Just Culture

Balancing Safety and Accountability

Sidney Dekker

• Publisher: CRC Press
• Year: 2016
• ISBN:
  9781351924559
• Edition: 2
• Topic: Technology & Engineering
• Subtopic: Industrial Health & Safety
• Index: Technology & Engineering

Building on the success of the 2007 original, Dekker revises, enhances and expands his view of just culture for this second edition, additionally tackling the key issue of how justice is created inside organizations. The goal remains the same: to create an environment where learning and accountability are fairly and constructively balanced. The First Edition of Sidney Dekker's Just Culture brought accident accountability and criminalization to a broader audience. It made people question, perhaps for the first time, the nature of personal culpability when organizational accidents occur. Having raised this awareness the author then discovered that while many organizations saw the fairness and value of creating a just culture they really struggled when it came to developing it: What should they do? How should they and their managers respond to incidents, errors, failures that happen on their watch? In this Second Edition, Dekker expands his view of just culture, additionally tackling the key issue of how justice is created inside organizations. The new book is structured quite differently. Chapter One asks, 'what is the right thing to do?' - the basic moral question underpinning the issue. Ensuing chapters demonstrate how determining the 'right thing' really depends on one's viewpoint, and that there is not one 'true story' but several. This naturally leads into the key issue of how justice is established inside organizations and the practical efforts needed to sustain it. The following chapters place just culture and criminalization in a societal context. Finally, the author reflects upon why we tend to blame individual people for systemic failures when in fact we bear collective responsibility. The changes to the text allow the author to explain the core elements of a just culture which he delineated so successfully in the First Edition and to explain how his original ideas have evolved. Dekker also introduces new material on ethics and on caring

1 What is the Right Thing to Do?

The dead girl was wrapped in a shower curtain.

When the police found the package in the trunk of her stepfather's car, they noticed the little girl had a rag stuffed down her throat, secured in place with a bandage around her head.

It turned out that the rag had been put there by her mother, who, days before, had shoved the girl under a bed and left her.

Under that bed, she had died. Alone.

Her body was now on its final journey, to be dumped in a wood.

The rag would have kept her from crying—crying from abandonment, fear, hunger. At three years of age, her body weighed in at 10 kg, or about 20 lb.

How can a society accomplish justice in the aftermath of something like that? What is the right thing to do?

The mother was charged and convicted and got six years in jail. That would be just to many people. To them, it would be the right thing to do. Some might say that the sentence was too short. The mother was also forced into treatment. Not right, some would say, not deserved. Very appropriate, and very smart and just, others would say.

But the prosecution was not satisfied. Not yet. They found another contributing party and produced a charge of manslaughter in the second degree.

The stepfather, you'd think. Aiding, abetting, driving a car with a body in the trunk? That would be him.

Except it wasn't.

The charge was leveled against the social worker who replaced the original worker tasked with looking after this family. The alleged failure of the replacement social worker was that she did not pick up on signals of the child's neglect. Here, in short, was the case. The family had been troubled from the very start. When the girl was one year old, the State had taken her out of the mother's care because of signs of abuse. She was returned to the family not much later. The paperwork that would have testified as to the family fulfilling the conditions for the child's return, however, was lost, or never produced. The child protection council was not notified either.

The social worker visited the family three times, and found little to report. After a while, she went on sick leave. It took months before a replacement was found. The replacement worker drew up a plan for the mother. It specified, among other things, what to give to a toddler to eat, when, how often, and other basic things related to child care and hygiene. The mother never really managed. The girl started falling behind in language, and started to look a little blue.

And then, one day, she was dead.

Was charging the replacement social worker with manslaughter the right thing to do? Barring any visceral responses—"no of course it wasn't!" or "yes, it definitely was!"—this is not an easy question to answer. It is an ethical question. It is a question about our values, about what we consider to be right or wrong.

That finding an answer might be hard, however, does not mean that the question resists systematic reflection. Ethics, as a branch of philosophy, offers that sort of systematic reflection. Now it is not an easily penetrable field, and any short treatment of what it might offer is likely unfair. But some such guidance is available. Consider three different ethical schools here:

• utilitarianism
• deontology
• consequentialism.

These are big Greco–Latin labels. Here is another way of putting them (again, oversimplifying things):

• getting the greatest good for the greatest number;
• expecting people to live up to professional duty;
• considering the consequences of the judgment.

Utility

Let us start with the first, where the ethical or right thing to do is that which produces the greatest good for the greatest number. Getting rid of an unsafe person (removing a social worker who does not pick up signals of neglect) could then qualify as ethical. The benefit to families, to children, to coworkers, and the organization, is greater than any cost. In fact, the cost is born mostly or exclusively by the individual who is removed and charged. All the possible benefits go to a lot of people, the cost goes to one. It could be argued that an even greater good goes to an even greater number here—the society surrounding this family and their State caretakers. They receive the good that those complicit in the death of the little girl get punished. Getting rid of a bad apple, a deficient worker, harms virtually no one and benefits a lot of people. In fact, any harm is inflicted only on the person or party who might deserve it anyway. So utilitarianism could perhaps argue that this would be the right thing to do.

Duty

But would we want to be a utilitarian with regard to this question? Let us take another position, that of deontology. Deontology studies the nature of duty, or obligation, and one specific way of doing that is to look at professional duty. The duty of care, for example, that comes with professions where (potentially risky) decisions about the lives of other people get taken. This is often called a fiduciary relationship. It is a relationship of trust between professional and client (patient, family, passenger, child), where the client has comparatively limited knowledge and power to influence what the professional might do or decide. The relationship, and people's willingness to engage in it, is founded on the trust that the professional knows what she or he is doing, and does the best for the person in her or his care. This is where deontology might suggest that going after the replacement social worker is ethical, is the right thing to do. She did not live up to her duty of care. She violated the fiduciary relationship. She knew what the child and mother needed, or should have known. And she should have ensured that this was leading to a safe situation for the child, not a lethal one.

But, of course, things are not as simple as that. The fiduciary relationship is also founded on the belief that the professional will do everything in the best interest of the client in front of her or him. When meeting with a client—a family, a patient—nothing in the world should be more important than the client seen there and then. The financial bottom line is not more important, nor is the clock, nor the next client waiting to be seen. The duty to do the best for the current client overrules them all.

But that works only in an ideal world. Giving all the time and resources to one family (living up maximally to the duty ethic relative to that client) takes away time and resources from others. This militates against the ability to live up to the duty ethic with those other clients. It creates a classic goal conflict, or ethical conflict even, for social workers (as it does for many physicians). And most families or patients could be argued to deserve or require more time than is accorded them. This is, in most Western countries, a structural constraint for services like social work, State family support, child protection, or healthcare. They are always under pressure of limited resources—not enough money, not enough people (remember it took months to find a replacement in the little girl's case), not enough time. And always more families or patients to be seen, waiting for help, attention.

So part of being a good professional, of living up to the duty ethic, is making sure that all families get the best care you can give them. That, of course, sounds like utilitarianism: The best to the most, the greatest good to the greatest number. A good duty ethic under limited resources and goal conflicts, then, means being a good utilitarian. It means juggling time and resources in a way that gets the most to the most families. But of course this militates against a more pure reading of duty ethic—that nothing is more important than the family seen there and then. There is no hope that such an ethical conflict can ever be resolved. It is felt by most social workers, and most healthcare workers, every day, all over the world. Organizations who employ or deploy such professionals often do little to encourage serious reflection over moral conflict, nor do they help their people manage it. The conflict simply gets pushed down into the workday, to be sorted out at the sharp end, on the go, as a supervisor draws up the schedules, as a social worker hurries from one family to the next.

This complicates any judgment about whether somebody lived up to professional duty. If we want to come to a fair judgment of whether pursuing the replacement social worker is the right thing to do, then there is a lot more we need to look at. Just considering the dead girl and connecting that, in hindsight, to the (now so obvious) signals of neglect that the social worker should (now so obviously) have picked up and acted on, is not going to be enough. What was the case load for this worker? What were the handover procedures when getting cases from the previous worker? How did signals of neglect come in over time, and how did they compare to the perceived criticality of the signals coming from other families in the care of this worker? Who made the schedules and what rationale were they based on? And we could go on. How was social work funded and staffed and organized in this State? Whether prosecuting the social worker is the right thing to do would depend on a careful collage of answers to all of those questions, and probably more.

Consequence

What are the consequences of charging the replacement social worker with manslaughter? Of course, there are all kinds of consequences. Not in the least for the social worker herself. Chapter 6 considers the consequences for the "second victim" in more detail. But what matters here are the consequences for the profession, and for the people in its care: Children like the one who died. One predictable consequence is this: Prosecution of the social worker is likely to tell her colleagues that they should stare harder and intervene more aggressively—or else.

And so they did. The very next year, the number of children taken out of their families' care in this State doubled. Only very weak signals, or mere hints of trouble, would be necessary for a social worker to decide to intervene. The cost of missing signals is simply too large. But that sort of response has consequences too: The cost gets displaced. It gets moved around the system and part of it may well end up on the heads of the most vulnerable ones. Because where do those children go? While in the care of the State, many would go to foster families or other temporary solutions. In many countries appropriate foster families are difficult to find, even with normal case loads. Doubling the number of children from one year to the next can lead to a lowering of standards for admitting foster families. This can have consequences for the safety and security of the children in question.

And there are more consequences. Doubling the number of cases from one year to the next will lead to a doubling or at least an increase of the paperwork, an increase in the supervisory and organizational attention devoted to them. It is unlikely that resources will quickly be made available to have the organization grow accordingly. So other work probably gets left undone. And there is a multiplier effect here. When noticing that a colleague suffers such consequences for having been involved in a failure, professionals typically start being more cautious with what they document. The paper trails of their actions get larger, get more pre-emptive, more cautious. It is one of the defensive measures that professionals often take. And, as research has shown, paying a lot of attention to the possibility of being held accountable like this, detracts attention and cognitive resources from the actual task.¹ In other words, social workers may be looking harder at paperwork and protocol and procedure than at children.

With all those consequences, is charging the replacement social worker the right thing to do? Consequentialism would suggest not. The things that get changed when a failure is met with an "unjust" response (the prosecution of an individual caregiver in the example above) are not typically the things that make the organization safer. It does not typically lead to improvements in primary processes. It can lead to "improvement" of all the stuff that swirls around those primary processes: bureaucracy, involvement of the organization's legal department, bookkeeping, micro-management. Paradoxically, many such measures can make the work of those at the sharp end, those whose main concern is the primary process, more difficult, lower in quality, more cumbersome, and perhaps even less safe.

Responding to Failure: The Organization

Considering whether punishing the social worker is the right thing to do is one thing. But if you run the organization, or a part of it, you are left with a tragic failure that might make you look pretty bad. What do you do? Responding appropriately to the death of a little girl in the care of your organization is incredibly hard. All kinds of interests are at stake—almost independent of whether a prosecutor decides to go after one of your social workers or not. These are among the questions:

• What serves the organization best?
• What should you do with the professional involved?
• What about the public image (the consumers of your services or goods)?
• What about the regulator who is watching over you?
• What about your own position or survival as organizational manager?

A question that runs through all of these is this. How can you justly deal with the individual who was involved, while also ensuring that your organization learns as much as it can from the event? How will you balance accountability and learning? Other employees will likely be watching carefully, to see what you are going to do. Here are the immediate options, and neither of them are only good.

If you come down hard on the social worker, because you feel that you somehow need to match the severity of your response to the gravity of the event, then you will create a lot of the same effects as the prosecutor would have done. Other social workers will be more careful to leave a paper trace, will be hesitant to tell you about near misses, and will clog your system with more false alarms than you can deal with. You might, in the eyes of some, have held somebody accountable. But your basis for organizational learning has gone out the window.

The alternative is that you do not sanction at all. You might believe that the social worker is not uniquely deficient, that she will indeed be even safer in the future. You might offer her critical incident stress management, to ensure that she does not succumb to her own guilt, remorse, trauma. You might invite her to share her story, her account, with the other workers. But how do you sell that message to the other workers in your organization? They may well have expected that some kind of sanction was forthcoming because of this violation of professional duty. So if you don't sanction, other workers may even be upset that apparently anything goes. Somebody lets a kid die on her watch, and nothing happens?

And how do you sell it to the regulator or to others in society who might be waiting for some kind of strong countermeasure? It is not that regulators are necessarily short-sighted and have no imagination. Very often, the rules around which their work is configured leaves them very few options other than to sanction, to recertify, to revoke, to write a letter telling you to watch out better next time. It can be very difficult to persuade a regulator that "you are doing something about the problem" when, empirically, you seem to be doing nothing of the sort. You leave the worker in place, after all. I have Seen that it takes a strong stand to convince the regulator, and indeed other parties in society, that you are in fact doing an immense lot—particularly to help the organization learn and hopefully prevent in the future. You ensure that the story, the account, is preserved and distributed. You take on board the recommendations it implies. You create a culture where your people will feel free to share safety-critical information with you. You balance accountability with learning.

An operations manager of a mine recently asked me whether I thought it would be just to fire employees who show up for work while drunk or drugged. This is precisely what his mine does. The employee is fired, no questions aske...