1. THE JUST CULTURE CERTIFICATION TRAINING
THE JUST CULTURE CHAMPIONS TRAINING
Next Steps
PRESENTED TO:

2. Just Culture Implementation
Taking the
Necessary Steps 2

3. Our Experience In Each Organization…
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
Facilitator notes:
Large population think the program can work, but are waiting to see if management will “walk its talk” before they take it seriously. They complain that there are too many initiatives at the same time, that there is a history of punitive culture, that managers aren’t visible to line staff much of the time, they want to see some results, or that they don’t believe that incidence reports are being taken seriously, etc.
Central is the desire to see managers “walk the talk,” no surprise to any of you. So how do you do that? Management accountabilities sounds threatening—but what we’re really talking about is expectations. I’m sure many of you could have written these—you’ve been trained and have been doing this job for years. 3

4. Words to Describe Implementation
A Journey
A Transformation
An Intervention
A Program
A Set of Tools
A Model
A Lifestyle
A Foundation
What exactly is it that you are undertaking?
We discussed that this is broader and deeper than a Banner Initiative – this will enter into every are of your mission, your business, who you are, and what you do.
The Just Culture implementation – feels most like a foundation movement. 4

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 5 5

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 ™ Movie and the Producer’s Commentary
Ongoing training – 12 month program
Measure Success
Benchmarking Surveys 6 6

7. Champions Managers Physicians All Staff Champions Training –
Just Culture Certification Training
Champions Training –
Implementation
Application
Event Investigation Training
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
Facility 3
Facility 2
Facility 1
Fac 1 Champions
travel to support Fac 2
Fac 2 Champions
travel to support Fac 3
Fac 3 Champions
travel to support Fac 1

10. Implementation vs Application
BANNER HEALTH
System Wide Implementation
Facility Application
Some Champions will be a sphere of influence at the System Wide Level to achieve Banner Implementation
Across Banner Health they will shepherd the implementation across System Wide Policy and Procedure
Explore system wide measures of success
Create the umbrella implementation strategy and ensure that resources are made available
At the Facility Level, Champions move into a role of Application
Application around the use of the Just Culture Algorithm™
Application around the use of Event Investigation and Causal Analysis, including Causal Diagrams
Promotion of the Just Culture philosophy & language
Facilitating local training initiatives to support Just Culture implementation at a local level, including delivery where appropriate
Providing local mentoring and guidance on the use of the tools – subject matter expert – internal resource
Provide local mentoring and guidance on the management of risk and achieving better outcomes in support of our values.

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
Key attribute in producing the best possible outcomes
Risk seen through events, near misses, and observing the design of our systems and our own behaviors
Without a learning culture, the staff is destined to repeat previous mistakes
A learning culture provides ability to identify solutions having the greatest impact
Create an Open and Fair Culture
This is neither a “punitive” nor a “blame free” culture – somewhere in the middle
We must recognize our own fallibility – errors and drift
All employees are accountable for their behavioral choices
Design Safe Systems
We must put our employees in reliable systems
Systems should anticipate errors, capture errors before they become critical, and allow recovery when consequences of our errors have reached the patient.
Facilitate good decision making
Manage Behavioral Choices
Humans will drift into unsafe places
We must productively coach our employees to reliable behaviors
Recognize when corrective actions will get us the results we desire
Create a Learning Culture
THR Champions Workshop, 1/15/08 13

14. Create an Open and Fair Culture
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
THR Champions Workshop, 1/15/08 14

15. Manage Behavioral Choices
Core Objectives
Manage Behavioral Choices
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.
THR Champions Workshop, 1/15/08 15

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
THR Champions Workshop, 1/15/08 16

17. Create a Learning Culture
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……
Create a Learning Culture
Key attribute in producing the best possible outcomes
Risk seen through events, near misses, and observing the design of our systems and our own behaviors
Without a learning culture, the staff is destined to repeat previous mistakes
A learning culture provides ability to identify solutions having the greatest impact
Create an Open and Fair Culture
This is neither a “punitive” nor a “blame free” culture – somewhere in the middle
We must recognize our own fallibility – errors and drift
All employees are accountable for their behavioral choices
Design Safe Systems
We must put our employees in reliable systems
Systems should anticipate errors, capture errors before they become critical, and allow recovery when consequences of our errors have reached the patient.
Facilitate good decision making
Manage Behavioral Choices
Humans will drift into unsafe places
We must productively coach our employees to reliable behaviors
Recognize when corrective actions will get us the results we desire
THR Champions Workshop, 1/15/08 17

18. Champions Responsibilities
Model brings together HR, RM, Quality (often) and Operations
Three staff departments have to look to CNO for operations leadership—80% of personnel under Nursing. CNO is pivotal person because of influence and direct authority.
CNO must depend on RM, HR, Quality to provide quality analysis, recommendations, identify issues early, and make well-thought-out recommendations for action
It’s much more than reviewing and responding to incident reports. Team is “minding the store” for organization—only place where cross-department issues can be identified, investigated, and coordinated to address broad risks to patient safety
The whole is much more powerful than each of the parts.
THR Champions Workshop, 1/15/08 18

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
The CNO is the lead Champion for Just Culture implementation.
About 80% of events occur within nursing units
Involved in both nursing and manager development
Pivotal position
Specific responsibilities
Visibility and presence at department and executive meetings
Coordination of cross-department efforts
Reinforces and recognizes managers who are effectively implementing change
Role model—tough job
THR Champions Workshop, 1/15/08 19 19

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
Collaborates with Unit Management, CNO and Risk Manager when events occur
HR Expert
Assures Consistency of Management Response
Ensures that the action taken by the manager matches the behavioral choice made by the employee
Coaches managers when they are contemplating administrative actions
THR Champions Workshop, 1/15/08 20 20

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
Investigations Expert
Systems Modeling Expert
Coaches Managers’ Response to Events
Challenge: No line authority—works in concert with CNO and others to produce results
THR Champions Workshop, 1/15/08 21 21

22. Patient Safety, Risk/Quality and HR
PSO/Risk/Quality 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

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
Before adoption of Just Culture, an event would occur. Unit managers, HR, RM, Quality, and CNO would investigate the event from a different perspective—but would have only part of the picture.
This is all changed. Now serious events are worked as a team that includes decision-makers. The right and left hands know what each other is doing.
Now HR, RM, perhaps Quality, and unit management provide input to the Team and it can see trends, clusters, outliers, and cross-unit or Department systems issues or risks.
Regular meetings scheduled based on reporting volume and content
THR Champions Workshop, 1/15/08 23 23

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?
Group works through each issue
Talk about managing report workload, strategies for addressing issues
THR Champions Workshop, 1/15/08 24

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
Duty to Produce an Outcome vs. Duty to Follow a Procedural Rule – who owns the system? Is it rate based?
Purpose and Knowledge
Risk vs. Rule-based – rules are subordinate to our values in managing risk
The Severity Bias – not only the ‘no harm no foul’ approach or ‘bad outcome, bad person’ but that be careful….the severity of the outcome doesn’t inform how we stand in judgement, but it does inform the magnitude of the risk that was undermanaged or unmanaged prior.
Who determines “substantial and unjustifiable”? – The Imposer – Banner Health, usually and nominally devolved down to a departmental level.
“Conscious disregard” and the Objective Standard
Was it reasonable that I see the risk? Was it substantial? Was it unjustifiable? Did I choose the behavior anyway?
Did I take the gamble, hoping that nothing bad happened and I didn’t get caught?
Organizational accountability in drawing the “bright line”
Identify the values to support
Identify the substantial risks
Set the expectation to achieve the outcomes, mindful of human behavior (HE, ARB, RB; Justifiable Breach)
Communicate, Promote, Educate/Train, Role Model, Mentor and Coach
Identify the punistive action that is commensurate with the risk
Remediation and levels of punishment
CONSIDER punitive action and then assess what will achieve the best outcomes, across competing values, for the individual, the workforce and the organization
Repetitive behaviors
Are there choices increasing the rate?
Is the system contributing?
Are there personal performance factors (PPF) impacting? Can we help? Will the employee accept the help?
Can we set requirements to manage these PPF?
THR Champions Workshop, 1/15/08 25 25

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
THR Champions Workshop, 1/15/08 26 26

27. Managers Responsibilities
Model brings together HR, RM, Quality (often) and Operations
Three staff departments have to look to CNO for operations leadership—80% of personnel under Nursing. CNO is pivotal person because of influence and direct authority.
CNO must depend on RM, HR, Quality to provide quality analysis, recommendations, identify issues early, and make well-thought-out recommendations for action
It’s much more than reviewing and responding to incident reports. Team is “minding the store” for organization—only place where cross-department issues can be identified, investigated, and coordinated to address broad risks to patient safety
The whole is much more powerful than each of the parts.
THR Champions Workshop, 1/15/08 27

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. 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
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
Educate Staff

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