Thursday 30 August 2018

Applying a "just culture" to learning from mistakes

The "just culture" is a midpoint between a Blame culture, and a culture of hiding failures. But how does it work?

Any organisation that aspires to learn, and to gather knowledge, must be able to learn from mistakes and failures. However this is a difficult thing to do, especially where failure may have fatal consequences. People often fear they will be blamed unjustly, and refuse to share knowledge of what happened.   Where such blame is frequently unjust, then we have a "blame culture"; a culture where people are blamed even when it was the system that failed, rather than an individual.

However sometimes people need to be blamed. Sometimes they were negligent, or acted as saboteurs. The opposite of a blame culture is a laissez-faire culture, where people can do what they like without fear of consequence.

What is needed is a just culture - where people are not blamed if the system failed. Such cultures are developed in aviation (see this Just Culture toolkit from Skybrary) and the emergency services, and other sectors such as medicine are attempting to adopt the same approach.

One of the clearest descriptions I have seen is the diagram, reproduced below from the Australian Disaster Resilience handbook on Lesson Management, and based on the ICAM incident investigation process. 

In this diagram we see the difference between the individual at the left side of the diagram who followed all rules and procedures and who is free from blame of any failure, but may still need counselling and coaching if the failure was distressing or serious, and the individual at the right side who deliberately violated clear workable procedures in order to engineer a failure, and who is totally to blame.

In most of the cases in this diagram the problem lies at least partly with the system, and the right response is to correct the root cause. This is a just approach to blame. 

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