There is a
great radio programme from the BBC Analysis
series in which Margaret Heffernan, a businesswoman and writer on business
issues, investigates why big private and public sector organisations often make
disastrous mistakes.
In
addition to looking at failures in commercial organisations, she also looks at
catastrophes in the British public sector such as Mid Staffordshire Hospitals
and the Rotherham child sexual exploitation scandal. She argues that in all these cases many people – possibly
thousands – were able to see what was happening and what was going wrong and
could have spoken out. But they didn’t. Coercive organisational cultures –
cultures of fear and blame – silenced people.
Heffernan
says that in order to avoid disastrous outcomes of this nature just cultures are required.
Organisations need their people to speak up readily when things go wrong or
when unacceptable practices are developing. She argues that organisations that
adopt a just culture are ones that
make more intelligent and more informed decisions. So they do a better job.
Regular
readers of this blog will remember that I have talked about Just Culture before.
Swedish academic,
Sidney Dekker, has written a book about it (Just
Culture: balancing safety and accountability Ashgate: Farnham 2007). A just
culture is not a no-blame culture - willful acts of wrong doing would still
attract punishment - but it is one in which the attitude towards error and
mistakes is one of welcoming employees’ reports and supporting and rewarding
those who draw attention to organisational failings and weaknesses. Unnecessarily
blaming people when things go wrong is avoided. It doesn’t take much to see
that an organisation that adopted a just culture would learn more quickly than one that
didn’t, but sadly there are still many organisations that still refuse to grasp
this basic lesson.
Returning
to Heffernan’s radio programme, she is unstinting in her praise of the aviation
industry for moving rapidly to adopt a just culture. She speaks of aviation organisations
that actively encourage people to speak out, to share their doubts and concerns
and fears, and to be open and honest. Interestingly she also notes that
organisations of this type typically embrace low hierarchy structures and
facilitate easy communication throughout the organisation.
It should
be a no-brainer that organisations that deliver child protection services
should be of this type. The work is complex, the environment treacherous and
consequences of unchecked error can be tragic. If people were able to speak out
without fear, to challenge and be challenged, to admit to their mistakes and to
have a passion for exploring the causes and consequences of error in their
organisations, and for devising ways to reduce error or mitigate its impact, then
children would be better protected. They would be safer.
Please, if you can, listen
to Margaret Heffernan’s programme. It could change the way you think.
