Just culture is dead.

It began as a beautiful idea but it is almost unrecognizable now. It has become something dirty and impure, a tool for power hungry people to label others and think they are doing something productive.

Just culture has become another bureaucratic policy, another mandatory training that people have to sit through while staring at bad PowerPoints and watching the clock.

If your organization thinks that embracing just culture is using an algorithm to decide if someone can be blamed for something or not, then it has already failed.

Just culture is a mindset, a belief and an approach to looking at things differently. At least it should be.

When used wrong just culture provides a way to label behaviors as wrong or right, reckless or not and determine what should happen to people. Just culture can be manipulated to show any outcome the person with the power wants it to. The algorithm is subjective and open to multiple interpretations. When used by people who cannot see the bigger picture it ends up being another avenue for justifying punitive behavior and getting rid of people. A just culture does not have a hierarchy where one judges who made a mistake and who was reckless – it has people that explore the concepts of human fallibility and understand the inherent flaws that come with being human.

Where there was once a genuine goal of improvement there is just cheap lip-service.

People with no real understanding of the process speak about it now because they have “done their research.” Quite often, these people are mistaking the map for the territory.

Spending twenty five dollars on flow charts will not bring about a cultural shift in your organization.  Using jargon and catch-phrases does not bring about positive change. delegating thinking and feeling to a proprietary algorithm chart rarely provides a complete picture of what happened inside the tunnel, and it on’t lead to understanding.

Using a rigid algorithm to pigeon-hole behaviors does not accomplish anything worthwhile. It does not explain the “why” or “how” the events occurred; you just know who you can punish and who gets a pass. It won’t make you safer or better or smarter. Compartmentalizing and creating false dichotomies does not make you a better agency.

I’m not an idiot, there are some people that need to be removed from the job so they can no longer inflict harm on others but I also don’t need a flowchart to tell me that.

The heart of just culture can’t be bought from a company or learned from a PowerPoint. Just culture needs to be built on a foundation of trust – trust in others to let them shine a bright light on your imperfections and to let yourself be vulnerable knowing that you are safe. This level of openness and trust may be uncomfortable at first; it can leave people feeling exposed and raw. It is not the default setting for the average human being but it can be instilled in some people over time, others will never get it.  After operating this way some people may begin to feel a sense of freedom develop as they no longer need to waste energy on reinforcing their defenses.

Without this level of trust everything else is meaningless bullshit.


3 thoughts on “Just culture is dead.

  1. Brian- new to your blog and blogging in general. As an FD that recently stood up ALS service with 4 ALS ambo’s, a yearly call volume of 10,000 and a population served of 141,000, we have implemented the Just Culture methodology. I noticed the multiple statements that you made regarding incorrect usage of Just Culture; “When used wrong just culture…” “Just culture can be manipulated….” ” When used by people who cannot see the bigger picture…” “People with no real understanding of the process…”

    It seems your experience has been negative to say the least. But to attack the process as opposed to the participants seems to me off base, as to say this isn’t perfect therefore we won’t use it. Any methodology/technology can be used for perverse means, examples of this are everywhere. I would also challenge you to find a process (for improvement) that is widely available, repeatable, specific, measurable and not cloaked in secrecy. I noted “trust culture”, can you provide this in a format or is it something conceptual that you have been thinking about? I would agree 100% that if members have no trust among their coworkers, no methodology will work. With any organization of size there will always be differences in opinions and personality, and without solid leadership, which you may be a part of, trust and justice has no chance. This is a classical environment for the “us (labor) vs them (management)” culture.

    We are looking at developing a risk management team that is a cross-section of our organization that works as a group to apply the algorithm. We believe that when applied only through senior management, the perspective can be skewed. We also think buy-in increases when the team is used, and these team members become advocates for the process and its merits. As I mentioned earlier we are new to ALS and Just Culture but are finding the majority of our issues are system/program related, not employees. As a manager I was always asking the why, when evaluating employee performance or behavior. When the JC algorithm is used correctly the why becomes the focus as opposed to the outcome.

    I’d be willing to bet that if leadership is using JC inappropriately there are probably a variety of other issues going on, which is unfortunate for the organization and it’s members. Hopefully you are a part of leadership in your own organization and can be the change that you speak of, or we can wait till a blog is posted about how Trust Culture is just bullshit……hopefully not.

    Thanks for the blog


    1. Thanks for the well thought out comment. I may not have conveyed my thoughts as clearly as I would have liked to in my post and tone is often lost in writing. I’ll try to clarify my positions here.

      My experiences with using it have not been negative. Much of this was brought on by the Vanderbilt nurse case and people saying that they believe in just culture but…she needs to be punished and in reading others experiences with being “just cultured” out of a job.

      I look at it like this, just culture sounds like a great idea but like many things that people advocate for like socialism and communism and maybe LUCAS devices, real life paints a much different picture than the idealized version that people promote. I think the idealized version could work, I think the real life version of buying a canned just culture is a failure for most places because they don’t build the foundation right.

      I can tell you the process for improvement and it is simple, it isn’t easy, but it is simple. Get people that believe in the cause of being better and that are willing to leave their egos out of it, have shared goals and always take care of your people. Treat them like your children – not in a paternalistic way but in the sense that you do not fire your children, they know that even if you have to correct their behavior that you care about them, and they still are able to feel secure. I don’t know if you can measure that sort of thing but you do know it when you see it and you know it when it is lacking.

      I don’t think the algorithm is bad or good really, it is just a process to follow. Where it goes wrong is when you add the human factor to it, the human factor of dealing with failure and people who have failed. Failing sucks…sharing how you failed is even harder, but when done right can actually be empowering and be how people are accountable for mistakes.

      You mention you are going to implement just culture and that does bring up a point. In the shallow sense if you use it as a process then sure – you can implement a new process. If it is used as a noun you cannot implement a culture easily….you have to guide your organization to embracing that culture, you have to create something.

      Maybe that is my point, if there is one, is that it isn’t the process of following the algorithm that really matters – most people know wrong from right, it is getting the culture established and nurturing it so that it flourishes and people truly trust each other rather than the false promise of security a algorithm that is filtered through human subjectivity brings.

      Here is someone smarter than me who can explain some the ideas better than me.


      And some ideas for processes: http://www.safetydifferently.com/restorative-just-culture-checklist/



  2. Brian-

    Can’t help but chuckle, you mention communism, socialism and the LUCAS device in the same sentence…..classic.

    I agree that JC as a noun will not work. I propose a journey and a true cultural shift, that will take time, with a focus on the professional relationships and how we treat each other. This is at the crux of the issue and hard for those that may have grown up in a more draconian environment. The algorithm is a guideline that ensures we don’t create pockets of inequity, but rather work with all from the same playbook- basic tenet of justice. The peer review we employ when using the algorithm, based on our lack of experience, has been very telling and has uncovered some of the bias we all bring to work based on our unique experiences and perspectives.

    In the EMS world that we have dove into, we are finding that when we focus on professional and effective communication we are much more likely to deconflict at the task level. When issues arise, shockingly, we can usually trace it back to a leader(s) that struggle with effective communication or have resisted the movement to a learning culture vs the blaming culture.

    In the fire service we are quick to try to define our situation and problems as unique, but I have found consistently that not to be the case. I would imagine and will probably find out, EMS is no different. The one main difference is in the practice of medicine, changes are based on empirical data or research, typically with a peer review component. The fire service is rife with experts with little science or research to back up their beliefs, and as of late some of the fire service have actively worked against science based techniques so as to continue practicing unsafe operations or behavior. We at times are our own worst enemy; it’s said there are two things firefighters hate 1) the way things are, and 2) change.

    Hopefully EMS is a little more pragmatic…….

    I noted your links to Sydney Dekker’s work and am familiar with his position and beliefs. I have been following David Marx with Outcome Engenuity, link below. I have found their approach and methodology to be very balanced and focused very much on the cultural shift necessary to sustain through the long-term the “Just Culture”. Also anything by Gary Klein is worth reading.


    I appreciate the venue and look forward to future posts, keep up the good work.


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