Getting To Know Just Culture

Core Concepts Comments (12)

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.

 

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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
2. At Risk Behavior
3. Reckless Behavior
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.
2. The duty to follow a procedural rule.
3. The duty to produce an outcome.

5_skills_header

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
2. System Design
3. Behavioral Choices
4. Learning Systems
5. Accountability and Justice

Image Overview - Click to open

Algorithm_header

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.

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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.

WhatsNext_Options

 

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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.

Option2

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.

Option3

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. 

Option4

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 www.thefinalcheck.org. 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.

Option5

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.

Option6

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.

 THANK YOU.

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» Core Concepts » Getting To Know Just Culture
On February 18, 2014
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12 Responses to Getting To Know Just Culture

  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!

  3. elaine stevens says:

    Do you have a Final Check Toolkit for Mislabeled bloods.

  4. […] other factors. Blaming or punishing an individual might feel good, but that’s usually not the just outcome and it usually won’t do anything to protect others. We need to fix the system and […]

  5. 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?

  6. 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?

  7. […] RCA. Blameless postmortem is an awesome concept that defines a culture around failure called a “Just Culture” that was introduced to me in a blog post by John Allspaw, Web Operations guru at Etsy. It’s a […]

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