Just culture

Safety experts in aviation often refer to the notion of a Just Culture - a way of safety thinking that promotes a questioning attitude, is resistant to complacency, is committed to excellence, and fosters both personal accountability and corporate... 

GAIN. A roadmap to a just culture enhancing the safety environment. 2004. http //lHghtsafety. org/files/just culture.pdf. 

Dekker S. Just culture. 2nd ed. Aldershot Ashgate PubUshing Limited 2012. ISBN... 

Dekker, S. (2007) Just Culture Balancing Safety and Accountability. Ashgate, Farnham. 

The Just Culture movement is an attempt to avoid the type of unsafe cultural values and professional interactions that have been implicated in so many accidents. Its origins are in aviation although some in the medical community, particularly hospitals, have also taken steps down this road. Much has been written on Just Culture—only a summary is provided here. The reader is directed in particular to Dekker s book Just Culture [51], which is the source of much of what follows in this section. 

A foundational principle of Just Culture is that the difference between a safe and unsafe organization is how it deals with reported incidents. This principle stems from the belief that an organization can benefit more by learning from mistakes than by punishing people who make them. 

In an organization that promotes such a Just Culture [51] ... 

Beyond the obvious safety implications, a Just Culture may improve morale, commitment to the organization, job satisfaction, and wilUngness to do extra, to step outside their role. It encourages people to participate in improvement efforts and gets them actively involved in creating a safer system and workplace. 

Promoting a Just Culture requires getting away from blame and punishment as a solution to safety problems. One of the new assumptions in chapter 2 for an accident model and underlying STAMP was ... 

The difference in a Just Culture is not in the accountability for safety problems but how accountability is implemented. Punishment is an appropriate response to... 

Fiankel, A.S., Leonard, M.W. and Denham, C. 2006. Fair and just culture, team behavior, and leadership engagement The tools to achieve high reliability. Health Services Research, 41,1690-709. 

Consider the application of these terms in the following example from Marx s primer on a just culture ... 

The concept of reciprocal accountability includes the leader s accountability for creating a just culture. In a just culture, the leader draws a clear boundary between acceptable and unacceptable behavior. Individual malfeasance, impairment, illegal acts, intentional violation of known standards or procedures, disruptive or abusive behaviors, and the inability to learn over time are aU incompatible with... 

Leaders are accountable for creating a just culture by clearly marking out the boimdary between acceptable and unacceptable behavior. 

Leadership actions are required to build the culture for transparency and learning, prerequisites for safety to be successfiil and sustained. These actions are in pursuit of a patient safety cultme, which is an accountable culture, a just culture, a learning culture, and a culture of parmership. 

Marx, D. Patient Safety and the Just Culture A Primer for Health Care Executives. New York Columbia University, 2001. [http //www.mers-tm.net/support/Marx Primer.pdf] McCandless, K., and Zimmerman, B. Simplicity on the Other Side of Complexity. Chicago Patient Safety Fellowship, Health Forum, American Hospital Association, 2002. 

The institution recognizes the critical dependence of a safety management system on the trust of the workforce, particularly in regard to reporting systems. (A safe culture—that is, an informed culture—is the product of a reporting culture that, in turn, can only arise from a just culture.)... 

Given the right circumstances, these systemic methods can facilitate a positive shift from a blame culture through no blame and towards a just culture approach to safety investigation, and to the reporting of normal errors . 

Continuous safety improvement process and hi ily adaptive to changing business environment All levels of the organization proactively support safety and embed in daily routine Strong and transparent just culture... 

Dekker S Just Culture, Balancing Safety and Accountability. Aldershot, Ashgate, 2007. 

The quote by Charles Perrow is from his seminal book Normal Accidents, published in 1984 (New York Basic Books). The many scientific and practical issues with human error have been discussed in Hollnagel, E. (1998), Cognitive Reliability and Error Analysis Method, Oxford Elsevier Science Ltd. The definition of just culture can be found at the skybrary (http //www.skybrary. aero), an excellent source of aviation safety knowledge that is also of considerable general interest. 

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