The Just Culture Community

Curated by Outcome Engenuity, LLC

Getting To Know Just Culture

Written by Dave Wise, 2 months ago, 0 Comments

Core Values Concept- Just Culture


With so many ways to make an introduction, maybe the best would be to start off by explaining what a company looks like that has integrated Just Culture into their way of doing business.  A Just Culture company, 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 company has Just Culture concepts which help 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.

A Just Culture is a result as much as it is a set of management skills and tools that make it possible. Just Culture transforms an environment from the inside out. Everyone gets on the same page and 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.

3_behaviors_headerA just culture company identifies 3 types of behavioral choices that every person makes and needs to manage. Click to open each behavior for its explanation.

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.
Image Overview- Click to open

3_duties_headerIt 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: Click to open each duty for its explanation.

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. Click top open each skill for its explanation.

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.

Image Overview - Click to open


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. 


Free downloads of your choice. 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 training 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.