A just culture is a culture of trust, learning, and accountability. A just culture is particularly important when an incident has occurred, when something has gone wrong. How do you respond to the people involved? How do you minimize the negative impact and maximize learning?
The primary purpose of a just culture, to most, is to give people the confidence to report safety issues. Because then people know that the organization will respond fairly. A just culture should enable your organization to learn from an incident, yet also hold people “accountable” for undesirable performance.
RETRIBUTIVE OR RESTORATIVE JUSTICE?
Most of the guidance available on just culture today—and the typical model adopted by many organizations—considers justice in retributive terms. It asks questions such as
• Which rule was broken?
• Who is responsible?
• How bad is the violation (honest mistake, at-risk acts, or reckless behavior) and so what should the consequences be?
Such a “just culture” is organized around shades of retribution. It focuses on the single “offender,” asks what they have done and what they deserve. But many managers have found that simplistic guidance about pigeonholing human acts does not take them very far. In fact, it leaves all the hard work of deciding what is just, of what is the right thing to do, to them. And it tends to favor those who already have power in the organization. Simply dividing human behavior up into errors, at-risk acts, or recklessness is really not very helpful. Somebody still needs to decide what category to assign behavior to, and that means that somebody needs to have the power to do so. There is little evidence that organizations with such schemes actually learn more of value from their incidents. Indeed, it is widely held that learning and punishing are mutually exclusive. And should an organization tasked with delivering a product or service be in the business of sanctioning or punishing its people at all?
Fortunately, restorative approaches to justice have been getting more attention. That is a great development—also for organizations wishing to adopt such practices themselves. Restorative justice asks very different questions in the wake of an incident:
• Who is hurt?
• What are their needs?
• Whose obligation is it to meet those needs?
Such an approach to justice and accountability is more inclusive than a retributive one. A variety of people can get hurt by an incident: not just the first victims (patients, passengers) but also the second victim(s): the practitioner(s) involved. Colleagues, the organization, the surrounding community—they too may somehow have been affected by the incident. Hurt creates needs, and needs create obligations. Restorative justices is achieved by systematically considering those needs, and working out collaboratively whose obligation it is to meet them. The second victim may have an obligation to meet the needs of the first, as does the organization. The organization, or colleagues, have obligations toward the second victim (as well as the first). Even first victims can be asked to acknowledge the humanity of the second victim, recognizing that they hurt as well. Reaching a restorative agreement requires that all affected people are involved and have their voices heard. That is hardly ever the case in retributive approaches. Retributive justice might be limited to a boss and an employee. Restorative justice involves them but also the community: first victims of the incident, colleagues, other stakeholders.
In both retributive and restorative approaches, people are held accountable for their actions. Nobody gets “off the hook.” Retributive justice asks what a person must do to compensate for his or her action and its consequences: the account is something the person has to settle. Restorative justice achieves accountability by listening to multiple accounts and looking ahead at what must be done to repair the trust and relationships that were harmed. This makes it important for others to understand why it made sense for the person to do what they did. Their account is something they tell. This also offers an opportunity to express remorse. Restorative approaches are open to multiple voices, and are willing to see practitioners not as offenders or causes of an incident, but as recipients or inheritors of organizational, operational, or design issues that could set up others for failure too. Restorative approaches are therefore more likely to identify the deeper conditions that allowed an incident to happen. They are better at combining accountability and learning, at making them work in each other’s favor. Where retributive approaches to a just culture meet hurt with more hurt, restorative approaches meet hurt with healing, and with learning.
JUST CULTURE AND SUSPICIONS ABOUT THE “SYSTEMS APPROACH”
We can trace the popularity of “just culture” to a relatively recent anxiety about “the systems approach.” The systems approach says that failure and success are the joint product of many factors—all necessary and only jointly sufficient. When something in your organization succeeds, it is not likely because of one heroic individual. And when something fails, it is not the result of one broken component, or one deficient individual. It takes teamwork, an organization, a system, to succeed. And it takes teamwork, an organization, a system, to fail.
Some people started fearing, though, that this gets people off the hook too easily. That it might allow them to “blame the system” whenever things go wrong. Even when all system provisions to do the right thing were thought to be in place.1 Safety thinker James Reason asked in 1999: “Are we casting the net too widely in our search for the factors contributing to errors and accidents?”2 It seemed as if the system approach made it impossible to hold people accountable for poor behavior. Were we no longer allowed to blame anyone? Patient safety champions Bob Wachter and Peter Pronovost observed
…beginning a few years ago, some prominent … leaders began to question the singular embrace of the ‘no blame’ paradigm. Leape, a patient-safety pioneer and early proponent of systems thinking, described the need for a more aggressive approach to poorly performing [practitioners].3
They proposed a retributive just culture program by listing the patient-safety practices that they declared to be beyond the reach of system improvements. Particular attention was given to hand hygiene or signing a surgical site before operating on the patient. Even when everything was in place for clinicians to do the right thing, many still refused, or forgot, or ignored the rules. What should a hospital do with them? Well, said Wachter and Pronovost: hold them accountable. That is, sanction them, punish them. Take a more “aggressive approach.” This was no longer a system problem: it was an accountability problem. And so they suggested penalties for individuals who failed to adhere to such practices. These included, for instance, revocation of patient care privileges for certain periods of time. The length of the punishment depended on the severity or frequency of the “offenses” committed by the clinician. Their proposal made it into the prestigious New England Journal of Medicine. A swift response by a colleague and me was published there soon as well.4
The appeal to punish noncompliant practitioners (or “hold them accountable”) is part of a string of such calls during the 1990s and 2000s. Aviation safety researchers, concerned at the enthusiasm of investigators to find all sorts of system precursors and “latent conditions,” called at one of their conferences for a refocus on active “errors” by front-line workers rather than mitigating factors in the system.5 Sometimes, they argued, accidents are caused by people at the sharp end—it is as simple as that!
At times, it seemed as if the systems approach itself was on trial.
A concerned surgeon wrote that hospitals have a big problem with unnecessary deaths from medical errors. And the numbers have remained high despite concerted efforts to bring them down. Why? Because we’ve embraced a so-called solution that doesn’t address the problem.
For the last 14 years, the medical profession has put its faith in a systems approach to the problem. The concept was based on the success of such an approach in the field of anesthesia decades ago, but it had been insufficiently tested in medicine overall. And today, despite a widespread embrace of systemized medicine in hospitals across the country, the number of unnecessary deaths hasn’t dropped significantly. There’s a simple reason for that: Most preventable mishaps in hospitals are caused by the acts of individual practitioners, not flawed systems, and there is plenty of evidence of that fact available.
In 1991, for example, a Harvard Medical Practice Study examined more than 30,000 randomly selected records from 51 hospitals. A table in that study attributed some 61% of harm to patients to either errors of technique (during surgeries and other procedures) or to a failure of doctors to order the correct diagnostic tests. These are both errors of individuals, not systems. The same study found that only 6% of adverse events were due to systems problems.
And studies have continued to draw similar conclusions. A 2008 analysis of 10,000 surgical patients at the University of South Florida found that, of all the complications among those patients, only 4% were attributable to flawed systems. The rest resulted from individual human shortcomings … including poor history-taking, inadequate physical examinations, or ordering the wrong tests.6
British colleagues agreed, noting the “increasing disquiet at how the importance of individual conduct, performance and responsibility was written out of the … safety story.” To reorient our efforts, they believed, the community would “need to take seriously the performance and behaviors of individual[s].”7
My collaborator Nancy Leveson and I wrote spirited responses in the British Medical Journal8 and elsewhere. When did the systems approach become synonymous with blaming the system or its management for problems and shortcomings? The systems approach argues that the interactions produced by the inevitable complexities and dynamics of imperfect systems are responsible for the production of risk—not a few broken components or flawed individuals. It does not eschew individual responsibility for roles taken on inside of those systems. It does not deny accountability that people owe each other within the many crisscrossing relationships that make up such systems. People working in these systems typically don’t even want to lose such responsibility or accountability—it gives their work deep meaning and them a strong sense of identity.
I have met “second victims” in a variety of domains.9 These are practitioners who were involved in an incident for which they feel responsible and guilty. The practitioner might be a nurse, involved in the medication death of an infant, or a surviving pilot who was at the controls during a crash that killed passengers, or an air traffic controller at the radar scope during a collision or near-miss. Never did I get the impression that these people were trying to duck responsibility, that they wanted to avoid being held accountable. In fact, they typically took on so much responsibility for what had happened—despite their own ability to point to all the system factors that contributed to the incident—that it led to debilitating trauma-like symptoms. In some cases, this overwhelming sense of personal responsibility and accountability even drove the practitioner to commit suicide.10
You will encounter in this book the case of a New Zealand surgeon, who was criminally prosecuted for a number of deaths of patients in his care. What received scant attention was that he was forced to operate with help from medical students, because of a lack of available competent assistance in the hospital that had hired him. Prosecuting the surgeon, who had little control over the context in which he worked, did not solve the problem. It would have similarly affected other clinicians working in that environment. In such cases, blame is the enemy of safety. It finds the culprit and stops any further exploration and conversation. Emphasizing blame and punishment results in hiding errors and eliminates the possibility of learning from them.
Nobody wants to unjustly sanction practitioners for their involvement in an incident. Nobody wants to jeopardize organizational learning by threatening people who disclose their mistakes. Unreflectively or arbitrarily punitive regimes destroy the opportunity to report safety issues without fear of sanction or dismissal. This is why you want to put a “just culture” policy or program in place. It might seem so simple. But justice, accountability, and trust are all hugely difficult to define and agree on. They are what social scientists call “essentially contested” categories. Reasonable, smart people can forever debate their meaning. What is considered just by some might be seen as a deep injustice by others. If you want to get anywhere with a just culture, you have to acknowledge the existence of multiple ways of thinking about those categories. Your point of view is not necessarily right, just like nobody else’s is. You have to commit to learning about, valuing, and respecting those other ways too.
A JUST CULTURE HAS MORE ADVANTAGES
The main argument for building a just culture is that not having one is bad for both justice and safety. But there is more. Recent research11,12 has shown that having a just culture can support people’s
• Morale
• Commitment to the organization
• Job satisfaction
• Willingness to do that little extra, to step outside their role
Indeed, the idea of justice seems basic to any social relation, basic to what it means to be human. We tend to endow a just culture with benefits that extend beyond making an organization safer. Look at the hope expressed by a policy document from aviation, where a “just culture operates … to foster safe operating practices, and promote the development of internal evaluation programs.”13 It illustrates the great expectations that people endow just cultures with: openness, compliance, fostering safer practices, critical self-evaluation.
Now it may seem obvious why employees may want a just culture. They may want to feel protected from capricious management actions, or from the (as they see it) malicious intentions of a prosecutor. They want to be recognized when they get hurt, they want their needs responded to, and also to have an opportunity to contribute to healing when they can. But this oversimplifies and politicizes things. A just culture, in the long run, benefits everyone.
• For those who run or regulate organizations, the incentive to have a just culture is very simple. Without it, you won’t know what’s going on. A just culture is necessary if you want to monitor the safety of an operation. A just culture is necessary if you want to have any idea about the capability of your people, or regulated organization, to effectively meet the problems that will come their way.
• For those who work inside an organization, the incentive of having a just culture is not “to get off the hook,” but to feel empowered to concentrate on doing a quality job rather than on limiting personal liability, to feel involved and able to contribute to safety improvements by flagging for weak spots, errors, and failures.
• For those in society who consume the organization’s product or service, just cultures are in their own long-term interest. Without them, organizations and the people in them will focus on better documenting, hiding, or defending decisions—rather than on making better decisions. They will prioritize short-term measures to limit legal or media exposure over long-term investments in safety.
ABOUT THIS BOOK
I wrote the first edition of Just Culture (Ashgate, 2007) on the back of a trend toward the criminalization of human error in aviation, healthcare, shipping, and other fields. This concern about criminalization hasn’t gone away, to be sure, and the coverage of it still has a prominent place in this third edition. Also, the psychological and sociological mechanisms inherent in criminalization (the power to draw the line, the power to call an act by a particular name, the power to attach sanctions to it) are not very different from what we see in other accountability relationships—even those inside organizations.
But in the years since publication of the first and second editions, I have met managers who struggle with the creation of a just culture themselves. This may or may not be influenced by what happens in society or law or regulations around them. What should they do internally? How should they respond to incidents, errors, and failures that happen on their watch?
So what will you find in the third edition of Just Culture? Chapter 1 develops the differences and commonalities between retribution and restoration more fully, giving you a good overview of the options open to you. Chapter 2 then asks a basic but often unasked question: Why do your people actually break the rules? It runs through a number of possible explanations, based on what we know from the literature about deviations so far. Each explanation suggests a different managerial or regulatory repertoire of action. Chapter 3 runs through what we currently know about honest disclosure and safety reporting—two of the typical organizational goals that a just culture is supposed to support. Chapter 4 moves out of your organization and into the surrounding environment, focusing on the criminalization of human error. This matters: it sets constraints and creates opportunities for what you can do inside your organization. Chapter 5 summarizes what you might want to do now. It puts the things you should probably do and questions you should probably ask in a manageable order and format for you. And it asks, What is the right thing to do when things go wrong? This chapter will take you through some of the basics of moral thinking that might guide you toward ethical answers on the right thing to do.
You will find case studies mixed throughout this book. These sections introduce people’s experiences and stories and invite you to reflect on them. Some of the guiding principles are great, you might think. But why are they even necessary? And how would they work in practice? How can you operationalize this? By offering you live experiences from the cases, this book makes the issues more “alive” and helps you address some of those questions.
ABOUT JUST CULTURE, ABOUT ME
A just culture is not a particular program or blueprint. There is no “pure” model that is ideal to implement in any community. You cannot buy a just culture off the shelf from a consultant. Because it won’t be a culture, and it will very likely not be just. Nor can you get a just culture by simply reading this book, or by getting your people or managers to read it.
Some of the more exciting and innovative practices for creating trust and accountability in organizational cultures have become visible after these things were first written about. They have emerged through dialogue, experimentation, practical innovation, human courage. Of course, the creation of a just culture can be guided by principles. Why would you otherwise even read a book about it? But you should never see these principles—or anybody’s principles about just culture—as your algorithm, your policy, your program for how to achieve one. A just culture can only be built from within your own organization’s practice. The various ideas need to be tried, negotiated, and bargained among the people inside your organization. And you need to test them with the various stakeholders that surround your organization, who want their voices heard when things go wrong. But most of all, you need to test them against your own voice, your own stand.
If you think this is hard, you are right. It is. Creating justice has been one of the most vexing challenges for humanity—ever. You are unlikely to suddenly solve the creation of justice in your own organization in a way that will satisfy everyone. But if you think it is too hard, you are wrong. Because not seriously thinking about it will make things even harder. A consultant who promises to deliver you a just culture with some algorithm or program may offer you the illusion that you’ve solved it. But justice and culture are not for sale. They are things you cannot purchase. Justice and culture emerge from the way you relate to other people, from how you listen to their stories and concerns, from the ethical principles you stand for and from how you govern your business, from the trust you gradually build up: the trust that is so easy to break and so hard to fix. You can be guided in how to do this, for sure, and you can ask or pay others to help you with this. You can be guided to do it better, to do it more humanely. You can be taught to do it with more patience, with more consideration, with more knowledge and wisdom. And I hope that this book will also help you with that.
Since the first edition of Just Culture came out in 2007, some people and communities have considered me one of the founding developers and advocates of the concept. This may or may not be true. Over the years, I have in any case tried to remain critical of the various perspectives on just culture (including my own) and open to other ideas. Hence this third edition. It speaks more directly to you if you struggle to create a just culture in your own community. And it examines more broadly and deeply the retributive and restorative options open to you.
But I come with a bias, just like everyone else. I have sat across from second victims on multiple occasions. It moved me to indeed publish a book under that very title (Second Victim, CRC Press) in 2013.9 These encounters inevitably turned the offending practitioners into normal people, hurting people, vulnerable people: people like you and me. These were not people who came to work to do a bad job. They were not evil or deviant. These were people who did what made sense to them at the time, pretty much like it would have made sense to any of their colleagues. But the consequences of an incident can be devastating, and not just for the first victims. The consequences can overwhelm the most resilient second victims too: even they are often still not adequately prepared—and neither is their organization. In one case, the second victim was murdered by the father and the husband of some of his first victims. In many others, the second victim just muddles through until the end, having lost a job, an identity, a profession, a group of colleagues, a livelihood, a dream, a hope, a life. It is only with considerable support, patience, and understanding that a community around them can be restored, and the trust and accountability that go with it.
So my writing, like any author’s, has been formed by those relationships. They have shaped my voice, my vision. In all of this, I endeavor to stay true to my commitments. Even that is an eclectic mix of commitments—a commitment to the voice from below, for instance, and a commitment to justice over power. It involves a commitment to diversity of stories and opinions, but also a commitment to critical thinking, open-mindedness, relentless questioning, and reflection. And it ultimately comes down to a commitment to my own ethical stand: doing our part to help build a world where we respond to suffering not by inflicting even more suffering on each other, but where we respond to suffering with healing.