February, 2018

21feb(feb 21)8:00 am22(feb 22)2:30 pmPhoenix, AZMedication Safety Focus in Partnership with ISMP


February-21-2018 - February-22-2018 MST


DoubleTree Resort by Hilton Hotel Paradise Valley

North Grand Ballroom, 5401 N. Scottsdale Rd., Scottsdale, AZ 85250



8:00 a.m. – 9:00 a.m.

  • Just Culture Overview & Core Set of Beliefs
8:00 a.m. – 9:00 a.m.

  • Introduction to theJust Culture Assessment Tool (JCAT)
9:00 a.m. – 10:00 a.m.

  • How System Design Influences Errors & Choices
9:00 a.m. – 12:00 p.m.

  • Just Culture Algorithm™ Practice Using Scenarios and the Just Culture Assessment Tool
10:00 a.m. – 12:00 p.m.

  • Human Behavior and Practice
12:00 p.m. – 1:00 p.m.

  • Lunch
12:00 p.m. – 1:00 p.m.

  • Lunch
1:00 p.m. – 1:30 p.m.

  • Just Culture and its Link to Societal and Corporate Initiatives
1:00 p.m. – 2:00 p.m.

  • Learning Systems/Root Cause Analysis
1:30 p.m. – 2:30 p.m.

  • Just Culture Implementation Overview
2:00 – p.m. – 3:00 p.m.

  • The Three Core Duties & Breaches of Duty
3:00 p.m. – 4:00 p.m.

  • The Just Culture Algorithm™
4:00 p.m. – 5:00 p.m.

  • Just Culture Algorithm™ Practice

Course Registration

REGISTER NOW $1,895 Per Attendee

Agenda & Brochure


Event Details

Just Culture Certification Course


Outcome Engenuity is pleased to offer our Just Culture Training Certification Course, in partnership with the Institute for Safe Medication Practices (ISMP). In addition to providing Just Culture training for leaders essential to driving cultural change, this course will also include examples associated with medication safety and will qualify for continuing education credits (CEUs). In addition to Outcome Engenuity Advisor Ellen McDermott (see bio below) this course will be taught by ISMP Vice President Judy Smetzer, RN, BSN. View her bio.

This course will qualify for 13.5 hours of Continuing Education.

This course is designed to help organizations achieve better outcomes, pursue sustainable and positive culture change through learning and justice, and to reduce adverse events. The course takes an in-depth look at specific accountabilities of all levels of staff and leadership, the nature of duties owed by organizations to their staff, clients, regulators, investors and other organizational influences.

This is accomplished by developing in-house expertise in the 5 Skills and the Just Culture Algorithm™. Participants are provided with the tools and knowledge to lead cultural change and build effective socio-technical, justice and learning systems in their organizations.

The Just Culture Algorithm™ is the premier tool used to achieve both justice and accountability across industries worldwide. The course examines how this tool relates to key principles of systems engineering, social engineering, and individual human factors. Opportunities are provided throughout the course to apply the learning and explore how organizations can realize consistently better outcomes in support of organizational values.

In addition, all participants will receive a one year subscription to the Just Culture Assessment Tool (JCAT) and the Outcome Engenuity Academy. JCAT will help participants operationalize Just Culture in their organization and the Academy provides additional learning opportunities through online training modules and scenarios.



Watch this brief Just Culture video from a live training course.



  • Describe the five skills that lead to producing better outcomes
  • Identify the role of an organization’s mission and values
  • Define the factors of system design and good design strategies
  • Describe the principles of managing the three core behaviors
  • Describe the legal principles that provide the foundation for Just Culture
  • Define the role played by imposers and the tools they use
  • Identify the role of ‘the reasonable person standard’
  • Evaluate the role of the ‘natural’ law
  • Define and contrast outcome-based and procedure-based duties
  • Define and describe the three duties and how to identify breaches of those duties
  • Demonstrate proficiency using the Just Culture Algorithm™ through guided practice
  • Describe Just Culture implementation strategies


Leaders interested in Just Culture as a means to improve their effectiveness including:

  • Pharmacy Managers
  • Clinical Leaders
  • Medication and Patient Safety Officers
  • Human Resources Directors
  • Operations Directors
  • Risk Managers


To effectively implement Just Culture an organization needs a critical mass of internal champions who understand the concepts and tools at a greater-than introductory depth. It has been said that not everyone is a doctor, not everyone an astronaut not everyone a gymnast, but we are, indeed, all judges. Employees have deeply held beliefs about how their peers, and their managers, should be held accountable. The Just Culture model may be at odds with some of those beliefs. The workplace is just too complex, and currently beliefs too deeply held, to drive cultural change with just one day of training.

Scenarios will arise that test a manager’s skill, and resolve to manage in a different way. Perhaps it’s an at-risk behavior leading to harm, but with the recognition that many of the other staff are skipping the same safety task. Perhaps it’s the recognition that one group of employees is being held accountable to a standard when others are not. These are not easy scenarios to address.

An organization needs well-trained internal champions to make Just Culture concepts a reality. And that’s what the two-day certification course creates – certified culture changing champions.


Ellen McDermottemcdermott@outcome-eng.com


DoubleTree Resort by Hilton Hotel Paradise Valley
North Grand Ballroom
5401 N. Scottsdale Rd.
Scottsdale, AZ 85250
Approximately $279/night
At course location, no discounted rate available
Map and Directions