Download presentation
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?
Similar presentations
© 2025 SlidePlayer.com. Inc.
All rights reserved.