Moving Beyond Supervision Zero Tolerance: A Just Culture for Quality Improvement

Control room, image made by author with DiffusionBee

Shattering the Glass Ceiling of Quality: A Call for Systemic Change

In the Netherlands, we have several regulators such as the Healthcare Inspectorate, the Financial Markets Authority and the Education Inspectorate. However, there are many more and for every social and economic activity there is a regulator. The task of this body is usually to oversee, promote and reduce deviations from the quality being delivered. To achieve this quality goal, laws and regulations have been drawn up and the supervisor is usually also concerned with their enforcement.

An important development is that work situations are becoming more complex and less predictable in advance. Cause-and-effect relationships are then not clear as the Cynefin framework indicates. However, laws and regulations are based on causal thinking and therefore become less effective. Professionals and other workers nevertheless have to act in complex and unique work situations and this requires them to operate in a self-thinking manner. To do so, they need autonomy and control space, which professionals have traditionally had but are increasingly constrained by more and more rules. In concrete situations, they have to make trade-offs and even break laws and rules if that is safer or better than following them. Only if they report such deviations can laws and rules evolve and continue to contribute meaningfully to their original objective of promoting quality. Experience has been gained in aviation in fostering this reporting process, and in doing so, a ‘just’ culture appears to be an important condition.

This brings us to a second phenomenon that is important for achieving quality or safety goals and that is the way in which regulation is carried out. Indeed, the human reflex is to create more rules when incidents occur because of the risk/rule reaction. Another reflex is to punish shortcomings to prevent recurrence. However, this creates a ceiling to increase quality. This is because punishment leads to shortcomings, mistakes and other undesirable issues being hidden in the workplace for fear of reprisals. The effect is that shortcomings only come to light through inspections and incidents. This leaves an important improvement potential untouched. Indeed, if workers proactively report what is going on and needs to be improved, earlier and deeper action can be taken and more real-time insight into opportunities for quality improvement is created.

Tapping into this quality potential requires counter-intuitive behaviour. First of all, it must be accepted that people make mistakes and this applies even to the most experienced experts. Mistakes are inevitable and belong. Zero mistake is a myth. Second, responding to shortcomings also requires a thoughtful rather than impulsive response. Punishment, zero tolerance and more rules are counterproductive. While the intention then is to prevent recurrence, a just approach works better to increase quality. This is because it distinguishes between unintentional mistakes and deliberate violations, reducing the fear of reprisals and increasing the willingness to report proactively. However, this requires a systemic approach and streamlining between parties such as regulator, legislator and implementing organisations. Indeed, no single party can achieve this alone. Aviation shows that streamlining is possible while achieving an impressive result regarding safety.

A command to you, the reader: Start by accepting that mistakes are inevitable and that a zero-mistake culture is a myth.

Focus on thoughtful responses to shortcomings, rather than impulsive reactions. Avoid punishment, zero tolerance, and more rules, which can be counterproductive, when this is somehow possible.
And finally, initiate a systemic approach that streamlines parties such as regulators, legislators and implementing organisations. No single party can achieve this alone.

Authors: Dr. Ing. Martin de Bree MBA Dr. Eva van der Fluit CMC Herman Hello

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