Just Culture Root Cause Analysis – A Necessary Marriage

摘要

Objective: In a "Just Culture" open reporting of incidents and near misses are encouraged and even rewarded. There is recognition that errors are usually produced by system failures and that we need these incidents reported for the sake of organizational learning and process improvement. Such a culture also requires that individuals be held responsible and accountable for their actions. The difficulty comes in balancing these two seemingly opposing concepts in such a way that employees see a fair and transparent system. This presentation describes how systematic root cause analysis addresses the tension between organizational and personal accountability and makes a Just Culture possible. Methods & Procedures: A review was made of current accountability (or culpability) models commonly used in implementing a Just Culture. The shared elements of these models were extracted and reviewed alongside a well-known expert system for root cause analysis (RCA). Most of the models use a series of questions to help determine the degree of organizational or personal accountability. The expert RCA system was used as a guide to help answer these questions. Results & Conclusions: The expert RCA system provided a consistent methodology to answer questions from the models. One of the most important aspects of developing a Just Culture is a fair and transparent system. The use of the expert system provided a simple and transparent structure and framework for answering the questions in the various models that produced a consistent and reliable result. It was much more likely that different people using the system would come to the same conclusion, making the system equally fair to everyone. Novel & Additive Information: Use of such an expert system provides many benefits to the organization in that the practitioners can use it as a root cause model for any type of undesired event or problem solving.