Just Culture is a system that holds itself accountable, holds staff members accountable, and has staff members who hold themselves accountable.

DO YOUR EMPLOYEES think twice before alerting you to a deficiency in your systems? Is your response to workplace accidents too narrow in scope?

If so, it may be time to consider Just Culture, a concept first associated with health care but with clear mainstream benefits. Just Culture places less focus on events, errors, and outcomes and more focus on risk, system design, and

In essence, your employees understand they are accountable for their actions in the workplace but they are not punished for system faults outside their control. Just Culture encourages staff members to voice their opinions and feel supported in doing so. In turn, the organization learns and improves by openly identifying and addressing its weaknesses.

Here are the four main objectives in a Just Culture.


When discussing a true open and fair culture, consider all the components. At XYZ Roofing Company, two workplace accidents happened a month apart. Two employees fell off a roof at different job sites, and, fortunately, neither was injured. They both failed to wear the fall protection gear that is required.

One roofer was a long-term, respected employee with a stellar employment record. She knew the safety policy but thought she’d be able to go quickly to the roof without protection. The other roofer was a short-term employee whose probation period for minor infractions had been extended.

XYZ Roofing opted to respond in two different ways. The long-term employee received “coaching” on the importance of fall protection when working at heights, while her coworker received disciplinary action.

Both responses may seem appropriate, but the root cause of the behavior choice was never determined. A company’s response to failures and near misses will create or negate a Just Culture.

The investigation should move beyond the employment record and determine why this behavior—foregoing fall protection—took place. How prevalent is it? It’s important to uncover what happened, what normally happens, and what the procedure requires; in other words, how the system was designed to work.

Coaching or discipline does not enable us to learn what we might do differently to minimize the chances of causing the same adverse outcome. This is not to say a company should adopt a “no blame” culture. Conscious disregard of clear risks or gross misconduct can’t be tolerated. But if noncompliance with a safety policy is common practice, that’s cause for concern.

What if the employees were injured in the fall or hurt someone on the ground? When a more critical outcome triggers a more critical response, it’s known as Outcome or Severity Bias. Society often fails to hold people accountable when there is no bad outcome. Conversely, society demands a punitive response if serious injuries occur. Consistency in response to behavioral choices is key to sustaining a transparent culture where we learn from mistakes and failures and adjust accordingly.


In a Just Culture, lessons learned are used to avoid more serious events. Acting on what is learned at both the department and organizational levels leads to solutions with the greatest impact.

Investigations should identify “systems” deficiencies rather than assign individual blame in every instance. At XYZ Roofing, nonadherence to the fall protection policy appears to be the norm. Is fall protection hard to find or not easily donned? Is staff perception one of production over safety? Without uncovering why, the policy may remain largely ignored. 


Human beings are fallible and mistakes are inevitable; however, we must reduce the opportunity for error by simplifying and standardizing policies. It’s also important to increase communication with staff, provide ongoing resources and training, address near misses, and respond to all incidents consistently, regardless of outcome.


Employees often drift into unsafe behaviors when there is no perceived adverse outcome. Working at heights with no protection, removing machine guards, and disregarding a care plan for patient transfers, for instance, don’t always result in injuries. Yet the risks remain. No matter the industry, employers must raise safety awareness among staff. To keep the risk perception at its peak, solicit team feedback through team huddles and focus groups and send reminders on the importance of safety vigilance. Keep this in the forefront and include staff in the discussion.

A Just Culture is one that is continually improving, resulting in greater employee engagement, employee morale, and safety.



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