Tuesday, December 16, 2014

The Just Culture Institute

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.


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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