The consoling conversation is one that acknowledges the event and the emotions of the employee, and seeks to provide an appropriate comforting response. The employee and manager should also choose to discuss the human error to better understand how it occurred and how it can be managed in the future. Be prepared to become skilled at consoling and at looking at the system to consider improvements to limit further errors.

Excerpted from the Just Culture for Managers™ training course. Click here for more information on this and other available courses.

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.

You 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.

We begin our discussion of event investigation with the key questions you should answer in your data collection process.

• What happened?
• What normally happens?
• What does procedure require?
• Why did it happen?
• How was the organization managing the risk?

Excerpted from the “Just Culture for Managers™” training course. Click here for more information on this and other available courses.

These are not “bad” people; they weren’t doing this to intentionally violate a rule or policy. They simply did not see the value in needing to do it in 60 seconds, or they figured out it’s really impossible to comply with the 60-second rule since it takes about 90 seconds to put all of their gear on. For that reason, they figured a way around it. They figured out a way to fix that to meet their employer’s requirement, but to still do things the way they wanted to do them.

Paul LeSage talks about this professional example of a workaround and discusses human nature to game the system in the video below.

We need to ask open-ended questions, teaching critical thinking around the sixteen design laws. We should keep coming back to the 5 essential skills making values-based decisions, really critically looking at reliability in the system and the integrity of the system. We need to look at the behavioral choices people make, and at the error rate that’s occurring and how we can affect it by improving those behavioral choices. But we do so understanding that how we respond to people and how we apply justice will directly influence the success of the whole model.

Fiona Lawton stresses the value of applying the Five Skills model in managing outcomes and minimizing risk in the video below.

You and I are evaluating an event and we decide that they breached a rule. But before we hold someone accountable for a breach of our rule, let’s ensure the integrity behind the rule. If it leaves many paths open, well then we can predict that we are going to have many options and many different ways to fail. If it was prescriptive, then we’ll say, “Was that the best way to get that result?” If the rule cannot achieve the desired outcome in the first place, for the collective benefit we need to reassess the rule.

Let’s critically evaluate the rule, look at some integrity checks and some predictive failures when using the rule, and determine how all of that could impact the results we’re designed to have. Now with integrity around that process, follow the rule and we will support you. Knowingly violate the rule and our accountability discussion is going to sound different.

Fiona Lawton discusses the need for integrity in setting procedural rules in the video below.

Fiona Lawton talks about the balance between transparency and reporting in organizations in the video below.

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.

The Just Culture Certification Course is a five-day training program designed to help organizations achieve better outcomes, pursue sustainable and positive culture change through learning and justice, and reduce adverse events. 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.

Leaders from a wide variety of industries come together to earn certification as Just Culture Champions. This allows them to return to their organizations with the skills they need to affect change and improve their systems, showing them the path of the Just Culture journey. “You and your champions must be voices of reason,” said CEO David Marx. “Everyone has an opinion about justice – it is through Certification Training that we give your champions the voice to carry the conversation, to lead the cultural change.”

For more information and to register for the course, visit JustCulture.org, email info@outcome-eng.com or call 866-785-0204.

About Just Culture

“Just Culture” is a process to implement organizational improvement, presenting a set of design laws that influence the ability to create desired societal outcomes. The five-skill model is designed to help change an organization’s culture by placing less focus on events, errors and outcomes, and more focus on risk, system design and the management of behavioral choices. It does this by defining three manageable behaviors based on an event’s degree of risk—human error, at-risk behavior and reckless behavior—and it strongly encourages the creation of an environment of free and open reporting within process systems. This helps to build a culture which encourages coaching and honesty at all levels, in order to bring about the best possible outcomes. Just Culture has been implemented by various organizations in such high-risk industries as healthcare, aviation and nuclear power to name a few.

In the Just Culture model, we talk about duties and setting expectations. It’s very important that when we peel back the layers of the duties that sit within the Algorithm – the Duty to Produce an Outcome, the Duty to Follow a Procedural Rule, and the Duty to Avoid Causing Unjustifiable Risk or Harm – what we’re really asking is how did we set the expectation for each other that created the duty for them to create the result. Did we set an expectation for you to just complete a task, leaving how you do it up to you? That falls under the Duty to Produce an Outcome. Did we set an expectation for you to complete a task but to do so in a prescribed or procedural way? If we did set that expectation, the counter point to that is a Duty to Follow a Procedural Rule. Or were we navigating through the complexity of life with the expectation that you will do so without causing unjustifiable risk or harm to others? If so, the duty owed is what we call the Highest Duty – the Duty to Avoid Causing Unjustifiable Risk or Harm.

How we set expectations in our organization clearly and consistently will enable others to truly understand the duty that they owe the organization and those who serve in achieving those results.

Fiona Lawton talks about the importance of setting expectations around the three duties – the Duty to Produce an Outcome, the Duty to Follow a Procedural Rule, and the Duty to Avoid Causing Unjustifiable Risk or Harm – in the video below.

Managing 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.

John Westphal, Advisor at Outcome Engenuity, talks about managing risk through system design and human behaviors in the video below.