Just CultureImplementation – Phase 1

Jill Hanson and Stephanie SobczakCertified Just Culture™ Champions

WHA

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Today’s Call

• Guest Speaker – Beaver Dam Hospital• Implementation – Phase 1• Aligning Just Culture with Incident Reporting

Processes• Defining the Process• Project Planning

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ACTION ITEMS

Begin defining your implementation plan

Define Just Culture Steering Committee expectations

Align HR policy language with a fair and just culture

Past 30 Days

Implementation Toolkit

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On the WHA Quality Center Just Culture page under

Stories From The Field

Beaver Dam Community Hospitals, Inc.

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A Just Culture Learning Exercise

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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.

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Poll Question #1 - What Would You Do?

If there was no harmful outcome?A. Take no actionB. Warn him not to make a mistakeC. Encourage different behaviorD. Discipline or punish

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Professional AccountabilityAn 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.

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Poll Question #2 - What Would You Do?

If there was a harmful outcome?A. Take no actionB. Warn him not to make a mistakeC. Encourage different behaviorD. Discipline or punish

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The Outcome Bias

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The lesson:Severity bias is deeply rooted in our

systems of judgment

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Can we really afford “No harm, no foul”

thinking?

Designing Effective Systems

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Designing Effective Systems

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Thinking About Human Intention

Levels of IntentionPurpose

Knowledge

Reckless

Negligence

At-Risk Behavior

Human Error

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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

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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

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Assessing Human Intention

Four OptionsIntend

ConsequencesDo Not Intend Consequences

Intend Action

Did Not Intend Action

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Plan to hit Jill on the nose hit Jill on the nose

Curling iron burn

Playing golf – get a hole in one

Plan to hit Jill on the nose Jill startles Steph Steph hits herself on the nose

Balance With Behavioral Change

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See Risk?

Want to Change Behavior?

Yes

Yes

No

No

Incident Reporting & Just Culture

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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

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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

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Changing Staff ExpectationsEncouraging 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

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Reinforcing RolesRisk/Quality• 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

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Web Based Incident Reporting - Example

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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

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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

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Incident Reporting – Defining Roles

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Qual Saf Health Care 2005;14:123–129. doi: 10.1136/qshc.2003.008607

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Fair and Just Incident Reporting

The Next 30 DaysACTION ITEMS

Review current incident reporting process and how the data is usedContinue working on your implementation planRequest Just Culture Algorithms from WHA, if you haven’t done so already

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Tools available on WHA Quality Center:• Just Culture Implementation Guide• Implementation Task List• Task List Template• Process Evaluation Template

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

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December 5th Webinar - Cancelled

January Webinar (January 2nd, 2013)JC Implementation – Phase Two

The Just Culture Algorithm

Thank You!

Questions?

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