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In the 1950th air traffic accidents occurred on regular basis. People thought that the reason for accidents may be the stage of development of aviation technology. In the 1970th there was the idea to focus on human factors for errors and accidents. Investigators analysed what happened, when it happened and who is to blame. In 1996 James Reason published the Normal Accidents Theory (NAT) emphasizing that people react differently to the same situation dependent on their thoughts, experiences and state of mind (Reason, 1997).
A culture of blame continued but the NAT contributed to the model of just culture. Nowadays, people investigate why incidents happened and how they happened.
The essay question 'non-jeopardy/ just culture confidential reporting' 'guarantees' 'active learning' implies that confidential reporting in a just cultural environment ensures active learning and that the level of active learning can be verified by the fact that people are able to report confidentially.
The essay will support the hypothesis that a non-jeopardy/ just culture is enabling individuals to confidentially report errors under a clear accountability policy to support organizational active learning.
First of all, the terms used in the essay will be defined to set the framework of the analysis. The next paragraph focusses on the reality of just cultural reporting. The discussion will discover the necessity to discuss the concept of just culture and High Reliable Organizations (HRO) first leading to a detailed analysis about HROs, the framework of just culture.
The next paragraph will look into reporting systems and their dependent variables such as a blame-free approach, accountability and the necessary contribution of the system to enable confidential reporting.
The last part of the analysis focusses on active learning as defined by Toft and Reynolds and if confidential reporting in a just environment guarantees active learning or not.
Finally, the discussion in the essay will be summarized to support the hypothesis created at the beginning and to answer the essay question. It further supports the thesis why confidential reporting does not guarantee active learning.
Defining Just Culture in High Reliable Organizations
The term non-jeopardy (blame-free) is used in the field of aviation and flight safety (e.g. Graeber, 2008). Nevertheless, the phrase "non-jeopardy reporting" is used in other industries as well. Nowadays, the term just culture manifested. In this paper just culture is used interchangeable for non-jeopardy culture and just culture. The terms errors and incidents/ accidents are not limited to these terms rather than summarize a range of events such as errors, mistakes, failure, accidents or incidents.
Charles Perrows Normal Accident Theory (NAT) was the starting point for the development of a just cultural approach. He argues that accidents are not preventable due to interactive complexity and tightly coupling of the system (1999: 4-6).
During the past ten years, organizations learned a lot and changed from pure profit oriented, hierarchy organizations into organizations with a focus on social responsibility, safety culture and value management. Organizations are going to reach a state of high reliability and safety objectives (Lekka, 2011). In general, a High Reliable Organization (HRO) is characterized as an error-free organization, tightly coupled and with a high level of interactive complexity. Examples for HROs are nuclear power plants, chemical companies or Air Traffic Controller. Weick argues that the characteristics for HROs are more specific as defined by Perrow (1999: 82). Weick defined organizations working under difficult circumstances with statistically less errors and incidents as high reliable. As an example, the German governmental development organization GIZ could be defined with the characteristics of a HRO. GIZ is working in 130 countries in the sectors reaching from capacity development in the field of education to police training, promoting German foreign politics. GIZ therefore has a semi-neutral status, vulnerable to a wide range of errors and incidents reaching from corruption to individual intercultural difficulties to diplomatic difficulties to direct attacks against the organization.
Interactive complexity as defined by Perrow (1999) can also include system complexity. Therefore the term HRO is not limited to interactive technical complex and tightly coupled organizations such as nuclear power plants rather than system complexity. To achieve a state of high reliability it is essential to take certain factors and developments into consideration and to foster developments such as just culture. Lekka characterized a HRO as an organization with a just culture, a clear definition of an HRO, mindful leadership, a learning orientation, problem anticipation as well as containment of unexpected events (2011: v). Reason identified four interlinked subcultures contributing to a safety culture. These subcultures are reporting culture, just culture, flexible culture and learning culture (Reason, 1997: 196). The essay will focus on two characteristics of a HRO; non-jeopardy / just culture and learning orientation/ active learning. In general, culture is not what an organization "has" rather than something what an organization "is" (Reason, 1997:220). A culture is the software of the mind (Hofstede, 1994). To set the context in the essay; it is assumed that any organization is trying to achieve the status as high reliability (error-free). Just culture is a part from the safety culture from the organizational culture. Just culture is characterized by a reporting system which supports a confidential (anonymous) reporting of all errors, incidents and near miss incidents without fear (blame-free), the follow up of incidents, the empowerment of staff on the ground, and the personal accountability of staff for safety (Lekka, 2011, Dekker, 2012).
In general confidentiality is defined as the intent to keep something secret from others (Oxford Dictionaries, 2013). Nevertheless, in the context of just culture confidential reporting means that the identity of the reporter will be protected (e.g. Bowers et al, 2007). Dekker (2007) adds that there must be a clear statement about accountability available to the group of reporters. If there is a need for an official investigation (e.g. the commitment of a crime) the identity may me disclosed for trials. A no-fault/ no-blame approach to a certain extent is essential for a successful development of a just culture (Johnston, 2005; Helmreich, 2000; Bohne and Peruzzi, 2010; Hader, 2006; Harper and Helmreich, 2011; IOM, 1999; Leape and Berrick, 2000, Cohen, 2000; Lekka, 2011; Provera et al., 2008, Reason, 2000). Contrary to this statement, Dekker (2008) cites Gain (2004) who argues at a different level. He states that a "no-blame" approach" is neither feasible nor desirable. Most people desire some level of accountability when an error occurs. Pellegrino support the statement and adds that a "blame-free system with an absence of personal accountability is wrong" (2004: viii). Dekker underlines that it is not enough to draw a line between acceptable and non-acceptable behaviour but it is necessary to identify who draws the line (2008: 177). He further states that if there is no line, "anything goes" - so why errors should be reported. Marx argues that it is about the balancing of the need to learn from errors and the need to take disciplinary action (2001:3). Dekker (2008) puts that in other words stating that "just culture is meant to balance learning from incidents with accountability for their consequences". He clearly argues that the accountability of people and blaming people are two different things.
The essay question suggests that there is a guarantee for active learning. Different encyclopaedias define guarantee as "warranty, pledge, or formal assurance given as security that another's debt or obligation will be fulfilled" (e.g. dictionary.com, definitions.net, 2013). A guarantee can lead to the claim of compensation (Gabler Wirtschaftslexikon, 2013). Therefore, the term guarantee, used in this essay is defined as an assurance that an activity will definitely lead to a predefined, accountable result.
The next paragraph links to the definition of active learning as indicated in the essay question as a result of confidential reporting.
Defining Active Learning
Toft and Reynolds (2005) define organizational learning at three levels, the 'organization specific learning' (drawing own lessons from events), the 'isomorphic learning' (drawing of more universally applicable lessons after the analysis of factors) as well as the 'iconic learning' (indirect learning while knowing that a negative event has taken place). At the level of 'organizational specific learning' organizations draw their own lessons. They may be involved in the same incident but analyse the incidents in the context of the organization.
Toft and Reynolds argue that Isomorphism is the most valuable level of learning beside the other two levels. Isomorphic learning can take place at four different sub-levels. At these sub-levels the framework of isomorphism is defined while taking different constellations of organizations, services or products, tools and procedures or the size and level of decentralization of organizations into consideration. The iconic learning defines that the pure knowledge of an event is already a learning event. Beside the levels of learning Toft and Reynolds identified that there are two types of learning available. First, active learning (knowing about something and implementing lessons) and second passive learning (knowing about something but not implementing lessons) are available to classify learning. Chance (2009) supports Toft and Reynolds definition of active learning. He states that active learning is a change of behaviour. The change of behaviour is only possible if an individual or organization draw their own lessons from an event and implemented the findings. Active learning defines the process of learning under certain circumstances using different concepts. Aim of active learning is the development of knowledge and capacity from groups of people or systems. Different factors may impact the learning process positively or negatively. Active learning only takes place if identified lessons are implemented. Toft and Reynolds differentiate between hindsight, the analysis of past events and foresight, the scenario building and implementation of identified lessons from hindsight analysis. Both concepts could lead to active learning and finally to active foresight if measures are implemented.
"Each year approximately 100,000 hospital patients die due to uncontrollable factors." (Bohne and Peruzzi, 2010). In the medical context factors such as a lack of standards, lacking information technology, unreasonable expectations or outdated work systems are identified as errors leading to death (Bohne and Peruzzi, 2010). Bohne and Peruzzi identified three levels of errors; skill based errors (unintentionally doing the wrong thing), rule based errors (learning the wrong rule or knowing the correct but applying a different or knowing the correct rule but bypassing it) and knowledge based errors (acting incorrectly due to a lack of knowledge). People in the medical industry get punished for making mistakes (Leape, 2001). There is a heavy punitive and blame oriented culture (Leape and Berrick, 2000, Cohen, 2000). Pilots and flight crews don't trust their hierarchy and the legal system. Beya (2004) underlines that errors can and do occur independently from the existence or non-existence of a reporting culture. The goal of just culture is to analyse what contributed to errors and how to avoid them. To reach this goal it is necessary to gather information about errors, accidents and near miss incidents. It is necessary that people are willing to report without fear being punished or blamed (Just Culture Community, 2013). Furthermore, errors or mistakes may be blown out of proportion without any reason (Bennett, 2011: 185). There is fear to be blamed for errors and near miss incidents. A "code of silence" applies if there is no just culture and trust available (Dekker, 2012). The resulting under-reporting leads to a barrier for organizational learning which increases the likelihood of incidents and accidents (Bennett, 2011: 185). The argumentation supports the thesis that the framework of a just culture as defined above must be present to foster reporting in the first place.
Living in a globalized world and operating in high complex and tightly coupled systems and environments it is necessary for organizations to reach a level of reliability, and safety and security to ensure business continuity, trust and care. To ensure the development or the continuity of a HRO the development of a just culture is essential.
The vision of being a High Reliable Organizations
In the past people believed that better technology will decrease errors and incidents and fosters a higher level of reliability, especially in the aviation industry. Evidence proofed that it is not essentially about technology but human error. Therefore an approach was implemented to discover what happened, when it happened and who is to blame. Nowadays, it is analysed how did it happen and why did it happen (Just Culture Community, 2012). This approach requires the participation of people and proactive reporting. The use of event reporting systems improved in the past 10 years. It is better to gather voluntarily, protected safety information before it leads to incidents rather than no reports and frequent errors and incidents. Anonymity through de-identification of reports increases trust from reporters towards the organization. Reason supports this argument stating that just culture is an atmosphere of trust and if there is no trust in the system, there is no just culture (1997: 195). One of the crucial points of an effective just culture is the perception of the just culture concept. Perception is reality (Bennett, 2011) and reality always wins (Ausland, undated). Just culture is about perception, trust and accountability (e.g. Bennett, 2011; Dekker, 2012; Lekka, 2011). As an example, confidential reporting contributes to the Aviation Safety Reporting System (ASRS) with more than 30,000 reports annually (Harpner and Helmreich, 2011) which contributed to an increase of safety in the aviation industry. Errors and near miss incidents are analysed under the aspect of system contribution to events. As a result corrective measures can be implemented before incidents or accidents happen. The ASRS acts as early warning and correction system. Another factor is that people want to participate in the design of their work environment and try to change their situation. If they are reporting errors and incidents and experience that their attempts are fruitless, they are going to give up trying. This negative example is called learned helplessness and can assist in driving a blame cycle (Reason, 1997: 193). A "blame culture" will dominate if an organization does not classify and consistently apply appropriate corrective measures (Bohne and Peruzzi, 2010) to reported errors and incidents. The creation of blame free - "just environments" is essential to develop a safety culture (Beya, 2004). This argument underlines that reporting is dependent on many different factors which can impact the idea of just culture and active learning negatively.
Reason identified several guiding questions necessary for a just culture as part of an organizational safety culture. He identified the necessity for board member commitment and responsibility, regularity of board meetings, a financial rehabilitation system for losses and incidents, the technical responsibility for the collection, analysis and dissemination of information, barriers in the line of command (how many hierarchy levels are between the technical unit and the CEO), the allocation of budget, and accountability (1997: 219-220). A crucial point is that a safety culture is pro-actively supported by physician leaders, CEOs and trustees and dependent on reporting from the operational level. If there is lack of leadership and there is no investment in time and resources, the development of a safety culture may fail (Denham, 2005). As an interlinked result the allocation of a just culture, the reporting of errors and near miss incidents and active learning will fail.
Why are people reluctant to report?
There is a need for a clear policy about accountability and the definition of a blame free approach. But it is not only about the creation of a policy. It is about the trust of employees in the policy and to their leadership and the realization of a blame-free but accountability approach. Reason underlines that there is an overriding problem of trust (1997: 196). People reporting errors and incidents demand confidential reporting. Only if they can be sure that their identity will not be disclosed, reporting will increase. The Identity must be protected by the organization (Lewis, 2005). On the other hand, an investigation may disclose the identity of reporters (Lewis, 2005).
Lewis statement supports a confidential reporting approach in a just cultural environment. The term 'confidential' may be misunderstood by potential reporters and requires a clear definition in the first place.
As an example, Bowers cited the chief executive's within the Higher Education Funding Council for Wales established a whistleblowing policy:
â€¦ That the member of staff will not be disciplined or subject to any other detriment to his or her career as a result, even if the concern turns out to be mistaken. (Bowers et al., 2007: xxx)
The statement underlines the commitment of the CEO to a just culture and guarantees that people will not be punished for reporting errors and incidents. Nevertheless, a no-blame approach does not mean that nobody is accountable. The challenge is that people are afraid to report incidents without legal protection (Robinson et al. 2002). Even if organizations anchor an accountability policy at organizational level (e.g. no legal punishment for errors and near miss incidents), there is no guarantee for no legal prosecution at state authority level. Therefore, people are reluctant to report. There is a need to develop an environment of error reporting and discussion without fear of blame and punishment (Beyea, 2004). People should feel safe to voice their concerns (Frankel et al, 2006). In 1992, Douglas stated that every death must be charged to somebody's account. Different examples have shown that people were charged for mistakes. They were charged for not doing their job and causing significant harm to others (Dekker, 2008). Nevertheless, the prosecution of people does not prevent people from making errors, but hinders reporting of errors (North, 2000: 66). Therefore it is not possible and feasible to support a blame-free approach in the perception of the term blame-free. A blanket amnesty on all unsafe acts would lack credibility (Reason, 1997: 195). Johnston (1991) states that punishing individuals will rarely play a productive role and interventions involving blame and punishment do not succeed. There is the need of a differentiation if errors and incidents occurred due to a lack of knowledge, reckless behaviour or a lack of organizational structures and procedures. Reckless behaviour and ignorance of rules and regulations lead to incidents. As an example, expatriate employees of organizations working in non-industrialized countries (development countries, industrializing countries and failed states) cannot easily cope with the overall situation or the restriction of freedom of movement. Therefore rules and regulations are interpreted at individual level. In a crisis country an international organization set a ´no walking policy´ due to a high risk of kidnappings. The organization discovered that people were horse riding in the desert in a high risk area. The involved staff argued that a no-walking-policy does not mean a no-riding-policy (Wagner, 2013). In an amnesty-blame-free environment no consequences would apply which increases the risk of future incidents. Nevertheless, blame-free reporting as part of a just culture should focus on process improvement rather than blaming of individuals (Bohne and Peruzzi, 2010). It should be examined how systems contributed to a specific error (Beya, 2004). Reason developed a test to identify if systems and structures contributed to the system or if errors occurred through human behaviour (Frankel, 2006 and Reason, 1997). This is supported by an evaluation scheme, published by the Just Culture Community (justculture.org) to identify root causes of errors. This fact contributes to the thesis that there must be a clear goal as the outcome of reporting. The goal should be the improvement of processes and the system, to learn from errors and incidents and finally to foster high reliability. Reporting contributes to the identification of the current level of performance and credibility and fosters their improvement. Trying to change the behaviour or minds of people without changing the system will not succeed (Norman, undated; Beya, 2004; Reason, 1997; Marx, 2007; Johnston, 1991; Lekka, 2011; Provera et al., 2008; Dekker, 2008). Changing the collective values of adult people is impossible but changing structures and systems is feasible (Hofstede, cited in Reason 1997:194). Reason underlines that it is much easier to manage organizations, workplaces and the conditions under which people work (Reason, 1997). To be enabled to change the system, it is essential to receive information about errors and near miss incidents for their analysis. The nature of errors must be understood (Beya, 2004) and root causes investigated (Bohne and Peruzzi, 2010). The analysis must be systemic (Lekka, 2011 and Provera et al., 2008) and corrective measures must be implemented and communicated. Another factor for a positive reporting culture is the fact that a feedback to the reporter is essential (e.g. Bower et al., 2007; Dekker, 2012). People will only report if their concerns are received and feedback is given.
CEOs and leaders play a crucial role in the promotion of blame-free, confidential reporting as part of a just culture. Leadership must reward the promotion of safety related efforts and the reporting of errors and near miss incidents (Beyea, 2004). It is essential that people understand that success and errors are important to learn and that both are rewarded by the leadership to the same extent. The analysis of reports may lead to the necessity to implement corrective measures, to change procedures or the system. Leadership must be flexible and open for change. Donahue and Tuohy argued that there is a lack of motivation to change structures, mandates and responsibilities in an organization. There is a high assumption by the management that "systems will work when they are called" (2006: 10). They often do not see the direct handling in action, and it is assumed that responders are up to date and well trained. A just cultural reporting may support the reflection of the reality on the ground to the leadership. Another critical factor is that managers and leadership are engaged in day-to-day problems. Their focus is shifted to other priorities. Additionally the organizational culture (as blame culture or a non-existent culture) and a lack of allocation of resources may hinder the learning from errors and incidents (Module 4, Unit 9: 9-6; Meyer, 2008). Provera et al. discovered that organizations are reluctant to invest in time and resources to foster open reporting, the assessment of incidents and the implementation of corrective measures. The argumentation shows that there is no guarantee for reporting at all, even in a just culture environment. A just culture may enable people to report.
After the analysis of all dependent variables it is necessary to analyse if confidential reporting in a just cultural environment guaranties active learning.
A guarantee for active learning?
Chances, Tofts and Reynolds thesis of active learning leads to the argumentation that if lessons are drawn from errors and incidents and corrective measures are implemented it may lead to the change of the behaviour of individuals. It means that the change of mind is possible through the change of the system, credibility and trust. This indicates that in the context of just culture confidential reporting, the analysis of root causes of errors and near miss incidents and the implementation of corrective measures foster active learning. There is no doubt that operators in the field often learn lessons individually. Trial and error is one of the most common methods in the field. The trial-and-error learner will - based on individual experience - repeat what worked well and avoid what did not work (Meyer, 2008). In high reliable systems it is fatal if people only learn at individual levels and do not report their errors and incidents. The error of an individual may lead to a chain reaction in other parts of the system or the organization due to the interactive complexity and the tight coupling of processes. Furthermore the lessons learned by an individual will not support the organizational learning at the macro level. As a result similar errors and incidents will occur in other parts of the organization. The essay question indicates that active learning is not possible if people are not able to report confidentially in the context of an existent non-jeopardy/ just culture. There is no guarantee that an organization as a whole is learning from the reporting of errors and incidents. Moreover reporting of errors and incidents support the organizational learning if the root causes are analysed and corrective measures are implemented, communicated and shared. A proactive reporting is fostered by a blame-free just culture with an accountability policy and the commitment from the leadership.
Organizations are aiming the level of a 'safe organization', defined as High Reliable Organization. There are no obligatory, measurable criteria available to proof that an organization is high reliable or not. Moreover organizations foster the creation of an environment or a culture of safety, learning and participation of people to ensure business continuity.
The commitment of leadership to a blame-free just culture supported by a clear definition of accountability, the allocation of resources, the insurance of protection of the individual and the motivation to change heavily support the active learning of an organization.
Nevertheless, there is no guarantee that confidential reporting leads automatically to active learning. The level of organizational active learning is not verifiable due to the fact that people are able to report confidentially in an just culture environment. Moreover the possibility to report confidentially enables organizations to discover the reality on the ground. The analysis of errors and incidents as well as the implementation of corrective measures, without blaming individuals, increases the performance and the reliability of individuals and the organizations. To award the proactive reporting it is necessary to feedback the reporter and to communicate the problem anonymously into the organization.
On the other hand, 'reckless behaviour' or 'unreasonable risk increasing behaviour' and 'criminal acts' must be punished. In fact a clear accountability statement and the line between acceptable and unacceptable behaviour and procedures must be communicated and available to all staff.
The reporting of errors and incidents will automatically increase if the organization is able to create a just culture environment. Therefore the focus must be on the development of a blame-free just culture rather than a discussion about the guarantee of active learning due to confidential reporting.