Thursday, November 13, 2008

Just culture

A flow chart of an individual's culpability following an unsafe act has been around for some time. I think it was developed by Professor James Reason, and I know a few companies use it (or at least claim to ) to guide their disciplinary processes.

Anyway, I was looking for a copy of the chart, which was proving difficult. Eventually found it in the following paper from Titled 'A roadmap to a just culture: enhancing the safety environment' and published September 2004. It was prepared by the Global Aviation Innovation Network (GAIN) working group for safety information sharing.

I think the paper's forward by Reason gives a very good account of the issues:

"The term ‘no-blame culture’ flourished in the 1990’s and still endures today. Compared to the largely punitive cultures that it sought to replace, it was clearly a step in the right direction. It acknowledged that a proportion of unsafe acts were ‘honest errors’ (the kinds of slips, lapses and mistakes that even the best people can make) and were not truly blameworthy, nor was there much in the way of remedial or preventative benefit to be had by punishing their perpetrators. But the ‘no-blame’ concept had two serious weaknesses. First, it ignored - or, at least, failed to confront - those individuals who wilfully (and often repeatedly) engaged in dangerous behaviours that most observers would recognise as being likely to increase the risk of a bad outcome. Second, it did not properly address the crucial business of distinguishing between culpable and non-culpable unsafe acts."

Andy Brazier


Anonymous said...

For a useful discussion see 'Just Culture' by Sidney Dekker (Ashgate, 2007). Also, an interview with Dekker on Youtube. Or Google a paper by David Marx 'patient safety and the "just culture": a primer for health care executuves.' I find the Marx approach a bit clinical, as it assumes the bosses values set the guidelines - not so sure this works in the wider world

Anonymous said...

David Marx's first book, Whack-a-Mole: The Price We Pay For Expecting Perfection, offers broad application examples of the Just Culture. It might be a helpful supplement...