We noticed a new website pop up recently that we thought was
pretty interesting and worth talking about – the Just Culture Institute.
First off, we want to say that although we know some of the people at the Just
Culture Institute, we have no formal affiliation with the Institute in any way.
That being said, we think that the site is worth looking at because it might
spark a conversation in your organization that is worth having, namely – how do
we react when something goes wrong?
The site presents two models of a “just culture” - the
retributive just culture and the restorative just culture (see the figure
below). In a retributive just culture, the focus is on finding who was at fault
for an event and ensuring that they are punished. However, as the Institute
notes, the results from this are not always what we’d like, in terms of reduced
reporting, reduced learning from events, and a lack of trust in the
organization.
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Source - Just Culture Institute |
By contrast, restorative just cultures seek to, as the name
implies, restore. They are focused on finding and fixing, rather than finding
and punishing. In this way the restorative just culture is more forward
looking, focusing on what we will do differently, whereas the retributive just
culture is more backwards looking, focusing on who did what when.
Now, many point out that accountability is important in
organizations, and the Institute readily admits this. However, as the site
points out, retributive just cultures and restorative just cultures have
different views on accountability. Retributive just cultures see accountability
like a monetary account – something that someone owes and must pay for. By
contrast, restorative just cultures see accountability as the need to create an
account of what happened, i.e. to tell a story with the purpose of making
people whole and systems better. In this way all people are accountable to
improvement, making restorative just cultures more forward thinking and
retributive just cultures.
The site also includes tips for implementing restorative
just cultures. One of key recommendations is the identification of the victims
in an incident. The site identifies first victims as those who suffer the
consequences of the incident. Second victims, key figures in a restorative just
culture, are those practitioners who feel personally responsible for the
incident and may suffer as a result. For example, in an incident where an
employee is seriously injured in a forklift accident where one of the causes
was “human error” on the part of another employee, the injured employee and
their family is the first victim, whereas the employee who made the mistake
would be a second victim. Restorative cultures do not neglect either and the
Institute provides recommendations and links to resources for helping deal with
all the victims in an incident.
Obviously, these ideas are a bit controversial, as many
believe that punishment is a vital part of a safety program. You need the
carrot AND the stick, they say. However, these ideas are often based on false
assumptions about human performance and counterfactual thinking brought about
by hindsight bias. And, at the end of the day, we’ve been working on the
assumption that retributive justice is the right system for a long time, yet it
doesn’t seem to be working as well as we’d like it to in the safety profession,
because people are still being killed in accidents. So perhaps it’s time to at
least consider a new approach. The Just Culture Institute is a needed step
toward consideration of a new approach.
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