1. Just Culture Implementation – Phase 1
Jill Hanson and Stephanie Sobczak
Certified Just Culture™ Champions
WHA

2. Today’s Call Guest Speaker – Beaver Dam Hospital
Implementation – Phase 1
Aligning Just Culture with Incident Reporting Processes
Defining the Process
Project Planning

3. Past 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 -

4. Implementation Toolkit
On the WHA Quality Center Just Culture page under

5. Beaver Dam Community Hospitals, Inc.
Stories From The Field
Beaver Dam Community Hospitals, Inc.

6. A Just Culture Learning Exercise

7. Professional Accountability
An experienced surgeon sees a new piece of equipment at a conference. Back at the hospital, a sales representative persuades him to use the equipment for a procedure. He has never used the equipment before and accidentally punctures the patient’s bowel. The surgeon repairs the bowel and the patient recovers fully. The OR has a policy that says new equipment will be officially approved and training will be conducted prior to its use.

8. Poll Question #1 - What Would You Do?
If there was no harmful outcome?
Take no action
Warn him not to make a mistake
Encourage different behavior
Discipline or punish

9. Outcomengenuity (OE) conducted training for some healthcare organizations where for the first group, we presented this first scenario (No harmful outcome) and the bar graph shows how folks did not lean toward punishment.  

10. Professional Accountability
An experienced surgeon sees a new piece of equipment at a conference. Back at the hospital, a sales representative persuades him to use the equipment for a procedure. He has never used the equipment before and accidentally punctures the patient’s bowel. The surgeon repairs the bowel, but the patient becomes septic, and spends 11 days in the ICU before expiring. The OR has a policy that says new equipment will be officially approved and training will be conducted prior to its use.

11. Poll Question #2 - What Would You Do?
If there was a harmful outcome?
Take no action
Warn him not to make a mistake
Encourage different behavior
Discipline or punish

12. The Outcome Bias
Outcomengenuity then presented the second scenario (Harmful outcome) to another group from the same organization, and the bar graph shows how the trend is now toward punishment.  

13. The lesson: Severity bias is deeply rooted in our systems of judgment
Can we really afford “No harm, no foul” thinking?
The story, of course, is that the behavioral choices were exactly the same, but the audience is biased based on the outcome. 
This demonstrates that even within a single organization, our context is driven by the outcome (Severity) bias.

14. Designing Effective Systems

15. Designing Effective Systems
Controlling Contributing Factors
Changing the rate of human error and at-risk behavior
Adding Recovery
Trying to catch errors downstream
Adding Barriers
Trying to prevent individual errors
Adding Redundancy
Trying to add parallel elements

16. Thinking About Human Intention
Action
Consequence of Action
Levels of Intention
Purpose
Knowledge
Reckless
Negligence
At-Risk Behavior
Human Error

17. Levels of Intention Purpose – Having the intention to cause harm
Knowledge – Set out knowing to cause harm, but it’s not my purpose
Example: Building collapses – person stuck in the rubble – only way to get them out is to cut off their leg to free them

18. Levels of Intentions
Reckless – Choose the act in recognition of the risk taken that’s not a justifiable risk
Example: Excessive speeding
Negligence – I should have been aware of the consequences, but I wasn’t
At-Risk Behavior – Chose the act, but didn’t choose the risk to take
Human Error – Didn’t even intend the action

19. Assessing Human Intention
Four Options
Intend Consequences
Do Not Intend Consequences
Intend
Action
Did Not
Intend Action
Intention
Action
Consequence of Action
Plan to hit Jill on the nose  hit Jill on the nose
Curling iron burn
Make sure to separate action from consequence of the action
Plan to hit Jill on the nose  Jill startles Steph Steph hits herself on the nose
Playing golf – get a hole in one

20. Balance With Behavioral Change
Want to Change Behavior?
Yes No
Receptive
Disregarding
Compliant
Unconvinced
Yes
See Risk?
Receptive = open/honest
Compliant = Doesn’t really see the risk to others “I don’t get it, but I’ll tone it down”
Unconvinced = Leaves you feeling frustrated when approaching them
Disregarding = Knows the risks – still continues to take risks anyway “reckless behavior” No

21. Incident Reporting & Just Culture

22. Utilizing Incident Reporting
A paradigm shift:
Existing reporting systems help to foster a proactive learning culture
See incident reports as opportunities to improve our understanding of risk
System risk, and
Behavioral risk
Where management decisions are based upon where our limited resources can be applied to minimize the risk of harm, knowing our system is comprised of sometimes faulty equipment, imperfect processes, and fallible human beings

23. Changing Managerial Expectations
Knowing their risks
Investigating the source of errors and at-risk behaviors
Turning events into an understanding of risk
Designing safe systems
Facilitating safe choices
Consoling
Coaching
Punishing

24. Changing Staff Expectations
Encouraging staff to:
Look for risks around them
Report errors and hazards
Help to design safe systems
Make safe choices
Choices that align with organizational values

25. Reinforcing Roles Risk/Quality HR
Helping improve the effectiveness of the learning process
Providing the tools to line managers
Helping to redesign systems HR
Protecting the learning culture
Helping with managerial competencies
Consoling
Coaching
Punishing

26. Web Based Incident Reporting - Example

27. More Than Just Reporting
Incident reports need to be combined with active surveillance methods, such as:
Direct observation or “walking the process”
Trigger tools
Chart audits
KEY Do something with the results

28. A Standard Process
– Analyze the reports  per incident  systemically  review for trend over time - Develop a plan to address - Document process improvements as a result of reporting

29. Incident Reporting – Defining Roles
Qual Saf Health Care 2005;14:123–129. doi: /qshc

30. Fair and Just Incident Reporting

31. The Next 30 Days ACTION ITEMS
Review current incident reporting process and how the data is used
Continue working on your implementation plan
Request Just Culture Algorithms from WHA, if you haven’t done so already
Tools available on WHA Quality Center:
Just Culture Implementation Guide
Implementation Task List
Task List Template
Process Evaluation Template

33. December 5th Webinar - Cancelled
January Webinar (January 2nd, 2013)
JC Implementation – Phase Two
The Just Culture Algorithm

34. Thank You!
Questions?