Just Culture:

A Balance Between Punitive and

Blame Free Cultures to Create Cultures of

Safety

Sources: David Marx, www.justculture.com, Michelle Freeman, MScN, RN

What is Culture and How Does it

Relate to Safety?

• Culture is the values, beliefs, and behaviors that we share with other members of groups

• “The way we do things here…..”

• Unwritten rules governing behaviour

• Culture provides cues and clues on how to behave in normal and novel

situations

Culture is implicated in accidents and incidents in aviation and medicine

What is a Just Culture?

• A Set of Beliefs

– A recognition that professionals will

make mistakes

– A recognition that even

professionals will develop

unhealthy norms

– A fierce intolerance for reckless

conduct

A Set of Duties – To raise your hand and say “I’ve made a mistake”

– To raise your hand when you see risk

– To resist the growth of at-risk behavior

– To participate in the learning culture

– To absolutely avoid reckless conduct

What is a Just Culture?

Human Error Management

• The idea behind human error management is “simple” • Move the reliability curve to the

right and decrease the risk of human error

• How? – Design systems to reduce

errors

– Focus on human behaviours • Create a just culture

The Behaviors We Can Expect

• Human error - inadvertent action; inadvertently doing

other than what should have been done; slip, lapse,

mistake.

• At-risk behavior – behavioral choice that increases risk

where risk is not recognized, or is mistakenly believed to be

justified.

• Reckless behavior - behavioral choice to consciously

disregard a substantial and unjustifiable risk.

The Three Behaviors

Reckless Behavior

Conscious Disregard of Unjustifiable Risk

Manage through: • Remedial action • Disciplinary action

At-Risk Behavior

A Choice: Risk Believed Insignificant or Justified

Manage through: • Removing incentives for

at-risk behaviors • Creating incentives for

healthy behaviors • Increasing situational

awareness

Human Error

Product of Our Current System Design

Manage through changes in: • Processes • Procedures • Training • Design

• Environment

Console Coach Discipline

Just Culture Facts

Fact: Humans will make mistakes.

• This does not equate to loss of accountability or that human errors are unmanageable

• Cannot manage error by simply expecting staff to be “error-free”

• Need to see errors and their effects as products of the system in which we put employees and their behavioural choices within that system

Fact: “To drift is human.” Humans will move

away from strict compliance

– “Drifting”- tendency for humans to engage in risky

behaviours and lose perception of the risks

– Often encouraged by pressures of work and workplace

cultures

– Need to accept this as part of being “human”

Just Culture Facts

Just Culture Facts

• Recognize that all human activities involve risk

• Task of manager is to recognize risks and diminish

(mitigate) risks

Fact: “Risk is everywhere.” Actively seek out

risks in the workplace.

Organizational Goals

for a Just Culture

• Create an environment of transparency around risk

• Learn why human errors and at-risk behaviours occur within the organization

• Learn to measure risk at both the unit and organizational levels

• Work with staff to design systems that reduce the rate of human error and at-risk behaviour or mitigate their effects

• Learn when to console, coach and discipline employees

• Focus on the risks inherent in systems and behavioural choices, not the actual outcomes of events

• Use data to build both unit and organizational models of risk

Organizational Goals

for a Just Culture