Professor James Reason is probably the world’s leading authority on how to promote safety in the workplace. His ‘Just Culture’ principles are extensively used in industries as diverse as aviation, railways and healthcare. Increasingly, his ideas are also being applied to service delivery.
At the core of Reason’s argument is a paradox: the safest organisations are those with the highest reporting of incidents, especially of ‘near misses’. This enables an organisation to learn from things that ‘almost’ happened.
To quote Professor Reason:
“By what means can we set about transforming an average safety culture into an excellent one? The answer, I believe, lies in recognising that a safe culture is the product of a number of inter-dependent sub-cultures ... An informed culture can only be built on the foundations of a reporting culture. And this, in turn, depends upon establishing a just culture. The other elements of a safe culture – a flexible culture and a learning culture – hinge largely upon the establishment of the previous two.”
So to have a reporting culture, workers need to have confidence that the organisation will treat them justly. Workers at the frontline need to be confident that they will not be unfairly blamed for errors that are the responsibility of the organisation and its systems. Above all, it is important that organisations don’t ‘shoot the messenger’.
The other thing that is important to a reporting culture is that workers have confidence that they will not be blamed for unintentional errors – except where they have been reckless. A policy of ‘no blame’ for unintentional errors recognises that we all make mistakes. To err is human. Only if someone has been reckless in their actions, deliberately violating organisational policies without good reason, should they be held culpable.
An interesting example of how these principles can be applied in health care is given in an article by Dr Philip Boysen.
Unintentional error: The worker is not accountable but may be involved in investigating the error and teaching others how to avoid it.
Risky behaviour, involving an unsafe choice: The worker is held accountable and is given coaching and support.
Reckless error: The worker is held accountable, and disciplinary action can be appropriate.
Aged care and disability providers investigating incidents – and Royal Commissions – might well benefit from formally adopting the Just Culture approach. We want a culture of reporting in order to foster a culture of learning. The Just Culture approach might well offer the best means of encouraging both reporting and learning.