The 3 behaviours that a Just Culture investigation focuses on.

handlingcomplaint in culture just and behaviours risk At

1️⃣ Definition 2️⃣ Why is at risk behaviour used. 3️⃣ The psychology of at risk behaviour: 3️⃣.1️⃣ the loud conscious fire alarm. 3️⃣.2️⃣ The muted subconscious fire alarm 4️⃣These behaviors encourage the use of at risk behaviour 5️⃣ Management of at-risk behaviours. 6️⃣ managing at-risk behaviour 7️⃣ What is coaching? 8️⃣ System redesign and rewards. 

The Just Cultue method of investigation looks at the extent of the behaviour behind the error, and holds all staff accountable for their behavioural choices. As the behaviour is only punished if the workers behaviour was reckless.

As staff are only held accountable for their behavioural choices, all staff feel they can admit their mistakes and bring their concerns to management. Without fear of retaliation.

Just Culture behaviours

1️⃣ Human Error

2️⃣ Risky Behaviour

3️⃣ Reckless Behaviour

just culture flowchart of examining worker conduct chart

1️⃣ Human Error

Human behaviour is variable as we have good days and bad days. Days when we are distracted or unwell. So it is safe to assume this causes variability in the quality and quantity of work produced. Sometimes this will result in a human making an mistake.  After all, to err is to be human!

So if this person had a one off lapse of judgement or made a mistake, it is fairer to investigate what cause the person to make the mistake and put measures into place to minimise the risk of this happening again. Rather than defaulting to blaming the person for behaving like a human.

the first port of call in a Just Culture is to investigate the intentions behind the behaviour and if the person acted within the guidelines of the Organisations values and procedures. The Just Culture investigates the conduct of the worker and not the outcome of the incident.

If the person had a one off lapse of judgement and/or slipped up. The the reason why this happened then can be useful to provide updated guidelines for the future actions and behaviour of all Staff. Which will reduce the risk of this happening again.

This can be really helpful if the error was made due to an unconscious Organisational bias or use of the mental filter.

Bias are the mental shortcuts we take to make decisions quickly. In some situations they re helpful. If we’re in a burning building, that may be valuable. But are unhelpful when investigating a healthcare complaint.

▶️ These are the most common bias made in the workplace during complaint investigations

Similarity Bias — We prefer what is like us over what is different

Similarity biases most obviously crop up in people decisions: who to hire, who to promote, who to assign to projects.

It occurs because humans are highly motivated to see themselves and those who are similar in a favorable light. We instinctively create “ingroups” and “outgroups” — boundaries between who we consider close to us and who lives on the margins. We generally have a favorable view of our ingroup but a skeptical (or negative) view of the outgroup. Hence why managers hire employees who remind them of themselves.

Overcoming a similarity bias requires actively finding common ground with people who appear different.

Expedience Bias

When we lived in caves and were at the mercy of wild animals, we needed to be able to make snap judgements of the situation to prepare to flight or fight. This is not longer the case but does explain that the tendency to rush into a judgement without fully considering all the facts.

Experience Bias

Experience bias occurs when we fail to remember that fact. We assume our view of a given problem or situation constitutes the whole truth.

To escape the bias, we need to build in systems for others to check our thinking, share their perspectives, and helps us reframe the situation at hand.

Safety Bias

Safety bias refers to the all-too-human tendency to avoid loss. Many studies have shown that we would prefer not to lose money even more than we’d prefer to gain money. In other words, bad is stronger than good.


Not checking the validity of your facts and allowing facts that come to mind more easily during the decision making process

?confirmation bias

Placing emphasis on the behaviour of the person who made the error &/ complaint for creating the situation. Whilst, at the same time underplaying the impact of the behaviour/s of the Healthcare Professional/s for the situation.

?atribution bias

Deciding the outcome and then excluding all evidence that doesn’t support the desired outcome.


▶️Mental Filter

How to address System Failures

▶️ Understand the Problem

Why was it created? who uses it now? Who would be affected by the change? Reliable data

▶️Choose the Change

Ask yourself how will mistakes happen and what shortcuts will be used before choosing the change.

▶️Access the progress

Once the system has been modified, ask for feedback and monitor the process. Dont assume it is better.

The limitations of No harm, No foul

2️⃣ Definition of at risk behaviour

At-risk behaviors differ from human errors as they are choices taken by employees. As these employees have acted like this for so long and nothing bad has happened.  They have become desensitised to the possibility of risks so they think they are acting safely.

▶️ Why is at risk behaviour used:

if an employee has to deal with time pressures and find work arounds to get the job done or face penalities. Then the use of short cuts that increase the risk but save time is appealing.

▶️ The psychology of at risk behaviour:

1️⃣ the loud conscious brain fire alarm

The slow conscious brain has a smoke alarm

Human brains have an internal smoke alarm which is  located in the part of your conscious brain.

The conscious brain operates very slowly to solve more complex problems, deferring to the subconscious brain for all but the most complex problems.

2️⃣ The muted subconscious brain fire alarm

Thus, humans make most decisions subconsciously, formulating choices they do not even realize they are making.  

Our subconscious brain manages about 80% of all human endeavors. It operates automatically and quickly, When you have repeated an action many times, your brain responds subconsciously. As there is no fire alarm in your subconscious brain, you are unaware of the impending fire.  It is only when you are doing something new that you use the conscious brain where the fire alarm of risk is.  So you need to be a new or difficult task to set off the risk fire alarm to make you aware of the possibility that your behaviour may be risky. So in hindsight as you were unaware of the risk and want to avoid the shame of your behaviour, it is easier to justify your choice pretend it was bad luck and/or the risk was to small to predict.

As it would be to exhausting for the fire alarm to ring every time the subconscious brain does something, the fire alarm for all subconscious decisions is set to mute.

▶️ These behaviors encourage the use of at risk behaviour

▶️ Successful outcomes reinforce the use of short cuts and 

▶️encourage  others to adopt these habits 


 ▶️ Colleagues enable this practice with the use of silence.

 ▶️And once this is common practice, pointing out the risks in these behavioral choices may be criticised.

▶️ Management of at-risk behaviours. 

 Admitting that at-risk behaviors exist is messy and taboo, but it is the first crucial step in effectively and justly managing the behavior. 

While it has traditionally been easier to harshly judge these behavioral choices,

 incorrectly label them as reckless conduct, 

and inappropriately discipline all who knowingly violate the rules, 

in a Just Culture, the solution is not to punish those who engage in at-risk behaviours.

▶️ managing at-risk behaviour 

▶️removing the barriers to safe behavioral choices, 

▶️removing the rewards for at-risk behaviors, 

▶️and coaching individuals to see the risk associated with their choices. 

7️⃣ What is Just Culture coaching?

Coaching explores the reasons for the behaviour so measures can be put in place to limit them happening again

▶️raise awareness of the risks of this behavior,

risks related to the behavioral choice that

?were not seen or

?were misread as being insignificant or

?Were thought to be justifiable. 

▶️Discuss the importance of making safer behavioral choice in the future. 

▶️Coaching conversations should be part of a daily routine where all share their perceptions of risk with the aim that all staff make safe behavioral choices. 

At-risk behaviors are not usually associated

▶️with a lack of knowledge about the rule, 


▶️a lack of awareness of the risk associated with the task or

▶️not following the prescribed process. 

Choosing not to coach at-risk behavior because it is uncomfortable or may not be well received by the individual or group allows the risk to continue unchecked until harm occurs. What is not corrected is condoned. 

▶️ System redesign and rewards. 

Addressing at-risk behaviors also requires remedying the system failures and tacit

3️⃣ Reckless Behaviour

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