This article explores the process of “how to build a Just Culture”. It is about building trust, about dealing with inevitable mishaps, and about developing the capability in an organisation to look at an incident from multiple perspectives before coming to a judgement.
People in Systems
In his book “Just Culture” Sydney Dekker lays out two views on human error, which can be seen as two ends in the spectrum of the debate on this topic. “The old view”, he states, “sees human error as the cause of incidents. To do something about incidents then, we need to do something about the particular human involved”. On the other hand, “The new, or systems view, sees human error as a symptom, not a cause. Human error is an effect of trouble deeper in the system”. Although both these points of view can be argued, he writes, “they leave an important question unattended: Can people in your organisation simply blame the system when things go wrong? To many, this logical extension of the new view seems like a cop-out, like an excuse to get defective or irresponsible practitioners off the hook. The new view would seem almost incompatible with holding people accountable”.
At this point, Sydney Dekker makes a step which may well describe the heart of what a Just Culture is about:
“... systems are not enough. Of course we should look at the system in which people work, and improve it to the best of our ability. But safety-critical work is ultimately channeled through relationships between human beings (such as in medicine), or through direct contact of some people with risky technology. At this sharp end, there is almost always some discretionary space into which no system improvement can completely reach. Rather than individual versus systems, we should begin to understand to relationships and roles of people in systems.”
A Just Culture may well be about how to act in this Discretionary Space which is not solely governed by logic and laws but also by context, emotions, intentions and ethics. Building a Just Culture is about seeing the actions of a professional in the context of the whole system.
Based on the above, complex environments can only exist and function through an interaction between man and machines. Machines, systems and procedures enhance the capabilities of people and enable them to achieve and influence things way beyond their physical and mental powers. People augment machines by adding a rich, context-based decision making power and ethical reasoning ability that cannot be captured in logic or functions.
In healthy complex environments, people and machines work as partners. They willingly and seamlessly work together to achieve the common goal.
Trouble arises when this relationship is soured. From the point of view of the people in the system, this occurs when they start feeling that the system is not working for them, but is working against them in what they know to be the right action to achieve their goal. This gets even worse if people feel that the system cannot be trusted and acts against their own sense of justice and their personal well-being. If the system is solely there to punish them they will start to avoid working with it, leading to more dangers. Sydney Dekker writes:
“The other thing a system can do is decide how it will motivate people to conscientiously carry out their responsibilities inside of that discretionary space. Is the source of their motivation going to be fear or empowerment? Anxiety or involvement? ‘There has to be some fear that not doing one’s job correctly could lead to prosecution’, said an influential commentator in 2000. Indeed, prosecution presumes that conscientious discharge of personal responsibility comes from fear of the consequences of not doing so. But neither civil litigation nor criminal prosecution work as a deterrent against human error. Instead, anxiety created by such accountability leads for example to defensive medicine, not high-quality care, and to an even greater likelihood of subsequent incidents. The anxiety and stress generated by such accountability adds attentional burdens and distracts from conscientious discharge of the main safety-critical task. Rather than making people afraid, systems should make people participants in change and improvement. There is evidence that empowering people to affect their work conditions, to involve them in the outlines and content of that discretionary space, most actively promotes their willingness to shoulder their responsibilities inside of it.”
So, the key to achieving high levels of safety (and high effectiveness) is the building of trust and the maintenance of willingness to shoulder responsibility in the Discretionary Space of complex systems. Responding justly to inevitable incidents and heartfelt empowerment and acknowledgement of this responsibility are central ingredients to building a good safety culture.
Dealing with inevitable mishaps
Complex industries are run by people. Whether they are process operators, operations supervisors, ship’s technicians, pilots, nurses, air traffic controllers, train drivers or surgeons, they are the specialists that form the heart of our services. They provide the everyday safety that society has come to take for granted. They form part of an essential chain that, together, make up the risk barriers that the industry has in place for protection against hazards.
Although carefully selected, trained and kept competent in what they do for society, they are humans and inevitably, humans will make errors. When people form the final risk barrier, mishaps may occur. Perhaps that is the biggest single fact with which society needs to come to terms.
A particular feature of complex industries, and a significant contributor to the achieved safety level, is the consistent learning from mishaps and safety events to prevent recurrence. When something goes wrong, it is imperative to find out what happened. Frequently this leads to conclusions about people that have made errors of operational, technical or organisational nature. It is then all too easy to point towards these individuals and apportion blame. But if society want these people to perform these jobs, a way to deal fairly and justly with the inevitable human errors that will be made as part of their job must be found. That is why society should insist on a “just” culture in complex industries.
The truth does not exist. Truth is an individual perception based on the perspective from which a person looks at things. What is true for one person is not necessarily true for another. One could say that there are always multiple valid perspectives on any situation. A sense of injustice occurs when people feel a situation is judged on the basis of a singular perspective that they consider not to be (completely) true, or if they feel that their perspective is also valid but has not been taken into account when assessing a situation.
It is not possible to take all perspectives into account, and when a person or group of people judge a situation they essentialy say: “This perspective, this way of looking at things, is good and valid and from this perspective what happened is good or bad”. If one judges too quickly, or judges on the basis of preconceived ideas, one runs the risk of being blind to important viewpoints and the subsequent judgement can quickly lead to a sense of injustice. If, for example, people look at the world thinking “Professionals do not want to stick to the rules and you need to punish them to keep them disciplined”, one will be quick to see proof for this idea and all subsequent actions will be aimed at punishing them. One will not be able to take into account the viewpoint of the professional (after all, these are unwilling people!) so one will dismiss it, no matter how valid their point might be. Ever heard of the term “What You Look For Is What You Find” (WYLFIWYF)?
Building a Just Culture is about developing the skill to take into account many viewpoints into decision making, without prejudices.
The Just Culture Experience
Taking into account the above, it is interesting to think about the question “How would people experience a Just Culture?”. The term Just Culture is common in the aviation world and is described by the Eurocontrol organisation as: “a culture in which front line operators or others are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training, but where gross negligence, willful violations and destructive acts are not tolerated”.
A broader description of how people would experience a Just Culture can be given by “broad brushing” some of the characteristics that describe the most important features of an organisation that ‘has’ a Just Culture.
All of the organisation’s staff have their own responsibility to act safely in whatever they do. They are aware that they fill the discretionary space in the system, and are entrusted to do so. They are responsible for their competence in the job and fitness for duty. Where appropriate, they carry a license. They act in accordance with their training and professional standards for their job. They adhere to written procedures. If, in the interest of safety, it is necessary to deviate from procedures, they will do so and give full account. They show teamwork and actively support co-workers during their services wherever appropriate. If unexpected things come up, even events that (nearly) go wrong in which they are involved, they are keen to take responsibility and learn what they might have done wrong so they can improve and the system can improve.
In the organisation all of the staff is appreciated as the most value-adding asset. They fill the discretionary space with cannot be reached by systems or procedures, and their capability to decide, judge and act is essential to the working of the whole system. The organisation provides them with the right environment, the right tools, the right training and the right procedures that are necessary to perform the job. Never is the staff brought into situations that could be harmful to them or others.
The personnel is clear, that in the interest of safety, the organisation wants to know, at all times, about unsafe events, unsafe situations that have presented themselves or could arise. They are keen to step forward and speak up when they perceive a situation as dangerous, think of a procedure as risky, or any other issue in their daily tasks that they judge as potentially harmful and is yet without good remedy. This specifically includes any situation or event that involves themselves.
When mishaps do occur, the organisation attempts to repair the situation as best as possible and restore the operations to normal. The organisation provides compensation for those that have experienced personal loss or damage. The organisation tries hard to prevent that same event from happening again. A case is not closed by condemning or finding the guilty one, but by discovering the underlying problems in the system, by rectifying this and by repairing the damages done. Everybody participates in this effort.
Protection and support
When it becomes apparent that staff has made an error, the organisation will neither assume nor seek personal fault or guilt. There is a strong belief that punishment is counterproductive to safety. The organisation investigates why this error was made and what can be done to avoid them or to mitigate the effects for future operations. The workforce is protected as best as possible from negative consequences resulting from human error or subsequent investigations and in principle the organisation will defend and support people should external prosecutions or litigations target them.
No tolerance for unacceptable behaviour
The above statements do not mean that ‘anything goes’. The organisation does not tolerate gross negligence, deliberately unsafe acts or recklessness from the staff, regardless of the outcome. There is constant discussion with the staff what the right professional behaviour is for their jobs and where the boundaries of tolerated and non-tolerated acts are. The organisation leaders and staff agree about what the consequences are if these norms are crossed.
Just Culture in an Organization
Practical example of Just Culture in an organization - EUROCONTROL video:
Illustration of Just Culture Evolution