just culture implementation – phase 1 jill hanson and stephanie sobczak certified just culture™...
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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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