An Example of Safety Leadership Success: Moving Towards a Just Culture
Want an improved safety culture that cultivates communication and problem solving? Make a systems approach the primary tool in your safety leadership strategy. This ninth blog is dedicated to one leader’s goal to help his organization move away from a discipline-first safety management strategy to one focused on learning and removing barriers to improve safe production.
Pat’s organization had a long history of using punitive management strategies when safety infractions, near misses, or when incidents occurred. Leaders in this organization were extremely talented in finding the smallest things wrong with a job and using fear-based leadership tactics to “fix” the problem. Years of this blame-the-performer style management practice led to some very predictable outcomes including strained relationships between management and employees, incidents and near misses being driven underground (not reported), compliance levels of performance, and a general distrust of management and the organization. Pat and the other senior leadership team wanted to change this.
Pat is a senior safety manager in a high-hazard organization. Pat was tasked with helping the site move towards a more proactive and collaborative safety management strategy that focused on the goal of improving safe production and the safety culture. The organization had a basic idea of what they wanted: more collaboration across all levels to drive combining production and safety, moving towards the use of leading indicators to measure safety success, improving relationships between management and workers, and shifting towards a coaching / systems approach as their safety leadership strategy. Pat knew that combining Just Culture and behavioral leadership strategies would be a major component in helping the site achieve this reality. Pat helped by engaging in the following leadership behaviors:
Improving bad systems. While Pat helped with many systems improvements, there are two to highlight here. The first system to highlight was the Incident Investigation process. The old system was just that, old. While it did okay with identifying equipment failures or environmental causes, it was not helpful in identifying root causes for anything related to the performers. Pat knew that failures at the performer levels were often caused by poorly designed work, systems, processes, or even leadership pressures, but they had no way of identifying those environmental factors influencing worker behavior. To improve this system, Pat adopted ADI’s PIC/NIC Analysis® as part of the incident investigation process. This allowed the leadership team to move away from pointing their fingers at the employees and move towards making a real impact by improving the systems and organizational practices. The second system improvement was changing the discussions to safe production by combining daily production meetings with leading indicators around safety. Adjustments were made so that if production was shut down for a safety-related issue, those numbers were subtracted from the daily goals so that the group was not penalized from making a safety stop. Improving these two systems was a drastic and necessary shift to help the organization move towards the safety culture they wanted.
Changing the definition of accountability. At Pat’s site, leaders used the terms accountability and discipline interchangeably. With the old investigation system, employees were immediately held “accountable” for incidents, near misses, or safety infractions. This led to the problems discussed above and suppressed the ability for open and honest communication. Wanting to move towards becoming a learning organization, Pat revised the process to be more in line with having a Just Culture, which included:
- Outlining a Just Culture decision tree to help identify the type of error and potential causes.
- Removing discipline for reporting near misses and for being honest in incident investigations.
- Building in accountability through reciprocity by the leaders and employee(s) helping with solution development and implementing solutions to improve systems and processes.
- Reserving discipline for willful violations after investigations instead of a kneejerk reaction.
This shift in what accountability did not stop there. It leads us to the third leadership behavior.
Focusing on what’s going right. Pat became a champion for helping leaders improve their positive reinforcement and feedback for critical safe behaviors. This is an important step in developing a Just Culture. Accountability in a Just Culture for leaders consists of creating a world that encourages desired behaviors. That includes improving processes, systems, and the design of work; it also includes ensuring that desired or safe behaviors are recognized and built into habits. Pat worked with other leaders to improve their feedback skills and helped them begin to notice the expertise in their teams. Pat also worked with the safety team to ensure they improved their feedback skills. This shift in leaders increasing their ability to notice and deliver effective positive feedback began to improve relationships and foster trust inside the organization.
The implementation of these critical behaviors by Pat was an important step in moving towards a Just Culture. In the beginning, there was pushback from the leadership group about “removing accountability” (a.k.a. removing immediate discipline as the first response), but once they experienced the improvements in trust, honesty, working together, and performance improvements, they quickly realized that it was a better approach. Pat worked hard to make this happen, and it has helped the site immensely in improving their safety culture. Any leader or organization who wants to reap the benefits of a Just Culture inside their organization should consider emulating these critical behaviors.