Just culture
Just Culture is a concept related to systems thinking which emphasizes that mistakes are generally a product of faulty organizational cultures, rather than solely brought about by the person or persons directly involved. In a just culture, after an incident, the question asked is, “What went wrong?” rather than “Who caused the problem?”.[1][2] A just culture is the opposite of a blame culture.[2]
A just culture helps create an environment where individuals feel free to report errors and help the organization to learn from mistakes. This is in contrast to a “blame culture”[3] where individual persons are fired, fined, or otherwise punished for making mistakes, but where the root causes leading to the error are not investigated and corrected. In a blame culture mistakes may be not reported but rather hidden, leading ultimately to diminished organizational outcomes.
In a system of just culture, discipline is linked to inappropriate behavior, rather than harm.[4] This allows for individual accountability and promotes a learning organization culture.
In this system, honest human mistakes are seen as a learning opportunity for the organization and its employees. The individual who made the mistake may be offered additional training and coaching.[5] However, willful misconduct may result in disciplinary action such as termination of employment—even if no harm was caused.
Work on just culture has been applied to industrial,[6] healthcare,[7][8] aviation[9][10] and other[11] settings.
According to James Reason, a just culture is one of the components of a safety culture.[12]
References
- ^ Baierlein, Jeff (2019). Risk Management for Outdoor Programs: a Guide to Safety in Outdoor Education, Recreation and Adventure. Seattle, WA: Viristar LLC.
- ^ a b Catino, Maurizio (March 2008). "A Review of Literature: Individual Blame vs. Organizational Function Logics in Accident Analysis". Journal of Contingencies and Crisis Management (Review). 16 (1): 53–62. doi:10.1111/j.1468-5973.2008.00533.x.
- ^ Khatri, N. (Oct–Dec 2009). "From a blame culture to a just culture in health care". Health Care Management Review. 34 (4). Health Care Manage Rev: 312–22. doi:10.1097/HMR.0b013e3181a3b709. PMID 19858916.
{{cite journal}}: CS1 maint: date format (link) - ^ Behn, Brian (January 29, 2018). "Just Culture basics for EMS". National EMS Management Association.
- ^ "Just Culture System and Behaviors Response Guide" (PDF). Los Angeles County Department of Mental Health. August 9, 2017.
- ^ Groeneweg, J. (2018). "The Long and Winding Road to a Just Culture". Society of Petroleum Engineers.
- ^ Harvey, H. Benjamin (June 17, 2017). "The Just Culture Framework". Journal of the American College of Radiology.
- ^ Boysen, Philip (Fall 2013). "Just Culture: A Foundation for Balanced Accountability and Patient Safety". The Ochsner Journal. 13 (3): 400–406. PMC 3776518. PMID 24052772.
- ^ Gain Working Group E, Flight Ops/ATC Ops Safety Information Sharing (September 2004). "A Roadmap To A Just Culture: Enhancing the Safety Environment" (PDF). Global Aviation Information Network.
- ^ "Just culture Finding the right balance between the aviation, judicial and political authorities". EUROCONTROL. Retrieved June 28, 2019.
- ^ Dekker, Sidney (January 1, 2018). Just Culture: Balancing Safety and Accountability. Ashgate Publishing. ISBN 9780754672678.
- ^ https://www.airsafety.aero/Safety-Information-and-Reporting/Safety-Management-Systems/Safety-Culture.aspx