the just culture certification training n.
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  2. Just Culture Implementation Taking the Necessary Steps

  3. 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…

  4. A Journey A Transformation An Intervention A Program A Set of Tools A Model A Lifestyle A Foundation Words to Describe Implementation

  5. 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

  6. 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

  7. Just Culture Certification Training Event Investigation Training Champions Training – Implementation Application Online Training Champions Just Culture for Managers Online & Classroom Event Investigation Managers Coaching and Mentoring Just Culture for Physician Leaders Just Culture for Physicians Physicians All Staff Safe Choices

  8. 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

  9. Implementation Support Model Fac1 Champions travel to support Fac2 Fac2 Champions travel to support Fac3 Fac 3 Champions travel to support Fac 1

  10. Implementation vs Application

  11. Champions Setting the Course Core Objectives Roles Expectations

  12. 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

  13. Core Objectives Create an Open and Fair Culture Manage Behavioral Choices Design Safe Systems Create a Learning Culture

  14. 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

  15. 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

  16. 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

  17. 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……

  18. ChampionsResponsibilities

  19. 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

  20. 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

  21. 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

  22. 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 PSO/Risk/Quality HR

  23. 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

  24. 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?

  25. 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

  26. 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

  27. ManagersResponsibilities

  28. 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

  29. 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

  30. 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

  31. Visibility of Top Risks • Maintain Visibility Of “Top 3” Departmental Risks • System Design • Human Behavior • Develop intervention strategies • Monitor the effectiveness of these strategies

  32. 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

  33. 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

  34. 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

  35. Measure Effectiveness • Create Metrics and Methods to Track and Analyze Risk and Risk Reduction Strategies • Share data and progress • Owed to the Champions

  36. 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

  37. 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

  38. 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

  39. Thank You! Please visit us at: Outcome Engineering, LLC Curators of the Just Culture Community 214.778.2010