Quezada (July 18, 2016) Introduction to “Just Culture.” ATS Incident Analysis Workshop. FAA Air Traffic Organization.
The Incident Iceberg illustrates major incidents that are readily visible, such as a wrong site surgery. However, the part of the iceberg under the water is where most of the risk lies unseen, unless people readily report minor incidents and near-incidents (misses). These risks are the early warning alarms of a potential disaster. Like an unseen iceberg that can sink a ship, they can lead to incidents if people don’t have the means to identify and course-correct before impact. The risk reporting system collects data on these minor events or near misses. This data is analyzed and disseminated to workers to support system improvement. In a safety culture, reporting is not only encouraged but is expected.
In the previous section, we set the stage for developing a culture in which people feel safe reporting potential problems. To understand where risk lies, we need a human-system interface in which people can report their inconsequential errors or near misses since they have the potential to cause injury. However, people do not readily report their missteps, especially if they believe it will result in disciplinary action. One study looked at barriers to voluntary reporting systems (VRS) and found the most common issue was the lack of trust between middle management and labor about policies, specifically about the other group’s commitment to following policies. The study found this lack of trust had the greatest impact on the success or failure of the VRS.
As previously mentioned, establishing trust is the first step toward building a reporting culture. Organizations must have the necessary skills and resources to collect and analyze safety information and disseminate it to frontline staff to help them improve performance. Management must be able to learn from the data and be willing to act on it as warranted.
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To build trust, you should |
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Several event reporting systems are available to electronically report events and near misses. Such a report needs to be accompanied by a Reporting Policy and appropriate training on the system.
In an informed culture, those who manage and operate the system have current knowledge about the human, technical, organizational, and environmental factors that determine the safety of the system as a whole. Data is collected, analyzed, and timely disseminated to those who need it.
A learning culture means the organization is able to learn from its mistakes and improve its systems and processes. It must be willing and able to discern the right conclusion from its safety-information system and have the drive to implement major reforms.
A flexible culture is an organization that is able to effectively adapt to changing demands. For example, in the Coronavirus crisis, outpatient clinics rapidly implemented Telehealth technology to continue treating patients virtually and limit the spread of the disease. Additionally, they quickly mobilized teams to create a Drive-Thru process for COVID testing with minimal risk to employees.
If you are struggling with a concept or terminology in the course, you may contact RiskManagementSupport@capella.edu for assistance.
If you are having technical issues, please contact learningcoach@sophia.org.
