OK, I relent. I said in “I am not a policy wonk” that I wouldn’t turn Safety Differently into a checklistable, to-do algorithm or procedure. Well, now I have. Or at least in small part.
As most of you know, there are so many ‘Just Culture’ algorithms and flow charts out there, yet all they do is recycle a counterproductive retributive justice paradigm. They always boil down to: who broke the rule, how bad was it, and what should the consequences be.
There is plenty of evidence that these retributive algorithms do little to create justice: they are instruments of power, a convenient way for HR to help managers get rid of people, a way to shut people up and not share their incidents and near misses. They also fail to address the systemic issues that gave rise to the harms caused, since they reduce an incident to an individual who needs to be ‘just cultured’.
I thought, there’s got to be a better way to do this. So I made a Restorative Just Culture checklist.
Consider it my Christmas present to the community. It’s in the Public Domain. Please distribute far and wide, and give restorative justice in our workplaces a chance.
To download, just click the link below:
The checklist is very good, but if the incident investigation process is good it should be needed very infrequently, at least for workers. For most accidents it should be completed by management, since the causes lie in the system.
I like it. I will certainly spread the good word
Great checklist! I believe the next paradigm shift in safety will only happen when leaders honestly admit that employees are human and make hundreds of mistakes every day. Very few actually lead to incidents. When they do though, they challenge the “Zero Injury” vision and culture and the result all to often leads to pointing the fault finger, usually at the employee. Well understood behavioral biases, such as confirmation bias, hindsight bias, overconfidence bias, anchoring bias and availability bias drive the process. When this happens leaders quickly lose the ability to truly believe a human made a mistake.
Great checklist. I’m convinced that the next big shift in safety performance will only happen when leaders embrace the fact that employees are human beings and will make mistakes. In fact, we make hundreds in a day and most we’re not even aware of. The leadership mindset behind the “Zero Injury” culture is driven by anchoring, overconfidence, attribution, hindsight and availability biases that most first line supervisors and many senior leaders don’t understand. Thanks for bringing out the human side Dr. Dekker!
One issue that might be developed a bit more robustly is the kind of harm that translates as a loss of trust in the system as a whole. Certainly in the healthcare field we see many types of harm – the initial injury experienced by the patient, the fear and uncertainty experienced by the family and close friends of the patient, the multiple harms experienced by the providers and close bystanders to name but a few. A significant harm that is easily missed and often camouflaged is the loss of faith or trust in the system as a whole. This is manifested by extreme reluctance of the patient (and their close contacts) to seek help for subsequent health issues. The consequences of delays can be very significant.
Even when a robust systemic (and I would add nonlinear) investigation has identified several factors contributing to the harm, even when those factors have been addressed and systemic changes made such that the “index harmed person” can feel fairly confident that there is reduced likelihood of others experiencing the same or similar problems, there remains, in many cases, an underlying breach of trust or loss of faith in the system as a whole.
Sidney is right to suggest that a holistic restorative justice approach is more likely to surface these fears and to begin the conversation about how to address the situation. Perhaps the answer is in finding ways to incorporate the harmed individual and their family and friends directly into future discussions that consider, plan for, and implement initiatives and improvements in the way care is provided (or for other systems the way in which services or products are provided or produced and distributed). Perhaps the checklist can be expanded slightly to include questions about whether the event has led to this kind of inclusion. After all, who has the strongest interest in promoting a restorative justice approach other than those most harmed?
A very prescient patient (who had lost two children at different times as a result of breakdowns in the way care was provided) recently asked the innocent question “Has anybody ever thought of creating the position of “patient-in-residence”?” After all ,universities have “scholars-in-residence” and some governments have a “poet-in-residence” (with the much fancier title of poet laureate) and some cultural organizations have “writers-in-residence”, where is healthcare in all this? Perhaps lacking in courage and imagination?
As I was trying to deep dive into this checklist and understand the logic supporting it, I realized its good intentions. But, are organizations and individuals ready for it? Whenever there was an incident, and I participated in and conducted many investigations (a lot more than I wished for), I always noticed these really ugly phenomenons happening, at least in my experience in Brazil: Organizations WILL TRY TO FIND GUILT and Individuals WILL TRY TO DEFEND THEMSELVES. The ugliness is that people representing management will refuse to admit facts that could revert back to pointing them as “guilty”, which in turn induces employees, especially those involved in an incident, to alter their interpretations of the facts, neglect information or just outright lie. The more serious the incident, the more powerful the phenomena is. When authorities and lawyers get involved, it gets worse, because THERE HAS TO BE SOMEONE TO BLAME.. How to handle that? How to build trust in such harsh environments? The “old” Just Culture diagram was more agreable to organizations because it could be twisted to find someone “guilty”.