Is Just Culture desirable for learning? – Part 3

May 10, 2022



This is the third part of a six part series to explore the relationship between Just Culture and Learning with a diverse panel of experts. You will hear different perspectives on just culture and learning including legal, operational, academic and safety. Stay tuned for future sessions in this series.

Further information

Nippin Anand  00:00

Hello, and welcome to the third episode of the six part series is just culture desirable for learning with me Nippin Anand on my podcast embracing differences. In this episode, I’m joined by Donna Cohan from Meerkat from Australia. Robert J. de Boyer, the author of the book safety leadership, and a manager in higher education, and a master mariner and a very dear friend for a long time now, Nicholaos Chalaris. We will begin this podcast with understanding what learning means from different perspectives, and explore the question is just culture desirable for learning. I hope that you will enjoy this podcast and find the discussion stimulating some new thoughts and challenging the existing ones. While that’s what embracing differences all about. Yes, we are live now. Good morning. Good afternoon. Good evening, wherever you are in the world. Thank you for joining us for this third session in the series is just culture desirable for learning. There are some familiar faces. Because we have a one new face, so it’d be good to get a very quick round of introductions. So Nico, since you are the new one on this series, and there’s a slight surprise also, you’re supposed to be Steve Shamrock. But Steve is attending the session on the seventh of April and Nichols has kindly accepted to do this one. So I’m glad you did that. Nicholas. Thank you. Nicholas, would you like to introduce yourself? And then we will ask Don and then RJ to introduce themselves before we kick off?


Nikolaos Chalaris  01:50

Sure. First of all, thank you for the invitation. I have been professional Seaman all my adult life and a little bit before I have moved from that lower ranks until the highest of these have a captain on ships the last 1616 years, more or less, I’m in command of suits have been really trying to deeply understand the concept of safety considering that in a in a role like mine, truly responsible one, I have to take care of that solution. In due time, I realise that some things work and some things don’t. And I started to question why things don’t work or if whatever we are towards is correct. And that is more or less the reason the time here have been driven personally and throughout our mutual discussions, but not only to find out how we can really improve things, or if what we’re doing doesn’t work and maybe doesn’t produce the desired result. So this is it some days in Greece? And apparently I’m not at sea. Right. Thank you.


Nippin Anand  03:01

Yes, we can see that you’re not moving. So we’re not at sea. Thank you. Would you like to introduce yourself?


Donna Cohen  03:12

Yes, I would thank you very much Nippin, also for the introduction and for the invitation to participate. So I come actually, originally from a biomedical research scientists background and I did that for a number of years, and then I changed direction quite completely and and after many different professions, I ended up working in the space of higher education, learning in health in higher education settings. And how I really got interested in working out how to do things better was a contract that I had when I first went out as a consultant, which was to develop a best practice framework for learning environments in clinical context, clinical learning environments, and that started about 14 years ago now and has kept me moving inevitably on the path of working out what is the best way for an organisation to create a learning environment that’s actually conducive to learning, but also to maintain it, and to contextualise it in the larger goals of the organisation around quality, safety improvement and so on.


Nippin Anand  04:30

Thank you, Donna. It would you like to say a few words?


Robert J de Boer  04:35

Yes, thank you again for inviting me as well Nippon. And some of the audience will already know me. My background is aeronautical engineering have line management experience in production and in engineering. And for the last 10 years or so, I’ve collaborated with Sidney Decker and others Nippin as well in ensuring that organisations take the next step in poor active safety management. And I’m affiliated with sto University of Applied Sciences in the Netherlands.


Nippin Anand  05:08

Thank you all three of you very humbled to have you all. So the topic of discussion is, is just culture desirable for learning. That’s really the question we want to ask. And given the nature of discussion that we’ve had in the last three or two episodes in the series, we’ve heard a lot about the concept of just culture and justice. And we’ve had very different views on that, I thought it would be wonderful to start with the idea of learning what what learning means, what sort of assumptions we are making when we talk about the term learning, and then see how that relates to the idea of just culture. So would that be a fair start, then? Yeah, I’m open who ever wants to talk about the idea of learning first? Yes, yes. Please go ahead.


Robert J de Boer  06:02

Yeah, so learning and we talked about this in the pre discussion. And I was going to focus on learning after the incident, which many of the audience will relate to as being quite unnecessary step. I mean, after all, you’ve had an incident, and then it’s good to take the costs and all the pain that’s involved in the incident, and at least turn it somewhat into something positive by learning from it. And what we find often is that there is learning and we spend a lot of energy in writing a report, after the incident investigation, first investigating, of course, the incident and then writing the report. And more often than not, including recommendations for improvements in that report. But the question I put before you is, is that really learning? In my perspective, that’s only part of it. The recommendations or the insights that are created through the investigation are important, surely. But from that we didn’t need to plan somehow how to implement improvements that we have gathered, sweetie insights, and then actually do the implementation as well. And as far as I’m concerned, we don’t actually reap the full benefits of the incident. I mean, the the positive aspects of the incidents, given all the negativity that it has created, if we don’t close the loop, and ensure that whatever we thought up beforehand, is checked, whether it has been implemented. And even one step further, whether it is as effective as we had thought it might be. And I think the real learning, certainly in many organisations currently comes from that, because we will find that many of the suggestions that follow from an incident investigation, actually quite superficial, train this or that person, add some text to a procedure, hang up a new sign, create some new safety clutter. And I’m pretty sure that if we made the effort, we would find that that does not really contribute to a better workplace, and therefore doesn’t really constitute learning. I’ll leave it at that for the moment.


Nippin Anand  08:15

Yes, so what I’m RJ is is the is really the challenge around the idea or the notion of implementation. And, and, and implementation in the sense that it actually closes the loop to use your own word. Yep. So that’s where you see that we are not learning as an organisation. Am I right in what I repeated?


Robert J de Boer  08:41

Yeah, that’s correct. And not just the implementation itself, ie hanging up the signs or creating the new procedures, but also checking whether that actually has the effect of mitigating the risk that appeared when we had the incident.


Nippin Anand  08:56

Is there instead of being abstract, is there value in in giving an example RG to help understand?


Robert J de Boer  09:06

Yeah, I think many of the audience will will be able to imagine your own examples. The example of hanging up new signs or creating yet another procedure and not testing their effectiveness is I think, is ubiquitous. One particular example that we came across was actually one step earlier in where we were talking to an organisation and they had their weekly safety discussion, and much of it was centred around which actions had not yet been executed. And this was a weekly return on the backlog of safety actions yet to be implemented. And to be honest, this was a catch 22 Because once such an extra safety action is on a list, it needs to be executed one feels that’s why we put it on the list after all, But really what we see is that in hindsight, not not the incident hindsight, but in in the moment of realisation that these actions might actually not be very effective. So we we delay executing them because we don’t feel they’re very beneficial anyway. And rather than going into discussion and saying, oh, we should take this off the list, that that in many organisations is absolute no, no, then we were there when a discussion was held, and we ventilate the thought that maybe this action wasn’t useful at all, and we should take it off the list. But no, we couldn’t do that, because it’s followed from an incident reporting being put on the list. And so it was going to remain on the list, even if the bacause log was multiple years.


Nippin Anand  10:46

Yeah, just build on that. A lot of times what you see as a corrective action is, is it is a very simple statement that this will be followed up in due course. It is what that really means. So yeah, it’s an interesting one. Thank you. Donna, would you like to?


Donna Cohen  11:06

Yeah, so I did actually consider the whole question about whether just culture is desirable for learning. And I came to the conclusion that it is desirable, but but there are actually two parts to that. Which come down to my views on the two key terms of the question, you sort of alluded to this, you know, namely, one is just culture, and one is learning and how to start with learning. So I think the first point I have to make is that learning happens in any setting any context or any culture that exists. It can be active learning, it can be passive, it can be formal, informal ad hoc. But the important thing out of all of this is that learning doesn’t always end up on the on what you might think of as the positive side of the equation. So like, for example, if you worked in an organisation say that, you know, turned a blind eye to bullying and harassment, in other words, a culture that tolerated that behaviour, then what you might learn, depending on your own situation, your own preferences, your own values, is actually how to bully and harass other people. Or if you’re the victim of bullying or harassment, then you might learn how to avoid or manage those bullying and harassment situations. Similarly, if you work in an organisation that doesn’t follow best practice for, you know, whatever the goods are that are produced, or the services that are delivered, then you might learn and most likely adopt for yourself the sub optimal practices, which you then in turn pass on to other people. So I think when we use the term learning, I think we have to be very clear about what we mean when we ask that question. Now, when I read the question, I guess I interpreted it with what you would have to describe as unwritten qualifiers because they’re not there in the actual statement itself. And what I felt that the question implied was a concept of learning that underpins improvement. In other words, that drives a positive outcome for the organisation. I also listened to your two earlier panels that discussed the question. And what I heard. And it was interesting, because RJ, you sort of said this a little bit earlier, you you sort of heard learning as shorthand for learning from errors or mistakes. But there I think is the rub, learning from errors, mistakes, near misses, and so on, is not the only kind of learning that could occur. And when I and that’s really why I said back at the start that I think just culture is desirable for learning. Because just culture or in fact, any kind of culture is not essential for learning, because people will learn under any circumstances, irrespective of the culture that’s in place. So I don’t think we can separate what we understand learning to be from what our understanding of in the context of your question from what we understand just culture to me. So when I look at just culture in a healthcare context, which is what I’m most familiar with, the depth of the definition, I think that is is pretty much accepted and used is that there is organisational accountability for the systems that they’ve designed, and employee accountability for the choices that they make. So that’s sort of how they define just culture in a healthcare setting. What that says to me, is that accountability works in both directions and is a shared responsibility. And I think that’s a good starting point for considering what type of culture is most likely to just to drive positive learning. What that definition doesn’t take into account unfortunately, is that employees are often not always but often. Their choices are a direct consequence of how the system was designed. So there’s actually a grey area in there between what is clearly an organisational responsibility or accountability, and what is clearly an employee accountability. The other definition of just culture that is commonly used is, it simply states that adjust culture is the opposite of blame culture. Now, the problem that I have with that definition is that it focuses on the conceptualization of just culture on those situations where something has gone, demonstrably wrong. And that’s because we only use the term blame when there is an outcome that’s undesirable or inappropriate or has caused harm in some way. But actually, of the five key components of just culture, only one of them, namely, learning from mistakes versus blaming individuals, is explicitly focused on how an organisation deals with things that go wrong. The other four key components, which are adopting a model of shared accountability, managing behavioural choices, designing, designing safety into all your your systems, and your processes, and a commitment of organisational leaders to share goals. None of those, I’m focused on how you deal with mistakes, errors, near misses, incidents, and so on. So actually, I think that there are two terms just culture and learning intertwined, but not in the way that we typically do that. I think that what jazz culture is mostly about is unshackling. Learning from its association with mistakes and errors. If we only believe that if we believe that the only things that we can learn from are those situations that have not turned out, well, then actually we’re not in a learning organisation at all, we’re just a reactive organisation that doesn’t encourage reflection by anyone, unless things are demonstrably broken. On the other hand, a learning organisation is one that learns from routine practice, that sees learning opportunities in everyday activities, including things that go right, which, of course, in most organisations is well over 90%. A learning organisation, I think, is an organisation where all levels of management, they don’t just tolerate and put up with feedback from their employees, but rather, they’re actively and proactively seeking it. They’re enabling it, they’re actually facilitating it. And that’s even when things go well. And, actually, as I was just saying a moment ago, those things are embodied in the key components of just culture. If we focus on just culture as prescribing our approach to mistakes and errors, we aren’t really implementing the whole notion of just culture. And one of the questions I think he came out of the second panel discussion was, well, how do we know if an organisation has adjust culture and is learning and I think it was Nick tarios, who said that learning can be seen to have occurred when things change. So that was his definition of what learning is that it causes things to change. Now, while I think that things won’t change unless some learning has occurred, I don’t think it’s necessarily the case, that learning will always result in change. Sometimes what you learned from reflecting on routine practices, is that you should continue doing exactly what you’re currently doing, because not worthy actually what you’re doing is being done as well as it could be in the current circumstances, and no specific changes needed. So learning is not about changing things. Learning, as I would define, it, is about reflecting on our practice, to determine whether things need to be changed. And so if we’re looking for some indicator that an organisation has a just culture in place, I think that we can start by asking whether there are opportunities for reflection on routine practice that take place on a regular basis, as part and parcel of business practices of the organisation not separate to them. Yes, we were doing quality this week, we’re doing safety this week, we’re doing, you know, focusing on errors. It’s not that it’s part of normal business practice. And so coming full circle, this is why I think that just culture is desirable for learning, because just culture when it’s implemented in its fullest meaning of the term creates the conditions for the broadest possible learning within the organisation.


Nippin Anand  19:35

Thank you. That’s, that’s a really elaborate answer. So, couple of things. Jana, before I go to what I’m hearing is, you started off with the idea of, of the example you gave was if people are being bullied, they’re being harassed and that’s how the culture of the organisation is. Then very soon, people will find a way to do Due to accept that and learn to respond to that. So, is that really learning? Or is it adapting to the culture of the organisation?


Donna Cohen  20:12

I think that it’s a little bit splitting hairs to talk about learning as being separate from adapting. I think that you adapt because of what you learn from things. I don’t think that adaptation happens without something somewhere in your mind, saying, Here’s what we’ve observed. And and here’s what I’ve decided is going to be my way to deal with what I’ve observed. And that’s, that’s learned behaviour. So, I don’t think there’s a difference. I think you’re right, that it does represent an adaptation. But that’s, if you like, is a change that occurs as a result of learning something, I learned that if I put my hand up and say something that that person over there is going to get annoyed and is going to have these repercussions. Therefore, what do I learn? I probably shouldn’t speak up. I don’t speak up.


Nippin Anand  20:59

Yes, and this is this is the idea of what you call single loop learning. And single loop learning is how we are trained, how we are schooled how we educated for our lives. But I’ll come to that. It’s interesting that is, and that is one way of understanding learning. The other thing I wanted to ask you was the idea around opportunities for reflection. Now, how would you tangibly explain what that means? In a in a concrete sense? How would you know there are lots of meetings that happen in an organisation? Then, what would you see as an opportunity for reflection?


Donna Cohen  21:40

So I’ve actually done this in practice in a healthcare organisation. And we we use the framework for the conversations that were had regularly once a week for about 4040 minutes. Once a week. We use the framework was of the national standards for safety and quality and health service settings, the Enescu HS standards that are here in Australia, most countries have some kind of a standard around hospitals and health services are meant to perform. So we use that as the framework. And we use that to provide structure to weekly conversations about how everyday practice was happening. So the starting point was not Oh, dear, Mrs. Smith had the wrong leg amputated. That wasn’t the starting point for the conversation, the starting point for the conversation was, oh, look, it is Monday afternoon at 2pm, it’s time for us to sit down and talk about what we’re doing in a tangible sense. So you, you have to plan the time to do it. Because otherwise the busyness of work will get in the way you want to bring groups into the conversation. It’s not just about individuals reflecting Of course, that’s part of it. But team based reflection in team working environment is so much more valuable. And it has to have a structure to it. Because otherwise, things just go off in all sorts of directions. And you don’t necessarily get to explore all of the things that you need to explore. And then directly linking those conversations into what RJ was talking about an action plan for implementing what you think are going to be the fixes for any problems that you’ve identified. But very importantly, that action plan should also build on the positive learning. So if you are reviewing general practice, and you think that this is going really well, this particular aspect of routine practice, what can we learn from that, that we could implement in other aspects of our business processes that aren’t working so well. So it’s about taking both of things that look like there could be problems that will manifest themselves down the line? And also things that look like they’re going perfectly? Well, nothing to see here, folks. But you can still learn positive things from that and then implement the consequences the readout of that?


Nippin Anand  23:58

Have you finished? Or do you want to say, oh, no,


Donna Cohen  24:00

no, no, no. Next person?


Nippin Anand  24:03

So yes, this is interesting, because one could, once again, one could argue that there are there are meetings held after an incident after extra normal meetings held in the offices, where we have opportunities for reflection, we have action plans, there’s good things come out from them and go back into safety management system. So apart from the structure, what what components do you see in that opportunity for reflection in that format that what does that really mean it? Maybe an example would help Donna?


Donna Cohen  24:38

Okay, so in a hospital context, when we were doing one of these conversations, where we were talking about a process in health services, that’s called Clinical handover. So this is where one practitioner who has been looking after a patient hands over to the next one who’s just coming on to the floor, and this process is often where If Mistakes happen, because the person who was on the floor knows what’s happened over the last eight hours, but if they don’t pass on that information properly to the person taking over, then you can have the wrong medication, the wrong dose things not done things done that shouldn’t be and so on. And because they were talking about it, just from the point of view of how well do you think this is doing not? Why did Mrs. Smith get the wrong dose of medication, nobody in the room felt that anybody was looking to blame anybody for anything, they were all just simply looking to explore. And by encouraging everybody in the room to speak up and talk about how they actually see those things, working from their perspective, people are now open to hearing other ideas and things that people are saying. So in this particular case, what they identified was that the nurses in the emergency department who were the primary caregivers, for the patients, and every so often a doctor comes along, there were a lot of missteps happening between the nurse and the doctor. And they said, Well, what can we do to fix this? And they said, why don’t we just put some whiteboards up in the cubicles and have a section there that is specifically for the attention of the doctor? So they said, Well, why don’t we trial it. So they did they, you know, it’s a 35 bed, emergency department, and they put them up in 10 of the units. And they trialled it for a period of a couple of months, it made an enormous difference. And so it was you could call that a superficial change. But actually, it turned out not to be a superficial change. More importantly, the idea came from the people who actually experiencing the difficulty in the issue. So they felt ownership over issue diagnosis, they felt ownership over identifying potential solutions, and therefore they were more likely to implement them. One of the things that often blocks implementation of good ideas is people go, Well, how would that person know they just came in here for 10 minutes and had a quick look around? And then they wrote their recommendation? Nobody asked me what I think. And so you’ll find that resistance that occurs to implementing change or even contemplating change, because the individuals who have to make use of the changes were never consulted about whether that was the real problem, or what they thought the solution might be. So in answer to your question, Nippin, it’s about having structure, it’s about encouraging everybody in the room to have a say, it’s about making the topic of conversation, not something where anybody can even feel remotely that they’re at fault or to blame because it doesn’t matter. You can write whatever you want. This is a just no blame culture situation. When things go wrong, people will go, Oh, what did I do? Is that my fault? But because that was not the starting point for the conversation, they were able to just simply talk about what was going on, and then give them ownership over the implementation of that solution as well. So those I think that’s what I think you can do in by engaging your frontline workforce in the whole process of reflection.


Nippin Anand  27:58

Great, I’m glad I asked the question. So many good things came out of it. Donna, I’m hearing if I’m hearing it, right, it’s I love the term Peter Singer uses. It’s called reflective conversations. And I think this is what you’re to also talking about the interdependencies that exist across the organisation, across departments across hierarchies, which only become visible, which only surface when you create the space for people to come and have those open discussions are not that I would use the word dialogue. So I think these conversations are very, very difficult to achieve in practice, as you and I both know. That’s great. It’s a good start. Thank you. And that’s what you refer to as learning if I’m not wrong, the the idea of reflective conversations. Yeah. Great. Thank you. Thank you, Donna. We go to Nikos now and knickers, you bring us back to the to the deck of the ship now. Which is where where you are on the bridge of the ship. Help us understand what learning means in your world.


Nikolaos Chalaris  29:13

That’s a great question and has also been a great discussion of now. As I mentioned before, I started even before I officially became another bartender 17 to go at sea. I’m now 46 This is the main job I’ve been doing my whole life. And I started from the lowest of the ranks climbing up all the way until masters position which is the most responsible position. This ladder that I had to climb up was essential and was really beneficial for my official involvement if I can say so. development as a professional because I took it from the lowest of the ranks. See how it really happens how the smallest of the in the easiest Some jobs are being done until the more difficult ones, and always has been a learning procedure. The interesting things that I think that I, that I still see and see most vividly nowadays is that I’m still learning. And actually, this is something that personally I love to do. So learning is a procedure, that is, when you are getting to a level of success in your job, it’s really normal that you become confident, because the experience that you have gained, and it the interaction with yourself, your internal discussion gives you the power and confidence to move on. And to take some times risks. You should do that, of course, carefully and in a controllable manner. But you have to because life has risks. And especially that’s the reason you cannot avoid it. All you know, that confidence can lead you sometimes to be reluctant, or to be overconfident, while you shouldn’t. But learning has to be something that in the context we’re working at, and personally with ourselves, something that we should remind ourselves to become part of our nature. If that stops, one colleague of mine told me, I believe that when you are 35, you can continue learning, you can continue reading, then you cannot, it makes some sense, but I am against it. So learning, it’s something that is ongoing. Now, how do you learn? That’s another issue? Maybe, to me the most important of all, it’s not experience. But we’ll add here a quote that I read when I was young, on a book, that experience is not what happens to us. It is what we learn from what’s happened to us. So I have seen a lot of colleagues that have had a lot of incidents, either good or bad, negative or positive. And they never diluted it, they never went and reflected back to it. To find out what happens. What’s what’s happened, why. From my end, I, I after every thing that is ongoing, I make my own evaluation myself. And I say, Okay, this went well, why did it go well? Deluded a bit, try to search it, to break it in bits and bytes and see, where did you do right? What could be done better? What could be done wrong? Of course, the same happens when things go wrong. But if you follow that mindset, definitely it will make you better and better. That will think is the context we’re living at. And maybe us in the medical undervaluation industries, I am in a job that the blame is straightforward and has severe consequences. Because if I make a mistake and is vital, maybe once I will get off it, if I’m lucky, and we get it in the second set of done, and mean that means I’m losing my job that I’m losing my financial security, my independence, my name, your reputation is destroyed. So there is a fear behind that pushes you back to to be on all the time, apart from your responsibility that at how, how serious Well, you haven’t the consequences. So how do we learn? And there is something unfair, that happens, at least in my industry. There are things going on, since our systems actually mainly subsistence work in current systems, bigger systems and bigger. So in their work in their life, there are a lot of humans that are working, there is a lot of technology, there is a lot of interference with the environment, a lot of legislation, many, many things that are being blended up. And things are going well. Ships are not thinking every day six are not exploding every day is not the majority of seats that are going wrong every day. All throughout all those years that I must say. Nobody ever came and told me hey, let’s see what did you do right now to serve your team? But everybody what did you do right today? How this all going thing goes well? Why is it to make the research and the investigation like you will do after an incident after something after an accident? We will focus on the near misses or all the accidents when things go wrong. Okay me find out have done let’s say 510 things and one wrong Why do we focus on the one that is wrong? And we don’t try to see how did any of those things have been good? Well at that time, of course we have to investigate and find out what went wrong don’t get me wrong, but why we don’t try to see what we’re doing right because apparently we do otherwise this the industry would have to work and learn from that as well. Because the most of the times it is the same person If that makes them things right and one wrong, and we go back to blame culture, we judge people, we go to heads, we make scapegoating. I believe not to learn definitely, this is not to learn, it’s just for the system to work for the insurance is to have somebody to blame for the system, just like politics, you know, this, somebody has to be blank. So everybody that seems just this is not justice, of course, at all. It’s just learning. On the other hand, to be fair, nowadays has to do with a lot of theoretical and technical knowledge that we didn’t have access before. A new technologies comes new ingredients, so materials, new mindsets, new theories that are coming all the time, because we are living in a world that is progressing. So we have to learn and we have to get that feedback. We have to do that proactively. If we do that, if we do have that knowledge proactively for sure, this will avert mishaps, for sure. But we have to have that in advance. We have to be open to that and to learn and try to avoid mistakes, mistakes that enhance our human nature. We cannot avoid mistakes. I’m I’m really sorry, I would love to be gathered to make mistakes. But I’m not. I’m just a human. I guess everybody here and that’s me. So we’ll try to judge people. A sometimes badly, strictly forgetting that human nature, and forgetting that the same persons have made it right so many times, well, why don’t we try to learn. One last thing from my end is that whenever I go to a new trip, because I truly love sex, I love to work with it. And as I stood without them, I don’t want to become a case study. So I said, Come, can everybody hear officers that are exceeding 70? But what is saved to your eyes? And they tell me to make drainage to follow the protocols. Okay, okay. Okay. That’s, that’s where they’ll be. So what is deeper 60. To me deeper safety, there are two things to my ears. The one is hardware, or software, the hardware is the equipment that we have. The ship is designed under some very certain rooms, we have to make sure that the hardware works. And it’s all goes fine. So we have weapons to fight. The other one isn’t software is us is humans. If we’re not trained properly, if we don’t have knowledge, if we don’t get to communicate better, if we’re not prepared, if that’s not preparedness, you cannot have, it doesn’t matter if you have the most high tech thing, it will, you will not be able to give. So if those things, at least add together at a basic point, then we can make a start if we don’t have highways can we do. And then the next thing that has to do with humans is productivity. And productivity is when things go right. Try to check what goes right. Make it a good practice. If you see something that is wrong, reported in advance, try to discuss it openly. Don’t be afraid before it’s too late. When it’s too late, once a minute, you see a naked cable coming out from the from the roof and it’s 220 volts there. This is apparently dangerous, you have to be proactive with that, report it try to avoid it. Try to make, as I say, a sort of not investigation, sort of like we’re making inspection URALSIB like somebody with fresh eyes will come on board and check. So that


Nippin Anand  38:30

you know I think there’s a lot in what you said, I just want you to capture the key issues. I think there’s two main issues that as I’m hearing at the moment, I think the first one you started off was very, very powerful. And our love to to get a little bit more insight from you on that. But I think you talk about the idea of learning as something which is very individual, which is something very personal. And I think that’s I find it very interesting. When you talk about the idea of how the more experience you gain, the more confident you become and the more difficult it gets for you to learn something. I found that very, very powerful. The other thing is that the the excessive focus on what goes wrong, which creates a culture of blaming individual and an unfair culture as a whole. This is what I’m hearing so far what you’re saying is, can we be a little bit more proactive in the way we approach learning? Am I right in capturing? Okay, sure. Sure. Okay, so we’ve had a few different takes on learning. I’m just trying to scratch my head here. It’s one is, I think, RJ is idea of, of very much rooted in the idea of PDCA which is plan, do check and act I think That’s, that’s what you’re referring to RJ Demings kind of work. And if it’s done in the spirit of PDCA, then we can achieve a lot more learning than we do, which presently doesn’t happen. And the funny thing is we all think it does. That’s interesting. And then we come to Donna, who has a more grassroots perspective on learning, which is learning from the bottoms up, but also learning as across departments across hierarchies, trying to understand system interdependencies and encouraging people to speak. Because in those words, is both information and the exclamation, which is what is said, What is not setting those things become visible, and you get a lot more collaboration and trust across the organisation. And then we come to Nikos who is who is very much rooted in the idea of learning as something that is that should happen more proactively. And at the moment, it’s far from, from what happens on the ground. What I would like to now do is to take the discussion to the next level, which is, maybe we can start with RJ RJ, how do you think we can achieve this kind of thinking to through just culture? What’s your view on that? Or is there a connection between the two?


Robert J de Boer  41:17

Yeah, yeah, absolutely. Nippin. Nichols and Dawn are already suggested, learning requires an environment in which there’s acceptance of theory of human variability. And acknowledgement that systems and halls in the interest of context, create outcomes that are most often very wanted, but sometimes do not, they will also need to relate to the times that we’re successful with the outcomes are as desired, to properly understand what is happening and to take the next step forward. And so what we’re really saying is that this not the learning itself, the instrumental act of taking a particular instance, and diet diluted, finding out what we should be technically or or otherwise solving. That’s not really the issue, the issue is to create an environment within the organisation in which we can do that continuously and productively. And so much of the challenge that I’m currently working in organisations about is how to create that environment. And it goes without saying that if we drive errors and ways and do your wave, that work is done. If we drive that underground, if we do not make that transparent, then it’s very, very difficult for the organisation as a whole, to take lessons from that, to improve on it, to check it for new risks that are being introduced, or to use it as a best practice elsewhere. And so the environment must be one have of curiosity, rather than normative approach to what how work is actually being done. Now, that is a gigantic step for many, many organisations and for managers in it. And to be honest, it’s That’s not weird, that’s not their personal disadvantage, or something which they, they from their personality have created. That’s the way that over the last couple of decades, we have educated managers and employees alike. Here the rules go and adhere to them. These are the procedures This is what to do. If at all, we have a change, read it sign for it appliance. And what we do an investigation reports more often than not is these word rules. This is where the non compliance or even better the violation was, therefore, that is what went wrong. But that’s not reality in today’s complex world, in today’s complex world, we need to understand how work is done. And from that understand what rules and procedures were, as were used as a resource and not as a binding legal entity that of course, there are laws that we need to adhere to. But 80% of the rules that are valid in organisations are self made. And many of the rules in in western world at least much more golden rules rather than procedurals. So, the way that we do work and the way that we describe working well as opposed to just it’s very much part of our own liberty, our own freedom of choice, and we need to now understand that that there can be through goal conflicts, some challenges between what we what we do in practice and how we think it’s done. And understand those those those gaps to to then improve on our work itself, we’ve termed that local ingenuity. That’s a new term local ingenuity. And the term describes on the one hand that it’s very decentral. Therefore local, very, very much in a place outside of what is usually seen, and we name it ingenuity on purpose to frame it’s it’s smartness that a solution driven approach that people take to work to manage the different goals that they have to achieve. And mind you those goals are partly tangible and describes, but partly very much intangible in formal not described. It’s conveyed socially, that doesn’t make them social goals, but conveyed socially. What about finishing this before the next shift? How about we can do this with two people rather than one so that the other way downs for one people rather than two, so that we have free up someone for important work elsewhere? That sort of thing? Does that answer your question or pose even more Donna wants?


Nippin Anand  46:04

I think it poses more questions, but I have to limit myself. I still ask one. That, first of all, I would like to get my understanding, right. I think what you’re talking about is to make variability in everyday work, institutionalise it to the organisational level, that it’s okay to have variability, because that’s how work is actually done. So you want to create this language or the language already exists, you want to make this language heard to the to the to the senior management thing interesting about local ingenuity is that there is a much simpler word we use in the maritime Well, it’s called seamanship.


Robert J de Boer  46:46

professionalism. Yeah.


Nippin Anand  46:49

What’s interesting, so I will


Robert J de Boer  46:50

not the same, that’s not the same Nippin All right.


Nippin Anand  46:53

But hang on, because the concrete example might help here, RJ. So many years ago, I was I was visiting a ship in Aberdeen and the ship, I had come from tropical waters in in, in in Africa, and she was detained first thing when she came to Aberdeen. And what was found on the ship was that somebody had drilled a hole under the lifeboat. And the reason for drilling that hole was it crazy as it may sound to too many people who goes and drills holes on the whiteboard. The idea was that ship came from tropical waters where she was experiencing a lot of rain, and water would get trapped in the boat. And there were two solutions. One was to to replace the bilge pump, which was faulty. The other one was to do something more creative, and drill a hole and then plug it so nothing goes wrong. And you can you can drain the water and you can plug it back and that’s your problem solved, it solved. Now, that issue had been raised many, many times to the management it had been overlooked. And why because it was not a commercial problem, because the bilge pump doesn’t cost more than $100. I think what I’m trying to allude towards is that it is in an organisation it is very, very difficult for people to are in not interested in an organisation in real sense, when you talk about curiosity, there is no space in good for curiosity in most organisations. It is it is very, very difficult to make people curious, and I don’t think it’s a result of 20 years of personalization, I think it’s it’s very much human nature. And I’d like to tie it back to Nicole’s point, that essentially, we are talking to people who are between 30 and 50 years old when we when we are speaking this language. And this is a very interesting demographic, because this is the stage where you have learned a lot of experience and you can’t let go of what you know, I think there is my view, at least, this is a big hindrance to learning. But I’m open to your comments on this.


Robert J de Boer  48:56

You’re addressing me, can I just screw you. So the example you gave was an excellent example of local ingenuity. And what you would want as as a small Senior Manager, is to first of all know that this happens, not only when it came back to Scotland or wherever it was, but also at the moment it was happening. And you would want to just consider which additional works were being introduced by drilling the hole and plugging it with a cork. So that that shows that local ingenuity must become transparent for it to be to be embedded within your organisation but that’s an excellent example of what you bring, I protest against the word seamanship, or its synonym professionalism. And the reason is that that has been misused by many traditional safety and and managers, safety addicts and managers in the sense that you are seamanlike Or you are preferred should know, if only you abide by the rules. And I’ve actually seen a video where accidents were only explained in terms of he was not professional, because he did not follow the rules. And given my earlier explanation, I can’t I can’t abide by that. So I prefer local ingenuity to that sort of more.


Nippin Anand  50:24

I agree, I totally agree it is, it can be the beauty of the word seamanship, but it can fit anywhere at all. But Don wants to say something.


Donna Cohen  50:34

Yeah, well, first of all, just in the example that you gave there, Nippin. It’s interesting to think that if they had asked everybody who is in the situation of what they thought a solution might be, someone might have come up with a solution of storing the lifeboat upside down so that water couldn’t collect in them. And then when they’re needed, the first thing that happens is they flip over so that they can be deployed right way out. But anyway, that was just came out of what you had just offered there. As an example, I think that there are two reasons why organisations don’t do more of this. And the first is that everything now is about money, and spending as little on it as you possibly can. And so that means that an activity that is spent doing something that isn’t necessary, we don’t have a problem here, why do we need to spend time talking about it, they say, well, we’ll have to trim that eye, that whole activity out so that we can afford to just run our organisation. This is certainly true in healthcare. But the second, and I actually think more important reason why senior managers don’t like to consult with the rest of the workforce on a regular basis, is for exactly the same reason that the blame culture impacts on employees is that if you turn it around, and the employees say, well, that decision that you made that I have to do X, Y, and Zed doesn’t work for me, managers feel that they’re being blamed. And so what we need to do is to find a way to enable a dialogue or productive dialogue between senior executives, middle managers, frontline teams about what’s actually going on, so that the senior people can understand why the frontline people are doing what they’re doing or asking for what they’re asking. And in exactly the same way, the frontline people can understand why it is that the people at the top of the organisation said I want you to do this, instead of do that, it’s not necessarily going to mean that everyone walks away feeling entirely comfortable about the solutions that are decided upon. But at least they understand the reasons for it, and are more likely to be supportive of each other’s positions through that level of understanding. So if we’re going to change this, and we’re going to go for really just cultures, we’re serious about that, we have to make sure that we don’t turn this into a way of blaming the people at the top of the organisation any more than we were blaming the people at the bottom.


Nippin Anand  53:05

I can’t agree more. And this is precisely one of the big problems with systems thinking, at least in the way it’s understood today, that it has to be somebody to who has to be blamed. So in my example, if it’s not the same man who drilled the hole, and it must be the guy who did not approve the purchase of the equipment, and I think you’re right, there’s something really important there. I’m just conscious of the time Nicholas, would you like to say something. In closing, before we conclude,


Nikolaos Chalaris  53:33

I would like to thank both of my colleagues here, they said it’s perfectly I will follow up and take it further. It’s a lack of trust, when there is no trust between the teams, then what comes it comes the hierarchy, the one that is on top will blame the other ones down. So he’s out. Come on, we’re not living in a dangerous world. We know how ethics work, we know how things are being done. So sometimes the management is blind is abrupt, is deaf, doesn’t want to listen, doesn’t want to see. And then it’s very easy to blame the ones beneath and underneath. The other thing that I want to follow up on what we only said then I said before, is the share of knowledge proactively will definitely assist what I’m doing with my items, everything every day when things go wrong, right or what, you know, everyday operations, we share the knowledge, we plan in advance, and then we can make a follow up but this has to be used for months according to a protocol. And first of all, the one that is on top has to have the responsibility and I don’t know how to say it politely to take it to be exposed and say Listen guys, this is first of all I will speak Firstly, I’m a captain to them and this was my mistake today. First me then the others will have the courage to come and say yes, yes captain, but I did that and we did that. So when then can proactively or concede that things will not get right If we don’t do that, in fact, I’m cutting the people under me to give me feedback, then I’m deaf as well. And then the same will happen with me and the company that I will try to relay a message. And the same thing happens. So yeah, I think we understand each other quite well.


Nippin Anand  55:18

Sometimes we do worse, which is we accepted or we expect an apology. And that closes the discussion, that’s even more powerful. Great point is. So we are almost at the end of the session, what I’d like to do is, is to just go around the room and just ask everyone to just sum up their their thoughts about about the question is just culture desirable for learning. And just please don’t take more than two minutes because that would mean you take somebody else’s time. Donna, would you like to give it a go? You’re muted, Donna.


Donna Cohen  55:56

I’ll try speaking without needing I was going to do sign language. But I think that just culture is desirable. When just culture is understood in its fullest, meaning not simply restricted to how we address things that go wrong, I think it is desirable. And I think it’s desirable, because it can’t be essential, because the reality is that people will learn no matter what the circumstances and what the culture. So what people learn, and how people learn, and how productive that is for an organisation entirely depends upon the environment that we create for that learning to take place. And if just culture is implemented, as I believe the full definition of just culture was intended to be, then I think that you can have the organisational learnings that you need in order to improve as an organisation make yourselves a good place to work and, and a good deliverer of services or products to your your clients or consumers.


Nippin Anand  56:57

Thank you, Donna. Very helpful. RZ, would you like to say something?


Robert J de Boer  57:01

Yeah, absolutely concur with what Donna just said? And so the challenge is, how do we go about creating an environment of justice or historic, historic Ness, if you want? How do we ensure that the management but also the employees that are at all levels of the organisation, are moving towards this way of, of interacting with each other? And that is still a challenge. I find it challenging when I work with organisations when we’re making progress, but probably not as quick as i i what your organization’s themselves would want. So I think that’s that’s worth the if the next thoughts next step in thinking out. Thank you.


Nippin Anand  57:47

Thank you. Merci. Nicholas, would you like to say something before we close?


Nikolaos Chalaris  57:51

Yeah, I would like following up to everybody. First of all, that’s a responsibility should be a should be according to the rank, the higher the rank, the higher the responsibility and responsibility not to blame. But to be proactive, to foresee something going wrong and put the measures in advance. So it doesn’t happen. And this starts from the top down from the CEO. And then it goes down. The higher you are, the more responsibility you have. The other things that for just culture to exist and to succeed and to serve is to be open to beat through just sort of justice that has been felt everywhere around it drew just cultural, and other one is that we share it all the successes and the failures. If we said it’s only between us failing, this is a true just cancel that we succeed. If not If it’s only one sided. It’s really not. That’s how I see it. Thanks.


Nippin Anand  58:50

Great. Thank you very much. And thank you to those who are listening. This is the this is the end of the session. And I would like to end the broadcast here. Thank you for everyone who joined us. What did you think? Well, we started this podcast with a discussion on what learning means from different panellists. From one perspective, the idea of rote learning really is tied to the Deming Cycle of plan, do check and act and the cycle is understood and followed to its spirit. The organisation can embark on a learning journey. Too often, as RJ alluded towards, the actions that we generate from incidents and events are discarded, delayed or not taken seriously, and hence the opportunity for learning is lost. From another perspective, learning in an organisational context is about creating space for conversations, conversations that cut across different departments and hierarchies. conversations that bring to surface interdependencies, relationships, frictions and tensions that usually go hidden in the siloed genes of the organism. Question. And then we have a ship captain, who believes that a lot of learning is about unlearning. I find it very interesting actually. Because in our mid life as professionals, we have all read the position by accumulating a certain set of skills and knowledge and it has served us so well. Are we really ready to challenge our assumptions in pursuit of new learning? And for that we have to unlearn something, we have to let go of something. It also explains the metaphor that learning is a journey and not a destination, never ending. Now let’s take a moment to reflect upon the key question which is, do we need adjust culture for learning? Well, all panellists believe that just culture is essential not only desirable when it comes to learning, it’s essential because just culture allows space for human variability. Having a just culture creates the opportunity to understand the non binary nature of work, the murky nature of work that we cannot always understand and measure against predetermined standards. From another perspective, just culture is essential also, because it creates dialogue between management and people involved in frontline activities as much as much as we want to understand the variability in everyday work. These conversations also allow people to ask questions, and seek clarifications from people in positions of power and authority. So it works both ways. And the captain is of the view that we have that having adjust culture also allows us to move beyond waiting for undesirable occurrences, for example, accidents and incidents, and learn more proactively when we remove fear. I think this is also a view shared by other panellists that just culture leads to more open and honest conversations, which is all very conducive for learning. Now, a thought that comes to mind after listening to all the participants or the panellists is that. That if all of this is really about openness and dialogue, moving beyond the siloed, thinking, understanding and learning from everyday work, and learning to live with imperfection, which some might refer to as performance, variability, in an engineering sense, maybe we need a more nuanced understanding of justice and just culture. What do you think, have be grasped the idea of what is justice and just culture can be clearly related with learning. That is the bigger question of this series. I leave you with those thoughts. Thank you, and have a wonderful day. Now for the best part. If you really enjoyed listening to this podcast and want to think, reflect, and dance with different perspectives, yes, dance with different perspectives, follow me on LinkedIn, on my company page novellus solutions, or email me at Nippin.Anand@novellus.solutions, and I will add you to our mailing list. There is a great lineup of events planned in the next few months, so I wouldn’t want you to miss them at all. As usual to all your curious people. Thank you for wanting to know more than what you knew yesterday. It’s both very rare and refreshing to find true learners in this world. I wish you a pleasant day and night. Goodbye