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.