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High Consequence and the Just Culture

Presented by Paul LeSage and Jeff Dyar

Paul and Jeff came to our region March 30, as part of the series of presentations around the state hosted by the Washington Fire Chiefs. Our session fell on a warm, sunny Saturday at the start of Spring Break in our area. We only mustered a dozen attendees.  Many of us were not clear exactly what we were going to be presented, which didn’t help attendance either. Those of us who made it there experienced an excellent introduction into High Reliability Organizations and Just Culture concepts, with an emphasis on event investigation through deconstruction and the application of algorithms that promote consistent, transparent decisions about coaching and discipline by administrators. Decisions that recognize human fallibility, promote the understanding and recognition of at-risk behavior, and the appropriate use of discipline for reckless behavior, in an open learning environment.

We left the presentation regretting how few people had taken the opportunity to listen to this important material that had challenged us to reexamine our internal investigation and progressive discipline procedures. It was so good and so important that we are now looking at how to bring Paul and Jeff back to our area and to ensure that we have fire administrators, union leadership, other city executive leaders (especially HR and City Attorneys), and some elected officials hearing this presentation. The session in Spokane was more broadly attended and we are sure they benefited greatly from this more diverse participation. Bringing Paul and Jeff back will be at our expense. Others in our state still have the opportunity to get to these free sessions and we strongly implore you to take it.

It is difficult to convey exactly what this presentation will bring to you. The flyer whets your appetite but it takes sitting in the room, listening, and applying the concepts using the algorithms and case studies to truly see where this can take your organization. This material is not trendy and gimmicky. It is founded in sound research and design, coming out of the airline industry and it has continued to be refined through its application in other high consequence areas, such as healthcare and our own discipline. The presenters are very familiar with it and our learning was enhanced as they responded to participant’s challenges and questions during the application of the algorithms during the case studies.

The sessions are highly interactive. Our thinking about human behaviors and choices, values and expectations, systems design, learning systems, and accountability and justice was directly confronted. How does outcome bias color our reaction and decisions to punish or not to punish an employee? How willing are we to look at ourselves and our organizations during an internal investigation? Can we distinguish between human error, at-risk behavior, and reckless behavior? And do we know how to respond if we can make the distinction? This presentation has valuable learning for us all. It can impact our organizational culture and environment, our effectiveness as managers, and the performance of frontline members of our organizations. With understanding, it is not complex or expensive to implement and maintain. Please do not dismiss its value, at least until you have heard and seen more about it firsthand.

By Chief Neil Hines, Kennewick FD, Chief Bob Gear, Pasco FD, and Chief Grant Baynes, Richland FD.

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Posted: Apr 11, 2013,
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