When an accident or an error occurs, it can be very difficult not to respond in a punitive manner. But it is important to remember, that you are seeing the event at the conclusion. You now know the outcome of each decision made to that point in time and it is all too easy to look at the outcome and decide that, surely, you would have chosen a different course of action. Yet, this is not fair to those that were caught at the beginning of a variety of choices, made quickly, and often under time pressures, that led to a bad outcome. In a Just Culture we recognize that we should view thing not by the outcomes, but instead by the processes leading up to outcomes. We must try to understand why the choices that an individual made in the moment, made perfect sense to them at the time. Judged this way, we often can begin to recognize that people are doing the best that they can under a variety of stressors and constraints.
To determine what action is best for an individual involved in an error there are some tools to guide us. Consider the chart below developed by David Marx, a leader in defining and implementing the Just Culture.
This algorithm invites us to consider three questions anytime we are evaluating what appears to have been an adverse event or a near miss.
First – ask what the employees action was – which column best describes that action that the employee took? Everyone is a little different – I consider people to be “hawks and doves” – yet this does give people a way to discuss the event and at least have a way for each person to describe how they understand what happened.
The next question to ask is whether other employees with similar training and background might have chosen the same actions. This is a chance to talk about what happened with other people in similar roles. It is not all that uncommon to find that many people may have made choices similar to those involved in the event. If it turns out that people at the front line often use similar processes as the person who was involved in the adverse event, it is possible that there is a process problem that encourages people to make poor choices. It is not appropriate to punish people for systems problems.
The final question considers what the work record of the individual involved n the event is. There may be issues with a process problem, but if that individual also has multiple concerns raised about their performance, it may still be appropriate to take some sort of action, including discipline, but it would also be appropriate to assess the processes that contributed to the event for possible ways to improve. This would make it less likely that individuals will commit similar errors in the future.
Firing people who are at the receiving end of systems problems will not make systems safer. Instead, it ensures that similar errors will continue to occur.