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JUST CULTURE

Does the overall culture of a company have at least as powerful an influence on worker safety as the actions of the workers themselves? In exploring this controversial safety philosophy, Phil La Duke of Rockford Greene investigates whether an environment where people feel comfortable making and reporting mistakes is better equipped to determine the root cause of a problem and implement counter measures to prevent recurrence.

Posted: August 2, 2011

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Does the overall culture of a company have at least as powerful an influence on worker safety as the actions of the workers themselves? Is an environment where people feel comfortable making and reporting mistakes far better equipped to determine the root cause of a problem and implement counter measures to prevent recurrence?

Some safety professionals believe that even though worker injuries are primarily caused by unsafe acts, they are seldom the result of a deliberate or knowingly reckless action. These safety professionals believe that the overall culture of the company has at least as powerful influence on worker safety as the actions of the workers themselves. At the heart of Just Culture is the belief that punishing people for making mistakes, even those that result in serious injury or death, is fundamentally wrong (excluding cases of depraved indifference or gross negligence.)

It’s been over ten years since University of Manchester Professor Dr. James Reason first coined the term “Just Culture” to describe an environment where mistakes were not only acceptable, but were expected and in many cases welcomed as opportunities to identify and fix serious system flaws. Reason’s work, and the subsequent research by others, found that making mistakes were more than a part of being human, but largely unavoidable.

Despite findings that the average person makes an average of 5 to 8 mistakes per hour, and presumably most injuries are not intentional, most organizations cling to the idea that the key to worker safety is awareness and discipline. Reason, and others, hold that as long as people are punished for their mistakes the errors will go unreported and no corrective actions to remedy the root causes will ever be possible. Mistakes will be driven underground, building the risk of injury until it reaches an inevitable lethal threshold.

Proponents of Just Culture believe it is imperative for organizations to seek out and correct root causes while mistake proofing to ensure that honest mistakes don’t result in fatalities. Just Culture advocates believe that people will always make mistakes, but they shouldn’t have to die for them. Creating a blame-free culture is difficult enough in itself, and the litigious nature of many cultures makes it tough for organizations to seek to fix the problem without fixing the blame.

THE NATURE OF MISTAKES
Some experts theorize that the nature of mistakes is rooted not in the imperfection of man, but in an evolutionary imperative that guides us through the dichotomy between inertia and adaptation. In a biological sense, change is dangerous, reckless and stupid.

Consider for a moment a sea bird that happens upon an ideal environment – ample food, safe nesting grounds, good mating prospects and an absence of predators. If the bird makes any change, however minute, it invites disaster and extinction. The smart move is to maintain the status quo. Inertia, however, leaves a species unprepared for sudden changes in the environment . . . and such changes devastate the populations.

Herein lies the dilemma: change exposes us to danger, yet inflexibility exposes us to equal danger. Mistakes are not unintentional; rather, they are subconscious experiments that test the safety of a change. Far from being universally undesirable, mistakes often result in serendipitous discovery and innovations. Mistakes, however, also frequently lead to injuries or even death, the ultimate proof of the danger of a change.

MISTAKES + SHAME = CRIMINALITY
There is a fundamental desire in civilized societies to remedy mistakes and make the injured party once again whole. This belief is an underlying principle of the laws of many societies and is at the foundation of most corporate policies – find the person responsible and hold him or her accountable for the wrong that has been done.

While this mindset is understandable, and even commendable for situation where the wrong committed is intentional, it is fairly destructive in situations where the action was neither conscious nor intentional. Should we seek to define a corporate culture we need only to analyze our rules?

As we do so, it’s important to recognize that rules that can be openly ignored are not really rules, rather the behavioral norms are the true indicators of the culture. In other words, while written policies may or may not truly represent to what an organization aspires, it’s only in the reaction to noncompliance that any accurate inference can be made. In even simpler terms, it’s not what an organization says it does that matters . . . it’s what it actually does that makes the difference.

BALANCING JUST CULTURE AND ACCOUNTABILITY
Clearly it is impossible to implement Just Culture without first drawing the line between “honest” mistakes and mistakes so irresponsible that they constitute negligence (they knew or should have known better than to make the mistake), gross recklessness (they took unacceptably high risks), or depraved indifference (they knew what they were doing could lead to catastrophic outcomes and acting without regard to that knowledge).

There are some clear guiding principles in determining where the line between blame-free mistakes and accountability:

Intent. Before we can determine whether or not a person should be disciplined for a particular action, we need to understand the root cause of the decision. It is unjust hold an individual accountable for acting with the best intentions – a nurse who violates a policy to save a critically injured patient, for example. Unfortunately determining intent is fraught with difficulties primarily because one need only lie about his or her intent to be absolved of any culpability.

Capability. Many mistakes are rooted in a lack of capability – the person makes mistakes simply because they are not physically or mentally equipped to do the job correctly. Obviously an organization cannot in good conscious hold a person accountable for mistakes made because a person was incapable of performing a task correctly.

Competency. Often mistakes aren’t mistakes at all. In some cases, what seems like a mistake is actually the way an individual was trained to perform a task. In fact, poor training results in many issues related to the gap between the knowledge a person has and the knowledge a person needs to do the job. This gap introduces variation into the process that can lead to catastrophic outcomes.

There is much work left to be done before safety professionals will be able to strike a balance between just culture and accountability. But this balance, once struck, will likely become the foundation of worker safety for the coming decades.

  • Anthony Russo wrote:

    Very insightful article. One part that stood out to me is the statement that “…as long as people are punished for their mistakes the errors will go unreported…”

    This is an undeniable truth as human instinct is for self-preservation and to avoid punishment, many will hide the deed.

    A culture that supports reporting is imperative. In my opinion disciplinary action is to be for situations of gross negligence or willful intent to circumvent a rule or policy. Occasional lapses in judgement and the occasional “Oops” should never be disciplined as that is the quickest way to get issues hidden from you.

    When these types of situations are reported, they should be analyzed for potential ways to prevent them. Possibly an additional training session or supervisor guidance. Make the employee a benefit rather than get reprimanded, and the reporting will stay true.

    An often overlooked task when something ‘minor’ happens is to extrapolate what could have been ‘major’ in that situation. Pointing this out to an employee can make them realize what could have been where they might not have seen it before, and hopefully prevent that ‘major’ from ever coming to fruition.

    Anthony Russo
    Dakota Software

End Comment -->
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