What does our model of accountability look like?

A Just Culture, an Accountable Culture, is a result as much as it is a set of management skills and tools that make it possible. The Outcome Engenuity model has consistently transformed organizational environments from the inside out. Everyone gets on the same page. Everyone is made aware of the companies’ values and how they are expected to make choices that protect them. Everyone is an active part of the plan and the solutions. Everyone is trained and held to achieve equal accountability.

Core Values Concept- Just Culture

Perhaps the best way to convey this is by explaining what an organization looks like that has integrated our accountability model into their way of doing business. This organization, like many others, has a mission. Its pursuits and reason for being are grounded in certain values it has determined are most important to it. Now imagine every employee protects those values by the choices they make and how they accomplish their duties.



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Of course, what life tells us is that people not only can, but will, make mistakes. Sometimes these mistakes hurt others or cause harm to the company; aware of that, this company has designed a system that can catch those errors before they become critical. If they do become critical, they have designed recoveries to stop or reduce the bad outcome.



This organization has the Outcome Engenuity Workplace Accountability model, also known historically as Just Culture, which helps it to constantly improve its systems at the core because its employees feel safe to raise their hand when they see a mistake or made an error or bad choice so the system can be updated and improved to help catch those events. This is a company that learns from its mistakes and near misses. It’s efficient because its expectations are clear. Its stable because it’s always learning. It’s profitability is strengthened because it is more efficient, stable and the risks are proactively managed. Employee morale is high since every person is treated fairly and is empowered to do the best within their positions.

The foundation of our proven model is in managing three types of behavior, against three types of duties, within a framework of five skills upheld by the organizations leadership and staff. Click each item below to find out more:


Our model of workplace accountability identifies 3 types of behavioral choices that every person makes and needs to manage.

1. Human Error
An inadvertent action. A slip, lapse or mistake.
2. At Risk Behavior
Choosing to do something in a way that unintentionally can impose a chance for harm to occur. The potential for harm is increased but is not recognized by the person drifting away from consciously safer choices.  Driving while talking on the cell phone is a good example of At Risk Behavior.
3. Reckless Behavior
Choosing an action that knowingly puts themselves or others in harms way. The risk is identified but ignored.


It holds its people accountable to one or more of those behavioral choices when they carry out three types of duties or expectations. These three duties are defined as:

1. The duty to avoid causing unjustifiable risk or harm.
Simply put, don’t do anything that is intentionally reckless. Yet at times we may need to make a choice to do the right thing where it protects life for example but may breach and harm another value in the process. The key word here being “unjustifiable”.
2. The duty to follow a procedural rule.
This is where we are expected to follow a procedure or policy in a specific way. Usually this is designed by the organization or some other type of entity that governs what the result should be and how this activity should be carried out.
3. The duty to produce an outcome.
Here you are free to create your own system of doing something but an expectation of a defined result is in place. Also a pre-determined acceptable rate of failure may be determined to manage the expectations. A good example is the requirement to get to work on time. The company sets the expectation and you set your own system up to make that happen. Your duty to produce their expected outcome. How many times per month you may be allowably late is determined by the company policy.


These behaviors and duties are at the core of the 5 skills a company applies to make this transformation possible. 

1. Values and Expectations
They should be reasonable and doable. Keeping in mind that employees will make mistakes and that systems will fail. Yet when people and systems are working together – great things can happen.

2. System Design
The company approaches system design in a way that allows its employees to strengthen it by their choices while it catches and recovers human errors and mechanical failures.

3. Behavioral Choices
The company directs and manages the behavioral choices of its employees. It does this by not punishing an unintended mistake, by coaching a person away from taking unidentified or unintentional risks and punishing the rare choice that someone may make that is reckless and knowingly dangerous.

4. Learning Systems
This company is driven to learn from its mistakes. It has learning systems that capture valuable data about events and performance. It encourages input from its people where they feel safe to raise their hand when they’ve made a mistake so it can be caught and they can contribute to the design of a safer and improved system.

5. Accountability and Justice
It treats every individual and event with consistency and fairness. It realizes the cause of an unwanted event could equally be from a system failure as much as it could be from a human error or risky choice. It all works together and responds in an unbiased and fair manner regardless of how severe the occurrence was.



The Just Culture AlgorithmTM is our primary tool for understanding and categorizing the choices of those in our organization. With it, we can evaluate an event based on a set of duties inherent to the system in order to determine which of the three behaviors was most likely in play. This gives us the ability to address the event and the people involved in a constructive way rather than simply reacting to the outcome. It can also show us how multiple behaviors can be associated with a single event, so that we can evaluate each behavior separately in order to more effectively determine the root cause.


Company wide performance and organizational improvements, where equity, fairness and accountability live at the forefront, that is a Just Culture. For the sake of our staff, those we serve and ourselves, we all need it.



You can watch the 43 minute webinar video recording provided below. It is presented by one of our advisors, Ellen McDermott. In it she does a very good job of further introducing Just Culture in a simple and comprehensive way, while still diving into the questions you may have before moving further.


Watch the 20 minute What is Just Culture video by David Marx.  Watch the Top 10 Questions – FAQ videos answered by David Marx, JD and CEO of Outcome Engenuity. Some of these questions answered are submitted by others going through the various stages of rolling out a Just Culture in their organizations.  With every organization and every role of a given position being unique, the importance of certain Just Culture concepts may be emphasized accordingly. This is another option to consider with those as potential insights when watching those 10 videos.


Contact one of our wonderful Client Relations Specialists. You can call or email us with any questions at all. We always enjoy sharing the good news of Just Culture and learning about the needs  of others and how we can connect the solutions for a custom fit for your organizational development. 


Check out the Just Culture Overview and share it with the other need to know leaders of your organization. We also have industry specific versions here: HealthcareEMSAviation.

Also consider reviewing “The Final Check or visit our website . Here you will see how we chronicled a hospitals use of Outcome Engenuity’s  Just Culture principles and tools to solve a serious risk to its patients that kept occurring.


Review some of our training topics and supportive tools. With great care and consideration we have meticulously developed world class live certification courses, online training classes, a printed and electronic interactive version of the exclusive Outcome Engenuity Just Culture Algorithm™ an Organizational Benchmark Survey,  analysis tool and more. Looking through some of those product and training descriptions may help you define some of the solutions of most interest to you right now.


Roll the dice and continue business as usual. Well we would call that At Risk behavior and we don’t recommend that. Doing nothing will potentially keep you from harvesting the organizational improvements that a Just Culture is proven to provide. You see the truth is we are all fallible humans who will make mistakes. We will drift into behaviors that don’t support the best values. We will hide the important information of an error if we continue to get punished for not being perfect. We will continue to lose precious profit and our resources will get tapped by bad outcomes and lack of performance. We hope you would decide to join the community of worldwide organizations which are living out the Just Culture everyday and are supporting each other in ways to make the world a better place to live. A more just and fair culture for us all.


15 thoughts on “What does our model of accountability look like?

  1. KENNY says:

    Is there a way to make just culture a mandatory law in all hospitals…the nurses are under so much stress that they need education not punishment.

    • Ellen McDermott - OE Advisor says:

      Kenny – I hear you. That stress you describe is a heartbreaking natural byproduct of the punitive culture that we at Outcome Engenuity work to change. Please take heart – leaders are taking a stand and supporting Just Culture as the right way to do business. You may be inspired by watching this video of Sandy Coletta, President and CEO of Kent Hospital, taking such a stand. The number of executives committing to Just Culture is increasing rapidly and someday I am confidant will see Just Culture integrated into our laws and regulatory bodies. http://vimeo.com/65249818

  2. oracle2world says:

    I just became aware of this site from a psychologist. I think you touched upon this, but I wanted to expand on one point.

    Statistically speaking, there will be “false positives” in a system, and punishing people who come forth, in good faith, to provide information germane to a process should instead be assured they did the right thing.

    As far as the saying “crying wolf”, few people have ever read the fable and caught on to the significance. The boy KNOWING knew he was giving false information. It is when people fail to speak up, is when really bad things happen.

    Airplane accident reports from NTSB illustrate this. Airplanes are complex systems, and small errors, more than one that cascade, end up with a crash. Tenerife illustrates this. The flight engineer of the KLM jet questioned the clearance for take-off – twice. He was ignored. See http://www.tenerifecrash.com/transcripts.htm for a transcript.

    Had the captain listened, and double-checked, the captain would look bad, so the flight engineer’s career was ended regardless. A cultural thing.

    If there are no false positives in a process … figure some real positives are getting overlooked. For the little guy, there is just nothing in it for them to speak up. For plane accidents, it is something usually very innocuous that starts the cascade.

    The American Airlines flight 587 crash was a software error, that does not appear in analysis of the crash. (No one in software is going to own to that one, that is career ending.) The reports go on and on about hardware, training, pilot error, etc. … but poor software design was the final straw.

    • Ellen McDermott – OE Advisor says:

      Dear ORACLE2WORLD, I like your analogy of the Boy Who Cried Wolf. If someone offers a risk report, and believes it to be truthful and pertinent, absolutely there’s the possibility they’ll get it wrong. We are only human and we make mistakes. But if the person intended to do the right thing then we will celebrate that. This is very different than if a person knowingly falsifies a report, or “cries wolf.” This person intends to create harm or risk in our system. and thus this quality of choice would be met with the appropriate accountability.

      I appreciate your comment of “[i]f there are no false positives in a process…figure some real positives are getting overlooked.” As an organization embarks upon their Just Culture journey they often see a significant increase in risk reports. It is not because the organization is suddenly riskier, but because people now feel encouraged and supported to report perceived risks.

      ORACLE2WORLD I hope you get a chance to join us in one of our classes and thank you for your interest in Just Culture!

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  4. John Morris says:

    There is a strong emphasis on reporting as a feature in a Just Culture and I understand that the quality of reporting would indicate the penetration of any Just Culture policy. Do you have tools to measure quality in reporting?

  5. John Morris says:

    You have very clear material on the benefits of Just Culture. I am a pilot in a major Airline and am interested in the tools you supply to implement Just Culture. Particularly I am interested in the reporting aspect; where the pilot/employee reports errors/mistakes of their own doing for the benefit of the safety management of the organisation.

    There are obvious requirements that any report should be frank and open, revealing a sense of accountability if it was to be of any value in a Just Culture but companies are not Just all of the time. It would seem important for an organisation to measure the penetration of any Just Culture by the number of reports and by the quality of them. I realise it is more art than science, but do you have any criteria you recommend to measure the quality of reports?

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  7. Ed Griffin says:

    In the webinar, I heard the question regarding recurring human error. Similar, I have a question on recurring at risk behaviors. If following an at risk behavior, an employee is coached….would a recurrence be considered reckless since it would now be understood that an employee was specifically made aware of the associated risks? Equally important, conversely, in order to punish an employee would insinuate a reckless behavior was displayed. To be considered reckless would, in turn, insinuate that an employee knew the potential for increased risk and chose to intiate the behavior anyway., right? It is hard to relate this to the driving while intoxicated example given in the webinar, but is it unjust and inappropriate to punish someone for for a behavior (regardless of result) if the investigation reveals that the employee did not fully understand associated risks?
    How else could I term “risks” if not related to life or death situations, and how can I relate the Just Culture model to typical operations? For example, an employee is given a verbal order to complete an objective (of no particular priority), but fails to complete the action. Subsequently, if coaching is provided to enable the employee to understand why the objective needs to be met, but this “at risk” behavior of failing to complete the objective recurs, is this considered “reckless” and subject to punishment?

    • Ellen McDermott says:

      Dear Mr. Griffin,

      What a great question! Ideally, if you have coached an at-risk behavior, and in coaching you’ve made clear not just that a certain rule exists but the true risk – the “why” behind the rule – then what you are looking at may indeed be reckless if the person now appreciates the risk but continues to take the gamble. However, you may be in a situation where although you’ve coached someone, you may think they still really do not appreciate the risk despite what you’re telling them. In this case, we’re going to honor the person’s perception of the risk and still consider it an “at-risk behavior”; however, now it is repetitive and at some point this warrants stronger measures. If you have an at-risk behavior and you’ve tried learning as much as you can about the situation plus you have coached the person on this at-risk behavior and yet it continues, you may now consider a stronger response – to include a punitive response – for “repetitive at-risk behaviors.”

      Imagine driving 10 miles over the speed limit. We all know we’re breaking a rule. So when we see a police officer on the side of the road we slow down back to the speed limit. But in general we tend to not appreciate the real risk associated with going too fast – the increased risk of a car crash or injury, for example. These risks are uncertain and not immediate, so they tend to be harder to appreciate. So as soon as we get out of line of sight of that police officer, we tend to pick our speed back up…we continue with our at-risk behaviors. Now if we get caught doing this, we get a speeding ticket. The speeding ticket is like a coaching session. But even after getting a speeding ticket, we might still feel perfectly safe driving 10mph over the speed limit and keep doing so. At some point we may have our license revoked for too many speeding tickets even if we still feel perfectly safe – this would be a punitive action for our repetitive at-risk behaviors, and the justification is that we as drivers pose too great a risk to allow to continue to drive.

      As Just Culture leaders we’re going to make sure to categorize the person’s perceptions of the risk accurately – “at risk behavior” as opposed to calling it “reckless” – for two reasons. First, because calling a choice “reckless” does carry with it a stigma – an accusation if you will – that the person understood the unjustifiable risk and yet acted anyway. This accusation is unfair if we truly believe that the person did not see the risk. Secondly, using the right label reminds us as leaders that our work is not done – that if one person couldn’t see the risk, how likely is it that others won’t see the risk, and will we see this problem resurface?

      “Risk” does not have to mean solely life/death or injurious situations. “Risk” is relative to your organization’s mission and values. For example – if a waiter accidentally charges a customer too much for dinner, this is a risk to that customer’s property ($$) and to that restaurant’s mission and values.

      Again – great question! Thank you for asking and please let me know if this wasn’t fully responsive to your questions or if you have any further questions or concerns!

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