectives

Create an Open and Fair Culture

Manage Behavioral Choices

Design Safe Systems

Create a Learning Culture

Core objectives1

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

Core objectives2

Humans will make mistakes.


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

Core objectives3

Core Objectives

Design Safe Systems

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

Core objectives4

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……

Champions responsibilities


Chief nursing officer and physician leaders

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

Director of human resources

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

Director of risk management

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

Patient safety risk quality and hr

Patient Safety, Risk/Quality and HR


Helping improve the effectiveness of the learning process

Providing tools to line managers

Helping to redesign systems


Protecting the learning culture

Helping with managerial competencies






At the champions meetings

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

Barriers to team effectiveness

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?

Potential challenges

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

Bottom line for champions

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

Managers responsibilities


Getting started

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

Identify risk

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



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

Visibility of top risks

Visibility of Top Risks

  • Maintain Visibility Of “Top 3” Departmental Risks

    • System Design

    • Human Behavior

  • Develop intervention strategies

  • Monitor the effectiveness of these strategies

Event investigations

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

Coaching and mentoring

Coaching and Mentoring

Proactively Coach and Mentor

Educate Staff

  • 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

Risk reduction

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

Measure effectiveness

Measure Effectiveness

  • Create Metrics and Methods to Track and Analyze Risk and Risk Reduction Strategies

    • Share data and progress

  • Owed to the Champions

Responsibilities owed to manager

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

Responsibilities owed to manager1

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

Just culture certification checklist

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:

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

The just culture certification training

Thank You!

Please visit us at:

Outcome Engineering, LLC

Curators of the Just Culture Community


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