“Employees are required to follow company policies, to make behavioral choices that are supportive of organizational values, and to avoid causing unjustified risk or harm to self or others. Nevertheless, we fully expect that every employee will face circumstances where a breach of one of these duties occurs, whether justified or not.
Where working under a duty to produce an outcome, an employee will be held accountable as directed by the code of conduct and individual policies. These policies put the employee on notice to the duty, and prescribe acceptable risk-adjusted, rate-based outcomes attached to each duty (e.g., time and attendance, dress code).
When working under a duty to follow a procedural rule within a system, an employee will be subject to disciplinary action when he or she has recklessly disregarded the risks associated with breaking the rule.
At all times, an employee will be subject to the duty to avoid causing harm to himself, to fellow employees, patients, visitors, and to the organization. Under this duty, employees will be open to disciplinary action when their actions involve a conscious disregard of a substantial and unjustifiable risk of harm.
In addition to these actions stemming from single events, an employee who has committed a series of human errors or at-risk behaviors whose cause does not originate within the work system, will be subject to disciplinary action when non-punitive remedial action (e.g., education, coaching) is not effective in changing behavior.
Decision-making in accordance with these provisions will use an objective standard, except where the employee may show subjectively that they had a good faith basis for believing that a particular breach was justified. Actions taken will be guided by the Just Culture AlgorithmTM version 4.0, which is supportive of these provisions.”
Changing Current Policies
- Focus HR policies on the behavioral choices of managers and staff, with less emphasis on errors and their undesired outcomes. The objective is to evolve to an HR system that is proactive to- ward risk and behavioral choices, rather than reactive toward errors and outcomes.
- Ensure that policies and actions (system redesign, consoling an employee, coaching, or disci- plinary action) are all related to the risk associated with a behavior, not the actual outcome.
- Remove any policy references to negligent or careless conduct as a basis for disciplinary action to reduce confusion. The term “negligent” has a social meaning that is out of place in a Just Culture.
- Remove any policy references to criminal conduct as a basis for disciplinary action. The term “criminal conduct” refers only to a societal view that punishment should follow a particular type of conduct. Unfortunately, in many legislative schemes, mere human error is criminal conduct (e.g., criminal negligence).
- Ensure that managers fully understand the three duties and three behaviors. Ensure that manag- ers have the skills to console, coach, discipline, and initiate system redesign where indicated.
- Ensure that the substance of the Just Culture concepts, as shown in the model policy language, are supported by general disciplinary policies as well as section- or domain-specific policies.
- Ensure that event reporting and investigation system design and policies support these provisions.