Just Culture
A system of shared accountability
What is a Just Culture?
Unintentional
What is Human Error?
Flattened Hierarchy
What is Deference to Expertise?
Does not equal a Just Culture
What is a no-accountability culture?
What is at-risk behavior?
Maintain real-time operational awareness
What is Sensitivity to Operations?
Using deficit-based language and making assumptions
What are some of the Don'ts of Just Culture?
Conscious disregard
What is reckless behavior?
Embrace uncertainty and complexity, avoid simple solutions
What is Reluctance to Simplify?
Changing shared values, beliefs, and assumptions...
What are the Do's of Just Culture?
Environment, Institutional culture, Team, Individual competency, Policy, Technology, and Equipment
What are the elements of the Swiss Cheese model?
Focus on potential failures
What is Preoccupation with Failure?
It's evolutionary and takes time
What is real Culture Change?
To make it hard to do the wrong thing
What is the primary function of the hierarchy of controls?
Anticipate that errors may occur
What is Commitment to Resilience?