Integrating the Just Culture Concepts

When working with organizations, we are often asked how they might better instill the Just Culture concepts into the “daily routine” of their operations. A common belief is that the use of the algorithm and coaching concepts are used only when there is an identifiable “event”, or something with an undesired outcome.

Because the Just Culture concepts have been developed to identify behaviors that are at-risk, integrating the terminology and viewpoints into daily practice before something happens is a more successful approach. Preparation starts with supervisors and managers initiating discussions with their staff on the primary risks inherent in their job area, and outlining some of the expectations associated with behavioral choices.  This is commonly done during regular staff meetings, where the supervisor can introduce the foundational aspect of Just Culture, where the organization focuses on the behavioral choice instead of the actual (or potential) undesired outcome.

Discussing how the organization will manage Human Error, At-Risk Behavior, and Recklessness is important. It is essential, though, during early integration efforts, for the supervisor to define how at-risk behavior presents the largest vulnerability to the customer, the organization, and the employee.

While there are many methods for the supervisor to employ when having this discussion, we have found it to be very helpful when the supervisor takes some time to carefully observe their own behavioral choices at work, and then use some of their own at-risk behaviors to illustrate the concept and the possibility of harm. “Humanizing” the behavior makes it real for the employees, and they are more willing to open up to a conversation about short-cuts in their department or environment when the supervisor presents actual examples and “owns” their personal potential for engaging in the behavior.

Importantly, supervisors need to be prepared to regularly use examples at every opportunity. Informal meetings or discussions are the perfect place to embed the concepts, and before long the expectations associated with a Just Culture become second nature.

Once we have identified where someone has breached a duty (or duties), we, as a supervisor, are compelled to use the algorithms in order to evaluate the quality of the choice. A common error supervisors make is that they believe they are simply judging the employee who breached the duty.  The supervisor forgets that the event investigation process and the algorithm are best used to develop a healthy curiosity about the system and the behavioral choices that are being made within the area they manage or control. Good supervisors are, in effect, “Looking in the mirror” as they go through the algorithm and event analysis.

Supervisors who know this appreciate that the very first question being asked under both Duty to Produce and Outcome and Duty to Follow a Procedural Rule (Was the duty known…) is aimed at clarifying whether the employee and their peers knew and understood their duty. This is directly related to the expectations we set as imposers.

Additionally, when we ask “Was it possible to follow the rule”, we are checking to see whether it was physically and logistically possible for the employee to follow the rule as it is written and used. For example, a client discovered that their rule required taking inventory at the beginning of each shift, a process that objectively took between 20 and 30 minutes to conduct accurately. However, the rule in place said that employees had “a maximum of ten minutes” to complete the inventory.  In the intervening years between the rule being written and the event, many more things had been added to the inventory, thus making it “impossible” to follow the rule as written.

Supervisors who understand that when they are assessing a breach of duty they are also evaluating their own ability to set expectations, manage risk, and develop a reliable system are generally the most successful in integrating a Just Culture approach.


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