Did the Social Benefit Exceed the Risk?

Just Culture AlgorithmWithin the Duty to Follow a Procedural Rule, there is a block that asks, “Did the social benefit of the breach exceed the risk?” You may ask, how does that actually work within an organizational context?  Well, if you look at that block, there is a small triangle in the bottom right hand corner that says “burden of production falls on employee.” So that’s where the employee will make their case, but then it’s the organization that answers “yes” or “no” to that question. So something happens and employee comes up and makes a case that the social benefit exceeded the risk. That’s where the organization is going to consider alignment with our values and our mission as an organization, and they are going to answer “yes” or “no.” One thing to consider is that if you answer “yes” to that question, you are essentially drawing a line in the sand and saying you are okay with this breach now, and you are going to be okay with this breach for this exact same reason in the future. When you consider the social benefit versus the risk, if you say yes now, you will say yes to that same weight in the future. However, we invite you to consider, if you are not okay with the breach happening again in the future – so you go to that block where it says “Did the social benefit of the breach exceed the risk?” and you answer “no,” you still have the ability within the next block to say “Do I get where this person was coming from?” Did this person in this moment have a good but mistaken belief that the violation was insignificant or justified? If the answer is “yes” to that question, what you’re looking at is At-Risk Behavior. So again, with the social benefit question – it’s where the employee will make their case, and then the imposer will answer “yes” or “no” to that question in alignment with their organization’s values and mission.

Ellen McDermott, Advisor at Outcome Engenuity, discusses this frequently asked question in the video below.

The Consoling Conversation

Consoling ConversationIn the Just Culture model, in response to a person who has made a human error, we suggest that a manager simply console the person. Human beings can experience a sense of loss when confronted with their own fallibility. There may be other emotions such as embarrassment, shame and disappointment felt by the employee who has made a human error. What then is the act of consoling? It is when we seek to alleviate grief, sense of loss or anxiety caused by the event by comforting the employee – our fellow, inescapably fallible human being. [Read more...]

The Importance of Feedback Systems

Feedback (Learning) SystemsFeedback (learning) systems are essential to our stewardship of limited resources, whether it be for our personal or collective happiness.

We are all the product of millennia of trial and error, and of handing down the wisdom of the ages through the generations. This is what makes human beings unique as a species, and how we have been able to utilize the knowledge of our forebears, by being able to record and communicate what has previously been discovered. We don’t have to reinvent the wheel each time. We can build on the knowledge we have been given, each time pushing ourselves further and further along the path of development.

Learning can be a very deliberate activity. While we can design great systems on the front end, we will always fail to anticipate some of the hurdles ahead. Learning from adverse events, and more importantly, learning from our near misses, is essential to our ability to maximize the outcomes we can achieve across competing values, and in the face of very limited resources. Good stewardship requires a good ability to learn.

Excerpted from “The Proposition.” Click here to read The Proposition online.

 

The Role of Event Investigation

Event Investigation ProcessYou have been dealing with adverse events for as long as you have been a manager. However, just as your boss is unaware of most of your errors, you are not privy to most of your employees’ errors. Many times, your employees recognize the mistake, correct it, and continue to perform their duties without significant interruption. At the other end of the spectrum are those adverse events that will receive a full-scale investigation because of their visibility, or the severity (or potential severity) of their outcome. Each of these events, to varying degrees, is relevant to your management of risk. Each is a window into the reliability of your work process, a window through which you can detect the factors influencing human error, at-risk behavior and reckless behavior. [Read more...]

Gaming Procedural Rules

Gaming Procedural RulesGaming procedural rules will happen often. A good example of this is firefighters who have to be at a fire scene or an EMS scene in six minutes 90% of the time. One component is the time it takes them to get out of the fire station. They are told they have to get out within 60 seconds – at the time they were getting out within 90 seconds. So they were pushed, and they were able to get out within 60 seconds. So, it was thought, “this is a great deal – they were able to get out within 60 seconds.” Suddenly, it was noticed that the transit time from going from the fire station to the call was longer by 30 seconds. So, they got out faster by 30 seconds, but it was taking them 30 seconds longer to drive there. [Read more...]

Applying the 5 Skills Model in Managing Outcomes and Minimizing Risk

5 Skills ModelWith the 5 Skills Model, we see work-arounds and people skipping certain steps. When this is the case, we have to ask why, and we need to start looking at incentive-driven behavior. Why does that seem like a good choice? Why is it that between choice A and choice B, choice B is the one that’s consistently being made, when really, choice A is what we had desired to happen. Where did the misalignment come in, and where can we spend our managerial effort bringing that back into alignment? [Read more...]

Integrity Checking Our ‘Procedural Rules’

iStock_000001462120MediumIn the algorithm, we have the Duty to Follow a Procedural Rule. The first question around this duty is “Was the rule known to the employee?” But there’s a step ahead of that – let’s evaluate the rule. If we haven’t done critical thinking, critical assessment and predictive failure modes, or predictive analysis around where those breaches could occur, can we effectively assess it? We’re presuming everything was done ahead of time. We’ve left that system design component out of it; we’ve left that values-based component out of it. [Read more...]

The Balance Between Transparency and Reporting

Balance Between Transparency and ReportingWithin the safety culture domain, there has been a lot of discussion about reporting cultures. The historical thinking is that you develop a reporting culture where the employees and the members of the organization feel free and willing to report so that we can get better outcomes. Well, what is it that we do with the reports? Yes, we will investigate them, we will pull them apart, and we are hungry to learn about them. But the tension comes in when we start talking about reporting and transparency. [Read more...]

Outcome Engenuity announces Just Culture Certification Course for Summer 2013

Just Culture Certification Course

Outcome Engenuity is pleased to announce that its Summer Just Culture Certification Course will be held July 22-26, 2013 in Dallas, Texas. This course will be taught by David Marx, CEO and father of Just Culture, and Scott Griffith, President. It will be held at the Westin Stonebriar, which is about 30 minutes from DFW International Airport. [Read more...]

Setting Expectations Around Duties

Setting Expectations and DutiesIn the Just Culture model, in the teachings that we have around the Algorithm, we introduce the language of duties. For some, it’s a new kind of language – it speaks to legal context and legal contracts, and in fact it’s informed by the 1928 case Palsgraf vs. the Long Island Railroad. We introduce some language around the duty that we all owe each other. We want to spend a moment to clarify how we conceptualize the duty language and what we do every day. If we ask you to do something for us – if we set a task, ask you to complete something, ask you to follow a rule, or ask you just to generally help us out to achieve a result – we have set an expectation. Some of those expectations might be a “just do it” expectation – we’ve asked you to go and do something for us, and now our expectation is that you will get us the result. The counter point of an expectation is that now you have a duty to achieve the result.  [Read more...]

System Design and Behavioral Choices

System Design and Behavioral ChoicesManaging risk within a socio-technical system really comes back to the two inputs: system design and behavioral choices. When we are looking at the system design, we’re really looking at the quality, or more importantly the unreliability, of that system and trying to understand what is making it unreliable. And then we look at the quality of the behavioral choices. The socio-technical system defines the values and expectations, and they are always present, but the two primary inputs are system design and the quality of behavioral choices. And that is what we work to manage daily within the socio-technical system, to mitigate or manage risk. [Read more...]

Justice is the Glue that holds Social Systems Together

Justice in the workplaceLaw 16 of The Proposition starts to really introduce the fact that within the fallible human being, our incentive-driven free will, our imperfect systems, our limited resources – it’s justice that is the glue that holds everything together. We spend a lot of time working with organizations that come to us to talk about justice at first, not because inherently we as individuals feel we are terribly unjust, but organizationally there can either be a perception by our employees that we are unjust. Or perhaps there are customers that are unjust. [Read more...]

Event Investigation

Accident InvestigationWhen we are typically good at event investigation, we can identify where the system failed – one of the components didn’t work, the redundancy system didn’t kick in, or the alarm didn’t go off. And we are pretty good at identifying when someone breaks a rule. Do we really understand why though? Do we pause long enough to peel back a few more layers and start identifying causes – did they break the rule in error, or did they break the rule thinking it was a good thing to do? Were they told to break the rule? Were they often told to break the rule? Is everyone else breaking the rule? [Read more...]

What is your Under-Reporting Rate?

ReportingWhen looking at your reporting system, one of the key factors to understand is not so much what your rate is, but more importantly, what is your under-reporting rate? That’s the specific piece of data that allows you to really start understanding your system. So, if you have 10 events per month, then you must make some assessment about whether that’s a picture of the reality or just a partial view. Understanding the under-reporting rate helps us get to a point where we might start seeing the reality of our system and allows us to have some intellectual honesty about it. [Read more...]

A Breakdown of the 16 Design Laws

It starts with the individual. Each individual has their own personal pursuit of happiness, whatever that may be. They also have their own free will – they have the ability to choose their path. They will make mistakes and poor choices, but that’s generally how they will navigate through life. They will value their life, liberty, and pursuit of happiness – and property interests as well. [Read more...]