1. Just Culture Assessing Readiness – Focus on Process Jill Hanson Certified Just Culture™ Champion WHA 1

2. Today’s Agenda Review Q & A on assessments Building the foundation for a Just Culture Just Culture and HR policies and processes 30 day action items 2

3. 30 Day Action Items ACTION ITEMS Determine if a Culture Assessment would be helpful Continue with Gap Assessment Draft an Implementation Plan Review HR Policy Language 3 Tools available on WHA Quality Center: Gap Assessment Scoring Implementation Planning template

4. September Action Items – Poll Questions Did you complete a culture assessment? Did you draft an implementation plan? Have you reviewed your HR policy language? 4

5. Benefits Of An Organizational Gap Analysis Perceptions relative to how people are treated when things go wrong Provide a review of organizational policies that will impact the implementation of a fair and just culture Incorporate analysis results into your implementation plan 5

6. 6 The Culture Assessment Individual Culture Assess. Intended for Managers and staff leaders Assesses the behavioral choice of individuals Checks for understanding of behaviors in a fair and just culture Org. Readiness Assess. Team based Overview of current practice as compared to a Just Culture Identifies where there are “gaps” before implementing

7. Completing The Assessments Organizational Readiness Assessment  Download the.pdf from the Quality Center Just Culture page (You will need a Quality Center login) Individual Culture Assessment  Send a request for a hospital specific secure, dedicated on-line survey link for the Individual Assessment tool (jmuehrcke@wha.org)jmuehrcke@wha.org 7

8. Discussion For those who have done the assessments, share what you have learned. Either: Organizational Individual 8

9. Building the Foundation for a Fair and Just Culture 9

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11. 11 Is your approach the same for: Staff? Management? Senior Leaders? Physicians? Contracted staff? Systems of Accountability

12. Practice vs. Paper Keep in mind that what exists on paper may not be what happens in practice This is very common – it’s important to understand how things really happen 12

13. Assessing HR Policies 13 What to look for: Is the purpose of the policy clear? Does the language align with a fair and just culture?  Are employees held accountable for workplace behavior? Is there anything missing that should be a policy?

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15. Assessing HR Policies 15 Does it distinguish between Consoling, Coaching & Discipline? How does the policy speak to managing repetitive behaviors – human error, at-risk behavior, repetitive behavior?  Does it allow for managing at-risk behavior?  Does it allow for managing repetitive behavior? Is it possible to breach any of the requirements or expectations thru human error alone? Is there allowance for a justifiable breach?

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17. Refining Existing HR Policies Goal is to be proactive toward risk and behavioral choices, rather than reactive toward errors and outcomes. How do we do that? HR policies should focus on the behavioral choices of managers and staff  Less emphasis on errors and their undesired outcomes  Focus on risk associated with a behavior, not the actual outcome 17

18. 18 Remove any policy references to negligent or careless conduct as a basis for disciplinary action to reduce confusion. The term “negligent” has a legal meaning that is out of place in a Just Culture. Remove any policy references to criminal conduct as a basis for disciplinary action. The term “criminal conduct” refers only to a societal view that punishment should follow a particular type of conduct. **Unfortunately, in many legislative schemes, mere human error is criminal conduct (ex: “criminal negligence”). Refining Existing HR Policies

19. 19 Ensure that the Just Culture concepts are supported within your policies Ensure that event reporting and investigation system design and policies are aligned and support a fair and just culture Developing Your Implementation Plan

20. Setting Management Expectations Ensure that managers fully understand the three duties and three behaviors  Do they have the skills to console, coach, discipline, and initiate system redesign Set clear and consistent expectations: – For the result – The risk to be managed – To rules/guidelines to achieve it – The key behaviors to do it well Give voice to the risk in the system Work daily to raise perception of risk 20

21. Early Implementation Phase Things to consider: – Develop orientation training for managers, clinical staff, and all other employees Educate on roles and behaviors – Review existing policies and procedures Examples include job descriptions, discipline policies, incident/occurrence reporting, etc. – Establish process for manager to consistently work with HR prior to any disciplinary action – Establish systems to learn about potential organizational risk 21

22. Engaging Patients and Families Establish process to educate patients and families on patient safety & their ability to speak up/be engaged in their health care 22

23. The Next 30 Days ACTION ITEMS Begin defining your implementation plan Define Just Culture Steering Committee expectations Align HR policy language with a fair and just culture 23 Tools available on WHA Quality Center: Gap Assessment Tools Data by July 30

24. November Webinar Beaver Dam Community Hospital - sharing their Fair and Just Culture Journey JC Implementation - Phase One Incident Reporting Process 24

25. 25 http://www.whaqualitycenter.org/Home.aspx

26. Thank You! Questions? 26