A Just Culture and the Substitution Test

This may not interest you, but I’m led to write it anyway. So here goes nothing.

Years ago, 1993 to be precise, I began my journey in total quality management. Along the way, as I sought to be a competent technician, and on the way to becoming a risk advisor, I picked up a suite of tools and skills in using them. By the early 2000s, I was auditing to established national and international standards, and I was investigating and analysing the causation of industrial incidents, where people could have been disabled or killed, and where there was potential for great property loss and environmental harm. These processes would involve me facilitating a multidisciplinary process, with numerous stakeholders and professions, whereby management decisions would be made.

(I hear me saying at this point, c’mon, get on with it.)

Inevitably in every incident there was either one human being at the pointy end or several. Part of incident analysis is establishing causation so decisions can be made about how to performance manage people. And the key tool we used was called a ‘just culture model’. It was developed by Professor James Reason (University of Manchester). It was a rules-of-fair-play model, and, given that every organisation I worked for was legally required to manage ethically, they endeavoured to have a just culture.

The theory was that nobody would be dismissed unjustly.
And, in around a hundred incident analyses,
I never personally saw it fail.

The best part of the model, I could see, as I put myself in the position of the person who could easily be blamed for the incident, was the substitution test.

The substitution test runs like this: could a different person (well-motivated, equally competent, comparatively qualified) have made the same error under similar circumstances (determined by their peers)? If “yes” the person who made the error is probably blameless. If “no” were there system-induced reasons (such as insufficient training, selection, experience etc)? If not, only then should negligent behaviour be considered.

The most interesting thing about the substitution test is how it challenges the thinking of those who would normally have the power of veto — the one who would dismiss the employee; the manager-once-removed (the manager above the employee’s manager), ordinarily.

I personally never saw one single case where there was negligent behaviour. In every case that I saw, there were managers and executives wanting reasons to move employees on, but every time they could not establish a case. This is because, quite frankly, if a peer were put in the same position, with the same qualities and the same situation and the same perception, they would have done the same thing. And if this weren’t the case, could it possibly have been a system-induced reason that caused the employee to behave the way they did? In my experience, I never met a manager or executive or situation that even got close to suspecting a case of negligence. This is not to say negligence is not possible, for it is, it is just extremely rare in well-cultured organisations that recruit and train well.

What is the point I want to make?

The point is this: by and large we never have human performance problems through malevolence in organisations with good culture. Everybody who is working for someone is trying to do their best. There are exceptions, but they are few, especially in organisations with good culture. There are employment situations, though, where doing your best won’t be good enough. This is an example of an unjust culture.

When it comes down to managing people, we must first understand that people mostly want to do the right thing. People take their work stresses home with them and may work themselves into a flurry of anxiety to please their boss and do their job well. It most often isn’t people failing the system. It’s the system failing people, and a just culture in any organisation (secular, Christian etc) is a wise culture to the extent that it understands the human dilemma within the system of work.

When people work in an organisation with a just culture, they go above and beyond because they know they are supported. But when people go to work and have no idea what to expect, in other words the culture is unjust, they live in fear and are bound to fail sooner or later.