While the topic of Just Culture pops up from time to time, its roots can be traced all the way back to the formation of the Aviation Safety Reporting System in 1976. By acknowledging that humans are imperfect, regulators encouraged aviators to safely share their own incidents and violations, which in turn become data that can be used to prevent future accidents. The long-standing success of such programs is due in part to the "get out of jail free card" concept, which waives aviators of any sanctions so long the certain criteria are met, even if it was a violation. The Aircraft Owners and Pilots Association shares an elegant summary of this process.
Misunderstanding Just Culture
It is understandable that some might misunderstand just culture. The word "just" instils a sense of fairness and righteous. Just culture is fair not simply because the "punishment" meted to employees is deemed fair. Instead, just culture aims to prevent employees from being unfairly treated when caught in difficult situations inherent in the system. NHS emphasized the use of just culture to understand how the health system led to sub-optimal behaviors while holding people accountable only when there is "evidence of gross negligence or deliberate acts". The American Nursing Association supports just culture in holding systems accountable for change, while responding appropriately to erroneous, risky, and reckless acts. In almost every academic publication, just culture’s "balanced" accountability brings into the picture the organization’s role in creating safe work systems, alongside individual actions and outcomes.
The theme of punishing individuals is further exacerbated by just culture algorithms used to decide “appropriate responses” to the perpetrator. The original intent for such decision aids was to break supervisors' punitive tendencies, through identifying moments to console, coach, and redesign. In reality, people appear obsessed by a legitimized power to deem the fate of those caught at the sharp end of the Swiss Cheese. Some even have fancy names like “culpability tree”—culpability comes from the Latin word “culpabilis”, which means “worthy of blame”. The algorithm usually talks nothing about how culpable the work system is nor holds the system owners accountable.
Marketing Criminal Justice
But if acting all Judge Dredd is what you desire, may I suggest you instead adopt criminal justice. Criminal justice expects individuals to obey the law and "do the right thing". It focuses primarily on holding criminals accountable for their misdeeds and getting them to restore their victims as much as possible. Dramatic courtroom scenes come to mind, as defendants fend off accusations while prosecutors squeeze out a guilty verdict. A criminal hearing doesn't even require a root cause analysis, which is an objective problem-solving method aimed to improve a system.
As a recent example, former nurse RaDonda Vaught was charged in court by her own institution for a medication error. In 2017, she had overridden an automated medication storage to access a larger array of medication, administered the wrong drug and resulted in the unintended death of a patient under her care. She was criminally charged and faced up to 8 years in jail, but in 2022 was finally sentenced to 3 years probation with the possibility of this record eventually removed.
Vaught cited emails and training from Vanderbilt staff that encouraged nurses to override safety warnings for medications in order to efficiently administer medications. Yet the high-profile court case focused on her and her actions, which became an effective "smokescreen that distracted from her employer’s inadequate safety systems". Since then, Vanderbilt University Medical Center continues to be a negative case study for just culture, its safety culture messages forever sounding hypocritical.
The good news is we don't have to publicly drag our colleagues through the court of law in order to administer criminal justice. Inquiries can be conducted in-house, based on the laws established by the organizations, followed through with HR-approved sanctions. In this atmosphere of fear and distress, every employee will soon either be law-abiding robots, or eventual criminals waiting to be disciplined.
Misusing Just Culture
Masquerading criminal justice as just culture is thus an elegant and cost-effective scam. By misappropriating just culture's ethos of fairness and empathy, we lure naïve employees into sharing their mistakes, convince them of their own faults, before going in for the kill with shame and sanctions. You can even go against statistical odds by painting every incident as some form of willful violation, as though bad humans are the only reason why incidents happen time and again. Rinse and repeat until trust in the organization is worthless.
How might you spot just culture being misused? I summarized some insights so you don’t have to:
A big emphasis of incident analysis is on apportioning culpability and blame on individuals involved. (Fact: Incident analysis seeks to understand the problems in order to promote improvement and growth. Just culture actually treats people first with compassion, so that learning and improvement for all parties can occur in a safe space).
Incident discussions begin by asking a series of questions in an attempt to incriminate the staff. (Fact: Discussions should broadly and factually explore how the incident happened, and during this process we often discover why certain people behave in specific ways.)
Outcomes of just culture evaluations are mostly punitive, or always create a sense of shame and suffering. (Fact: Reckless acts and wilful violations, driven by selfish or wicked intent, are rare. Sanctions should therefore reflect this frequency too, particularly for at-risk behaviors where attention should instead be spent on working with these individuals to improve safety.)
Just culture discussions rely heavily on hindsight and assumptions to explain what individuals should have done but did not do. (Fact: Like any good-quality incident analysis, just culture evaluations should be mindful not to fall into hindsight bias, which can paint genuine human error into reckless acts.)
Mindful Adoption of Just Culture
As alluded at the start, just culture contributes toward a safe reporting culture for organizational improvement, through a transparent process of acknowledging genuine errors, addressing at-risk behaviors, and asserting zero tolerance for reckless acts. Just culture alone isn’t enough to compel professionals to "choose wisely" or "act safely" in a problematic system. Neither is just culture a menu for dishing out penalties and an accessory for turning root cause analyses into sentencing hearings. Treating employees like criminals is hardly the cornerstone of a strong safety culture.
Fortunately, most safety advocates are mindful of the trauma that second victims endure, and they do patiently guide these imperfect but well-intentioned colleagues back on track. Ironically, we tend to be too gentle with recalcitrant offenders, the muted corrective efforts sending the message that rules and protocols do not apply to privileged individuals. Having the moral courage to adopt just culture approach for such situations would truly promote fairness.
Have you encountered criminal justice disguised as just culture? What kind of language does it use? Always happy to hear your thoughts!
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