Let’s get out of the blame and shame business
Just Culture is a management philosophy designed to hold people appropriately accountable. According to one of the current thought leaders in Just Culture, there are three basic kinds of behavior: human error, at risk behavior, and recklessness.
The larger message of Just Culture is that blame is a counterproductive and useless exercise that feels good but doesn’t really accomplish much angers the people being blamed and make them defensive.
If we take a look at the three behaviors, only recklessness deserves blame and shame. Just Culture gained traction in industries where blame was so pervasive that people would conceal their mistakes and hope for the best. If a nurse knows, for example, that she has accidentally given the wrong medication to a patient and if she admits her mistake she will be fired, there is a good chance that she will at least be tempted to say nothing. In high consequence industries where the tiniest mistake can kill people, blame conceals the errors.
It strikes me as odd that we in the safety profession continue to extoll the virtues of a blame-free workplace and the wonderful opportunity we have to learn about the causes of injuries while promulgating blame-based systems out of the other side of our mouths.
Behavioral observations can create a climate of blame. Whenever someone stands in judgment of us it is only natural to feel defensive. But my intent is not to create another angry argument for or against BBS, because quite frankly there is a whole new trend toward blame-based safety, which holds that leaders are to blame for injuries. In their acts and decisions, in what they done and what they have failed to do. While there is no small benefit in drawing leadership’s attention to the role they play in worker safety, the time for accountability is before people get hurt.
I have said many times that everyone plays a role in safety, but too often we only hold people after someone has been harmed or property has been damaged. People need to be answerable for ensuring the workplace is free of hazards, for the decisions they make, and for managing one’s performance inhibitors (the things in one’s life that make human error and unnecessary risk-taking more common like stress, lack of sleep, drug or alcohol use, etc.).
Blame remains a pointless exercise because once we have determined who’s at fault there is no reason to look further (it’s the same reason your lost car keys are always the last place you look.) That’s not to say that people shouldn’t be held accountable, but people need to be held accountable for their actions irrespective of the outcome. This is a basic tenant of Just Culture: the extent to which one is accountable is independent from the outcome. Actions taken and decisions made in good faith are not punished no matter the outcome, and recklessness is subject to discipline even if no harm occurred as a result. It’s a bitter pill for some to swallow, but swallow it they must.
