1. Just Culture Collaborative Jill Hanson and Stephanie Sobczak Certified Just Culture™ Champions WHA 1

2. Today’s Call Assessing Readiness - Culture Organizational Readiness Assessment Just Culture Principles Implementation Planning 2

3. RECOMMENDED ACTION ITEMS Determine membership and convene your Just Culture steering team Read and discuss the Silent Treatment article -OR- Conduct a Staff Safety Assessment Review most recent AHRQ Patient Safety Survey Results Conduct Organizational Readiness Assessment  Organizational Assessment for Team Discussion  Individual Assessment 3 Past 30 Days

4. Last month poll #3 responses 4 Based on today’s information, how likely is your hospital to continue participating in this collaborative? a.Very Likely – 100% b.Not sure yet c.Not Likely

5. 5 Mid Month Survey Results Mid month survey results will be shared live during the September 5 th webinar

6. Just Culture FAQs Q: Do we need to stick to the 12 month schedule? I think the pace is too fast/too slow for our hospital. A: No, not at all. Cultures vary widely and so the pace of implementation will vary a great deal. Consider this a forum for learning and your hospital should proceed at a pace that fits. 6

7. Just Culture FAQs Q: Is there any measurement related to this collaborative? A: No. We discussed looking at improvement in AHRQ survey results over time, but each hospital differs in the frequency of applying the survey and the timing of the survey. We are interested in improvements you note. 7

8. The Pennsylvania Gap Assessment 8 Now posted on the Quality Center Just Culture page under Resources and Toolkits / Articles

9. Background Pennsylvania Patient Safety Authority 2007 survey 118 Hospitals responded – 59% fully implemented Just Culture – 11% partially implemented – 30% not yet implemented 9

10. 2010 Just Culture Project Ten Pennsylvania hospitals volunteered – Different regions – Different types Self-assessment survey developed by Outcome Engenuity 10

11. Self- Assessment Survey Organizational Assessment completed by patient safety officer Individual Assessment completed by 10-15 organizational leaders Same questionnaires that were shared during last month’s Just Culture webinar 11

12. PA Just Culture Project Conclusions Hospitals may think they implemented the Just Culture principles, but they haven’t changed… Their policies and processes The perception of their cultures 12

13. What’s the risk of not being “ready”? 13 Open Discussion….

14. 14 Just Culture Principles

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16. Perfection Is Not A Viable Option! Better results come from admitting to our shared fallibility, both at the individual and system level Better results come from admitting there are competing values and limited resources Better results come from designing more effective systems 16

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36. Just Culture Implementation  Educate leaders on Just Culture principles  Conduct a readiness assessment or cultural assessment  Review HR policies, incident reporting practices, and disciplinary processes  Align the above with Just Culture terminology  Train managers and staff  Apply the tools to real situations  Become well-versed in event investigations, designing safe work practices. 36

37. Implementation Planning 37 Task – Phase 1Who?By When? Conduct readiness assessment Steering GroupSept 15 Conduct Review of HR policies / make recommendations for change Jane and George Oct 15 Finalize HR PoliciesExec TeamNov 1 Train Senior leaders and Directors in Just Culture Sue and JeanDec 1

38. What do you anticipate the most challenging concept will be for managers to embrace? 38

39. 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 39 Tools available on WHA Quality Center: Gap Assessment Scoring Implementation Planning template

40. In October Focus on revising HR Policies Guest: Mike Murphy and Beaver Dam Hospital 40

41. Thank You! Questions? 41 Jill Hanson and Stephanie Sobczak Certified Just Culture™ Champions WHA