Is Just Culture desirable for learning? – Part 5

June 23, 2022



This is the fifth 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, Clive Lloyd, Kym Bancroft, Daniel Hummerdal, jay banerjee


Nippin Anand  00:00

Hello, and welcome to another episode of embracing differences. I’m your host Nippin Anand, and this is the fifth in the series of six episodes on the topic is just culture desirable for learning. I have with me some reputed names in the Risk and Safety world that include Daniel Hummerdal, Clive Lloyd, Kim Bancroft, and Jay Banerjee. I also wish to remind the listener that this is a recording of a LinkedIn event. So you can always watch the video of this event on my website novellas dot solutions. I hope you enjoy this. Okay, we are live now. Good morning. Good afternoon. Good evening. Wherever you are in the world, welcome to this first session in the series is just culture desirable for learning. My name is Nippin. I’m the founder of novellus. And I’m joined by four very intelligent people this morning or evening, their time, of course, to debate on this topic. We’ll start with a light introduction from everyone. And then we will delve into the topic. Jay, would it be okay if I asked you to give a light introduction about yourself?


jay banerjee  01:25

Hi, there. Yes. Thank you everyone, and very exciting opportunity. I’m Jay I work in healthcare. I’m a doctor in Leicester, United Kingdom. I work in emergency medicine, interested in patient safety specialists because I used to be an arch a fellow who 20 years ago. And and on top of that, I still continue to do a lot of work specifically in the area of improving quality of care for older people. I’m also doing a master’s in law from member University and medical law and ethics because I really want to understand how the law shapes our behaviour, especially when it comes to just culture.


Nippin Anand  02:03

Brilliant. Very pleased to have you on honoured to have you Jay Thank you. Clay Hello clay. Would you like to say a few words? Not that people need there, but we’ll do it anyway as a ritual.


Clive Lloyd  02:14

I know you want it to be quick enough and so I’ll be very, very brief. So my name is Clive Lloyd. I don’t play cricket just for those who might have tuned in for that reason you’re going to be sorely disappointed. I’m a psychologist and I for a living. I try to humanise organisations. They will do me.


Nippin Anand  02:34

Great. Thank you, client. Thank you for joining us. Hello, Kim. Good evening.


Kym Bancroft  02:41

Hello Nippin How are you? Good, good. So yes, I am the head of HSE for Surco, Asia Pacific. And I’ve worked across many, many industries for almost 20 years in safety and Clive and I go way back, I think to some diamond mines back there and Yellowknife live in all the all the great places in the world where there’s heavy industry. And just culture is a concept or a theory that’s particularly dear to my heart. I really put a strong I like a high amount of value on it. And I’ve seen how it can really benefit an organisation. It’s challenging to put into practice those. So looking forward to fleshing that out tonight Nippin In terms of what good looks like for for just culture. Thank you.


Nippin Anand  03:28

Like again, once again, very honoured to have you. Daniel, you have been absent from LinkedIn. So it’s so nice to see you after a while.


Daniel Hummerdal  03:38

Thanks, Nathan, it is a pleasure to be back. And thank you for for inviting me to contribute to this session. So in my substantive role, I’m the head of innovation for Worksafe New Zealand. At the moment, I’m in a sort of seconded into a transformation lead role for the organisation but working out of Sweden. So based in Lynch tripping, over the last 15 years or so I’ve been in different safety, innovation roles in a range of industries. So I’m really focusing my work on developing better practices, better solutions, better procedures and processes for organisations that can align more with many of these values that have heard already about more humanising organisations. So I’m, I’m looking forward to discussion.


Nippin Anand  04:26

Yes, so are we thank you, thank you, and maybe we can start with you, Daniel. Help us understand what’s your perspective or what’s your view on just culture?


Daniel Hummerdal  04:40

So, I’ve taken as a starting point for this discussion, the the expressions that I’ve seen of just culture in quite a few organisations where I’ve been involved in meetings were often the leadership team, sometimes with the help of supervisors sitting down to determine the accountability for undesired Are Bolivians. And at their disposal, they have some sort of process or, or framework to support the decision to decide the accountability of essentially, I guess you have all seen these where there’s sort of a flowchart of deciding the intent behind it and the sort of the attenuating circumstances that surrounded the action. And when I tried to explore why do organisations have this in place, and where is it coming from everyone says that this is a big step forward, because before that, it was completely ad hoc whimsical decisions about accountability. So this is a huge step forward about creating transparency and starting to create a just culture and, and that tends to be across the line that people think that this is a step forward. I am quite sceptical of that notion. Because just because you put something on paper, just because you make it available to everyone to see it doesn’t make it just, you can have whatever in that. And of course, you get all kinds of different outcomes. So pretty much everything that I’ve seen that is in practice in large organisation is actually it’s really backward looking, it’s more about blame. It is holding the organisation back from from learning, it’s actually impeding learning of constraining learning. And, and the main main reason for that is, of course, that the whole framework is a sort of a comparative framework we’re looking through, we’re looking at what happened, we’re looking at the world through a lens of what should be in place, or through a lens of what is already known. That means that the information flows from the organisation on to, from the framework on to the organisation, if you will, to signal what is important and what is right and, of course, meaningful to have that to some degree. But that’s my point. If we want to have learning if we want to see the world in a new light, if we want to be surprised, but what’s going on in our organisation, we’re just sort of fundamental elements for any learning activity, we need to have processes that will ensure enabled information to flow from the world on to us as decision makers and not the other way around. So I think it’s quite possible to create those. And I know that there are some organisations now are having much more, I guess, open frameworks or open questions that will trigger curiosity that will allow them to learn new things. And and when that happens, when that works out, you start to see how how they sort of blame game moves towards empathy or sympathy for people involved, as to why they didn’t use the right equipment or why they didn’t follow the procedure. And when we get to that level of understanding of how people’s behaviours and their decisions made sense, we have a much better chance to take action that will create a new level of performance for the future. That doesn’t mean that we forget about accountability. And I think that’s a mistake that has happened in this discussion many times that we, we think we have to do away with the accountability discussion. But I think that’s a naive notion. If you listen to how organisations talk. We need to think about that. But I do think that this notion, you’ve probably read about future looking accountability versus backwards looking. So when we can sit up to think about well, what kind of future would I have on how can this person be part of, of creating that future they will want to have, I think we can maintain the notion of accountability. But we really need to think carefully about what the just culture to is doing to our organisation to our people. I think it impacts culture and influences culture, but he doesn’t set the culture it’s too one ofI to to be to have that sort of impact. So yeah, that has that as a starting point.


Nippin Anand  09:11

It’s an excellent starting point. And what what I took from this conversation, and it’s a typical problem in the maritime world, at least, I’m naive about other sectors, but is how preconceived notions preconceived ideas actually hinder learning? I think it is what you’re trying to say in that’s my interpretation, of course, and that kind of impedes any sort of open mindedness to new ideas that don’t fit with our worldview, and hence get rejected. But I think for the benefit of the listeners, it will also be interesting, you mentioned the idea of forward looking accountability. It could you expand upon a little bit and then we can move on to Camden


Daniel Hummerdal  09:58

national so We start with the contrast backward looking backward looking accountability is really to look at what what happened in the past and compare it to the processes and procedures set up for for yesterday’s performance. So we’re just looking at that. But if we think about that those are sort of arbitrary, they are in constant process of being transformed to the next level of or next iteration of what we have in place. And if we open up that system, to say, sure, that was our best guests with yesterday’s notion, but actually, let’s look at this incident to see not only what was problematic with the behaviour, but what is problematic with us as an organisation, and what does this incident invite us to become? Right? In terms of changing the system that is enabling performance, both good and bad? Then we open up the future and our decision becomes much more difficult, because we start to question a lot more things about becomes a much more complex thing. But by opening up the future to be many more things than just the change behaviour of this individual. We have a future looking process. And then you invite the accountability aspect into that how can this individual that has had has been involved or maybe has some sort of problematic notion of trust in relation to to his team or supervisors following this incident? How can they be part of creating this new new world live, you want to have to see that this is not about just absolving people of responsibility, but actually involving them for the future that they wish to surely would want to see. To avoid these things from from repeating


Nippin Anand  11:47

is great, I mean, a future licking process and and tapping into the experience, imagination, creativity and experience of the worker, not the work, it’s a very loaded term of the person. Great, that’s forward looking accountability. Thank you, Daniel. That’s my kind of you to share those those thoughts. Kim, let’s talk to you now, what do you think about the idea of just culture.


Kym Bancroft  12:14

So I come from a slightly, perhaps a slightly different perspective Nippin, from the practitioner perspective, having gone into an organisation that was heavily focused on flame, and then taking on that challenge around, changing those mental models around people being the problem. And looking at how we can shift from a heavy well entrenched blame game that that existed. And you I think we were quite successful in putting, I think, from memory, we did have a flowchart, but I relied on some research there from Diane, who I understand has been on one of these forums with the new pin. And there’s some published research that she did. So I’ve just got the name of the article here, if anyone’s interested in it, it was from individual behaviour to system weakness, the redesign of the just culture process of an international energy company, Diane Chadwick Jones 2018. And, and in there, there was a flowchart that I found particularly interesting that I did draw on because I found the organisation that I was in, they really didn’t know, you know, they wanted something to grasp to that was traditional. So whilst there are very, there are a lot of, you know, drawbacks from having that flowchart. Especially, you know, given that they’re all very similar and very traditional, I found in this case, in developing a guideline for them, that it was useful in starting to turn the dial away from, from the blame game. I also found it to be really important to start to establish learning reviews and what we sometimes called learning teams, and spending some time talking with leaders around these things called cognitive biases that they have that they’re not really familiar with, like hindsight bias and counterfactuals. And, you know, giving them insight into Okay, actually, this is, you know, what I sometimes bring to an investigation, this is what I bring to the table, this is sometimes what clouds good learning, they were then able to start to control for them. So when we had some significant incidents occur, you know, we were able to sit back and go, Okay, hang on a second, let’s try and put this just culture into practice. Let’s try to set that forward looking accountability that Daniel was talking about there. And if and I have to say, worked well, and we managed to turn the tide on the blame game, except when a really significant incident occurred. And it was almost like, oh, hang on a second. This just culture framework. We like it for these types of incidents that are they had some type of severity to them. By here, we’ve got, you know, an incident that could have been a fatality, it had a high risk potential to it. So therefore, we’re going to leave the just culture for I’m looking at the door. And we’re gonna go to a traditional investigation, we couldn’t simply apply that framework to this situation. So that’s where I found it starting to get a little bit challenging and making sure we follow through with it because we didn’t really want to have two sets of frameworks at play. And as some of you might know, from the Australian landscape, industrial manslaughter laws are now well and truly in place, and we’re starting to see case law emerge. So I do wonder, does that lead organisations to move back toward a more wretched beauty of culture? Because they assume that’s what they need to have in place to avoid these industrial manslaughter laws in place? Thanks, Nippin.


Nippin Anand  15:43

Great, great. And what I’m hearing Kim is the usefulness of of some kind of a consistent approach to the notion of just culture. And then it kind of becomes a challenge when something of consequential nature happens. And we tend to fall back on the on the on the same old ideas of Orthodox safety. If I can use the work, you talked about system weaknesses and how how you were able to identify some of the safe system weaknesses using that framework. Would you like to elaborate on that a little bit Kim


Kym Bancroft  16:27

shows I what I did was I took that paper from Diane, I found it really useful to set up the system for the organisation I was in obviously, in collaboration with interested parties, such as HR and I, they were very concerned about what this system looks like that I was putting into place. And it almost felt like the whole HR policies we had in place were written for that very, very small percentage of employees who might engage in some kind of criminal behaviour. And so we’d set up those policies for the rest of the people who do not engage in criminal behaviour, and it just trying to do a good job, and errors sometimes happen. So yeah, the system, you know, wrapped up nicely into this, you know, standard operating procedure and this guide, and it and it did look also at the forward looking accountability. And just going back to Daniel’s points before about that, I think organisations, they like the idea of just culture, but when it starts to, you know, the rubber hits the road, and they have to put it into practice, they don’t know what forward looking accountability looks like, they don’t have a frame of reference for it, perhaps because in society, perhaps it’s not something we see vastly and openly. So I really very much had to work hard with the stakeholders to go okay, in putting this system into practice, here we have an event, normally, we would blame this person, perhaps they would be terminated and then no longer be working for the organisation. Let’s try out this forward looking accountability component of the system. And let’s put this into practice. And it was them when they got that practical experience in seeing how we worked with this individual or individuals involved in the incident, to actually decide on how we were going to learn from this, how we were going to move forward and become better as an organisation that they then started to build that mental model for the forward looking accountability. So that had a significant part of the whole system that that we had in place.


Nippin Anand  18:28

Thank you. Thanks very much for sharing that. We’re going to apply now, Clive, would you like to share your thoughts on what you think is this idea of just culture?


Clive Lloyd  18:40

Yeah, sure enough, and look, I’m working almost exclusively these days as a practitioner. And that means most days, I’m working around oil and gas mining, construction globally. And most of my clients, most of the people I work with actually would consider themselves to have a just culture. And then we talk further. So for me adjust culture first up is pretty rare. They also infer that a just culture is this binary thing. Where if you’ve got a just culture, it’s different to an unjust culture. There’s one or the other. It’s often viewed as binary. And I really don’t see it in that way. I don’t think it’s binary at all. If anything, it’s more of a continuum, if you will. Most of the companies who believe they have a job, just culture beliefs. So because they have some sort of policy or set of policies or flowchart it’s very common. And for me, it is never the flowchart or the policy that’s going to actually determine a just culture. A policy simply cannot make make it safe to speak up. I was in a very senior leaders office the other day, and I’d been there most of the day. And he said, Clive, you will notice that I have an open door policy. And I indeed did know that indeed, I did notice that the door Warren had been open all day, I thought was a little bit odd those that nobody actually walked through it. Again, you can have as many policies like that as you like, it does not mean it’s safe to speak up. So look for most of them, how did they see adjust culture? And look, the way I largely viewed just culture is sort of ideal, maybe idyllic, some might say utopian state, whereby maybe a company has what they’re consistently able to balance, learning from safety work with with accountability. And again, somehow they’re able to draw that line consistently. But for me, the thing with that line is, it’s not actually so important where that line is, and I agree with Sidney Decker on this, it’s much more important that the processes behind determining who drew up that line is understood and also agreed upon. Otherwise, I think, you know, it’s just really very unlikely that we’re going to get to this place of adjust culture. The other thing I’d like to discuss maybe later is the learning aspect of this, we’ll come to them because, yeah, it’s learning. For me that is viewed as often the rationale, the justification for the need for a just culture. And it also then infers that, well, you don’t get learning if you don’t have a just culture. And that is simply not true. Because people are always learning people will learn just as much, if not more, from an unjust culture, if you will. I think we’re suggesting with a just culture, we are learning in a bit more well directed way, and learning things, perhaps that we would view as valuable towards safety or work. Whereas possibly, I’m going to suggest we’re still learning very much. And the way I’m viewing learning here is I’m a simple man, right? Neurons that wire together, fire together, we’re constantly doing that whether the culture is just or otherwise. But that’s a bit of a snapshot, I guess, of how I see that.


Nippin Anand  22:07

Yes, neurons that wire together, fire together, I’ll remember that metaphor. Thank you for educating me. But coming back to your your, your, your your key issue, as I’m hearing is this constant balance between learning and accountability is what you call just culture. What’s particularly intriguing to me is that what you when you say, who draws that line is more important than anything else. So what what do you mean by that? Like? Could you please elaborate on that?


Clive Lloyd  22:33

Yeah. Well, again, I think we often think that it’s within a company, that we decide where that line is. And that’s usually fraught, because there are many things that influenced that that are not even within the company. There are, of course, the laws of the state laws of the land, there are public perceptions, there are public expectations, all of which flavour where that line is likely to end up. But at the end of the day, somebody possibly within the company is going to need to draw that line. And often that is not made overt. Often, the flowchart just is the flowchart, without a mention of who actually drew that up, who effectively eventually signs off on it. And I think there’s there’s also marvellous opportunities in understanding this process, really great opportunity. So I do work a lot in the field of psychological safety and trust. And when I’m working with clients, it’s the process of sort of understanding what adjust culture is all about, that can be a really valuable tool to create trust in the first place. Because we need to get a bit transparent about who is going to draw that line, who has the power to, for example, decide whether something was a mere accident as opposed to a blatant violation. You know, we who makes that decision, who judges that somebody is going to sign off on it. So we need to take all of those things into account. Kim mentioned industrial manslaughter laws, if you don’t think that’s going to impact or affect where the line is drawn in a company. Again, I think we’re being a little naive. Yep.


Nippin Anand  24:16

So what I’m hearing is a process of understanding the just culture process. All right, brilliant. That’s that’s, that’s interesting. Thank you. Thank you. That’s, that’s very, very. So this, as you can already see, there is there’s different views on on the the notion of justice and that’s fantastic. We’ll go to Jay now, Jay, what’s your view?


jay banerjee  24:39

Thank you. Well, I’m actually going to pick on replay of left review because I think there’s no better place to start and how we do things now. And the bottom line is how we do things now in the in the NHS is that there is something called the just culture Guide, which the NHS has published and you’re supposed to follow that, but it also really clearly says you should not be using that until you know, you’re absolutely certain that this is the human being who was to really responsible, and then he go through it. It’s sort of derived from the original James Reason, you know, incident culpability, get a cover guide, and you basically then come out, but by seeing that individual do it, I think, to me, this is probably the first error in our process of understanding and using just culture. I think the question should be asked, first and foremost, every time an error happens, was this purposeful, with a desire to cause harm, because we know, going by the people who work it that I don’t know, 95 to 99% of people do not come to work in any industry with a desire to cause harm. So therefore, the intent was not to cause harm, we should automatically eliminate the fact that this is not viewed as an individual, because doesn’t matter, they were driven by the desire to cause harm, but harm happened right? Now. And once we have dissociated the individual, we then start looking at why did the harm happen. And then it becomes a very different discussion, easy to say, much harder to do, because biases. And one of the biggest problem with biases, I think, is that it is lack too. It is linked to self competence, self confidence, and self esteem. So every individual looks at another person’s error, the first thing they tend to say is, why would never have done that, you know, how could the idiot even do that? Because I’m an exceptional person, you know, I can never possibly commit an error. And it goes back to that, you know, the throwing stone metaphor, you know, we are very, very keen to throw stones without ever asking the question, would I could I have done this in this situation? And I’m just an emergency physician. And I have to confess every time I look at these things, and I say, I could have done any of those, or only on a normal day, I could have done any of those. Which brings us to the next question is what is normal and what is abnormal? Because we have the habit of every time and harm happens, we consider the harm to be a special cause variation, it should never have happened. Okay? Because harm is not allowed to happen in systems. And I knew the civil aviation authorities in a different league when it comes to acknowledging that, but there’s a big challenge in healthcare because debt, as an outcome in healthcare is a normal outcome. There is nothing abnormal about people dying in hospitals, they always do. The key question that we need to understand is, was this debt a preventable death and avoidable death? Row number two, if it was, what was it in the system that didn’t work. And the inquiry should always be starting with the mindset of what was wrong in the system, because if humans are learning culture, then it has to be designed towards improving the system because that is what a learning culture is all about. It is not about improving an individual. It’s about improving the system. It’s as it is what you know, this common kind of usage in the safety literature about shifting, shifting your your your doc, you basically take your normal distribution curve, and he moved the entire curve to one site to shift the performance of the entire organisation rather than trying to chop off those apperances at two ends and pretend your organisation is so so much better that does aberrant individuals have been sacked. So if you’re going to move towards a just culture, the next thing we need to do, which is probably the easiest thing to do is start measuring daily performance. Only when we know what is normal? And what is variation within three standard deviations of each and every activity that we do. Will it become easier to define? Why was there a departure that was outside three standard deviations? And then ask the question, right, let’s see, what’s his departure due to a system design? Or was this viewed to an individual behaving differently? And that is a key because even when you start looking at those 1% of events outside three standard deviations, and attractive over time, you might find they are part of his separate normal distribution curve where those events are the common cause variation. And it’s so important to understand the data that without the data, we absolutely should never even ask the question, what I’m seeing, is this normal, or is this just a variation of normal and they should be expected in the system. And that is where I think we are lagging really, really badly. And it’s a shame because NHS also has the awesome safety one and safety to guide really looking at the approaches and getting people to think about you know, designing for the person, but we don’t look at those because we are so biassed in our system that we could never have done this. You have a committed designer that first instance we get we beat up other people. And it’s a real shame.


Nippin Anand  30:07

It is in wonderful articulation. And what caught me thinking was this, this, you know, from your first point, which is how do you disassociate associate yourself in those moments? I think practitioners from a particular profession are always divided between what they say and what they do. That’s a big flaw in the interviewing techniques also, that we rely so heavily on what people say and not what they actually think of how they make decisions. But a bigger point is that I see you’re using the word system and culture. And I would really love in very few words to be just, I’m just being conscious of time. Could you help me understand how you see the difference? Or is there no difference in your world? Because I just want to understand from you, do you see any difference between the word system and culture?


jay banerjee  31:04

No, no, absolutely don’t. I think they are exactly the same. And one and same thing. I think the so in my mind, because as an emergency physician, I’m very much given to doing I’m an activist, you know, there is a time for thinking there’s time for doing great if you can combine the two. But the bottom line to be is, once I’ve understood all of those and read all the papers, what does it look like for the patient? What does the patient experience in order for the patient experience the right kind of care, we need to have the right kind of system. And the right kind of system has to have the right culture meaning the right processes. So the structure of the system and the way the processes are designed and delivered, will basically dictate outcome, I’m going back to the very simple Donabedian strike out here. And if you’re going to really understand the structure, and how the processes are designed, you have to understand how we design both of those to support the staff who’s going to deliver for the customer. And the problem is that most of us are so deeply inside that culture, we lacked the ability to step outside and properly look at it objectively. And I think if we are going to learn from from you know, using just culture, expanding it, the first thing we need to stop doing is getting individuals who belong to the industry to investigate their own systems. We need safety technologists have nothing to do with that industry. So one of the best things that has happened in the in the UK recently is this, the new world has I mean, it’s not that you buy but it’s been there, all the professional standards, standards authority, I have seen but when I read of them and learn from them as like, Oh, this looks really interesting. So they’re basically they’re regulating the regulators. They’re providing overview over how GMC works and see what GDC works, etc. But what was really encouraging about it, not a single person on that boat comes from a health and social care background, because that is an exclusion criteria. And I thought that was really, really clever. Doesn’t matter how much I feel I am reasonably, you know, objective in my approach, I am part of the system, I can never be purely objective. Great.


Nippin Anand  33:13

Thanks, Jay. That’s, that’s very, very wonderfully articulated once again. So in the interest of time, we have about 20 more minutes to go. And I’ll be crisp with the next question, which is, I will start with Daniel, how do you understand learning? But also how do you contextualise learning within the notion of just culture? It makes sense the question. So in other way, what is your view on learning? And is just culture desirable for learning?


Daniel Hummerdal  33:48

Would be great if you would send these questions beforehand, but let’s go. Not that particular one. But the learning notion. I do believe it was Dr. Drew Ray, who said something like learning happens when you can do new things. Or you can do things in a new way, if you will. So until you sort of achieved that understanding things or realising how things are connected in a new kind of way, you haven’t really learned anything. So with that sort of definition on learning on on the the ultimate end goal of we need to lift our game we need to be able to do things in a new way as an outcome or something that has happened. Then the question is whether the just culture, process or framework allows us to discover things to learn things that we didn’t know beforehand, and I’m not just talking about categorising things or putting them into a flowchart here. But actually, how does the process allow us to step outside ours? selves to move to more holistic I’m I’m a little bit Ajay, you mentioned the snow, the ideal of objectivity, which I don’t really believe is achievable, I think we can move to more and more holistic understanding. But it’s something that is it quickly becomes very complex to you, the more subjectivity you involve, the more perspectives you take in to understand the complexity of the system. But the process should be about inviting more and more individual points of view about how the system is performing, or what it looks like from different angles. And I want to go back to something I think it was Clive who said, it matters who gets to draw the line here. And I agree with that, and all the frameworks that I looked at, they had been consulted with the unions and so on. And there seems to be some sort of recognition that this is important. But I also want to bring to part of the discussion is not just who does it, but actually what is the mindset we bring into these all the procedures, they take the individual as a starting point, that the individuals accountability is at stake here. But as I think Jay mentioned, this is also about the team or about the organisation that surrounds the individual. But rarely do we start with that, that comes as some sort of a circumstance later on. But I think the process needs to be reversed. Or it would be really interesting to have a process that starts with how the organisation set the system up for success. How did that play out in this in and gradually way make your way towards the last line of defence the individual in the system here to sort of look at the surrounding ecosystem and start with the big picture. And rather than then this sort of unique, it’s, the case is almost over if you start with individual, and we’re here to decide the accountability on the dividual. While there’s only so much space, because the battlefield of what the decision has already been set up. So sure, who gets to decide where the line is drawn, but also what is actually the model that we have when we go into this is safety about individual behaviour, is safety performance about something much wider about system and how how performance comes together and falls apart? Well, if it is, then we need to fundamentally re change that. And I think there is a huge opportunity to create learning outcomes by asking more open ended questions and invite more complexity, more subjectivity, and just hear people out to be surprised about what’s going on.


Nippin Anand  37:52

Yeah, what I’m hearing is, again, our process process, or the the the organisation itself, because it’s an institution process comes from a way of thinking challenges our worldview, constantly. And I think that’s, yeah, that’s a fair point. Great. That’s a very wonderful articulation, without much notice. So thank you.



I should read my emails, I guess.


Nippin Anand  38:20

Kim? Well, we’ll get to you now. What’s What’s your view on? First of all, what’s your view on what is learning? Let’s start with that first, and then we’ll get into why just culture is imperative for learning or not?


Kym Bancroft  38:35

Sure. Thanks. Nippin. Yeah, like Daniel Oh, a bit like we went in, we answered. And I thought, I think it’s, you know, it’s a such a valuable question, because oftentimes, we go, yeah, we just want to learn from this, but we don’t actually stop and go, well, actually, what is learning? And I really liked Daniel’s Point. Well, you know, it’s about gaining perhaps an insight that we haven’t had before and then acting on it. So it’s, you know, very much something that we do and get involved in. So for me, it’s really, you’re learning about unresolved concepts that perhaps haven’t emerged before. And they’re brought to the forefront through this process and the system that we’re putting in place to, you know, try to get to this restorative culture. And so for me, in my experience in, you know, setting up the learning environment, in under the just culture umbrella, it’s really about building that environment for people who perhaps, are used to being invited to share their realities of being at the sharp end, very much instilling that trust, that they understand whatever information that they’re going to bring forward. We’re going to deal with that in the way that they would like you know, we’re going to with it respectfully is not going to be used against them. And that’s when we start to get those that second layer of stories start to win. Merge was start to then unpack the system. And we move vastly away then from this, you know, judgement that we put on it and this hindsight bias and everything we thought was going to happen, we actually find this this this rationality involved, I do apologise if everyone can hear me, by the way. So, yes, on so your two questions in Nippin about just culture and learning 100% I think it’s, you know, the restorative culture concept, if we can get that ecosystem, right, with the people that we have, you know, at the sharp end, we can very much move into this full new state of learning that perhaps we’ve never had inside our organisation before. And in my experience, practically speaking, if we can get that right, that’s when the organisation and all the stakeholders who are perhaps hesitant about just culture and embedding it start to go, well, actually, this is a really valuable concept for us to have, this is very rich, this will help us move forward as an organisation, this will help us become safer. And that’s when we start to really build that trust. And I think then, if we’re very careful to nurture that, and nurture that learning culture, I think we can really start to see quite incredible things happen. And we can really start to shift away to the, you know, shift to that concept of, you know, people empowering people as a solution as we as we talk about, you know, in real sense of actually doing that. Yeah, so that’s my, that’s my thoughts. I’m just gonna go shut my dog up. Nippin


Nippin Anand  41:34

No, don’t worry, I have a follow up question for you. But I’ll come back to you later. Clive, what’s what would you think about the this notion of learning in the first instance, how would use elearning?


Clive Lloyd  41:49

Alright, so I’ve touched on this before. Look, I’m a cognitive psychologist. So we could spend hours talking about the mechanics of learning what it actually is, from a brain perspective, if you like. So we don’t have that log sort of time. So let me just say this. What I said before learning fundamentally, is neurons that wire together, fire together, and we’re doing it right now. I’ve learned that Kim has a little dog. I have learned the Daniel actually prefers questions in advance, we’re constantly learning, right? We’re doing that. And so for me, when we say, you know, or the inference being that we need to adjust culture in order to learn, that is not true, don’t get me wrong, it may be desirable, because we want to learn specific things. But we are learning whether the culture is just or not. So to paraphrase further, some current safety, vocabulary, in a sense, this is, you know, learning as imagined versus learning as done right. I’ll give you an example here. company I’ve been working with, for quite a while they had an incident in the field to operate a two operatives, one guy actually got a laceration lost time injury, both of those operators were stood down. pending an investigation, this is all part of their just culture flowchart. When they came back after the investigation, the suggestion was, we’re not going to fire you or anything got what you listen to the language here. This doesn’t sound very just to me. But anyway, what you have to do now is go to every other site, they had several other sites. And we want you to stand up and talk in front of the crews about you know, what you did? The consequences of what you did you explain that you took a shortcut. Now going, what is the intent here? The intention is that when those two guys stand in front of those crews, the intent is people will learn about not to take shortcuts and all of that stuff. Of course, that’s not what happened, you may as well have pinned on the back of those guys a sign saying, I’m an idiot. And as they’re at the front, most of the people who are listening to these two gentlemen speak, neither of them are motivated to do what they’re doing. Neither are particularly good at public speaking. Pretty much every operative listening to them is feeling sorry for them. And thinking, Gee, I’m glad I’m not in their shoes, and what they’re learning more than anything, because they are learning is gee, if I have an incident and nobody sees it, there’s no way I’m gonna be reporting it because otherwise they’ll make me do that too. Learning as imagined, learning as done. So again, when it comes to just culture, I think we’re making the assumption that what we mean by learning with a just culture is we’re going to learn good stuff, we’re going to learn things that are going to be helpful for our future state of safety as was alluded to before, and maybe even work in general. But again, neurons that wire together fire together, they’re always doing that it doesn’t mean the learning is correct, helpful, productive, intended or even conscious. And so you know, part of what we need to understand with the just culture thing is well, what learning we actually are After, let’s get really clear on what are the best methods, the best mechanisms to actually ensure that we’re we’re not getting unintended learnings to. And that’s a mistake many companies still make in their flowchart approach. A flowchart can never be objective as to whether somebody took a reckless risk, or it was just a mere mistake, no flowcharts gonna do that no processes going to do that. There needs to be agreement on who does make that end call. We need to know who that person is. And we also need to agree that that’s probably appropriate. Those are my thoughts.


Nippin Anand  45:36

Yes, I think you did mention something, in previously also alluded towards it this time leatherback, which is that we are learning whether it’s a just culture or whether we face injustice. I think that’s the key point you have you’re trying to say. Okay, great. Thank you. Thank you, Clive. That’s, that’s very helpful. Kim, I know you’ve got distracted by the dog. But I just wanted to have one follow up question with you. Is that was there a lightbulb moment in your in this shift in this journey for you, when you started to see the power of this, this what you were trying to bring in? Any example? Any any story you would like to share? Very briefly, of course. Is there anything you would like to bring? Because I know you, you. You didn’t mention this last time? Just just recently? Yeah. When you focus?


Kym Bancroft  46:37

Yeah, thinking you’ve been a yes, so many light bulb moments and you pin in and, you know, stories that I probably can’t share, does that have confidentiality for the individuals involved, but one in particular, where, you know, there was some of the safety team came rushing in and they had been this incident and they wanted blood, the ops manager quickly came in to say, look, Kim, this is what’s happened, this is what the safety team wants to now happen, they want to get rid of this guy, they’ve been trying to get rid of rid of him for some time, this is, you know, they kind of almost, you know, we’re using that as a bit of an excuse. But we were able to, you know, really pause the process and say, Okay, let’s do this learning review, let’s look at it through this new way of, you know, this new restorative just culture methodology that we’re trying to bring into place. And I think, you know, at the end of that, once, we were able to just uncover so much rich learning and so many different layers of what was going on with the individual in the system. And, you know, the individual, his, the just his rational explanation for what he was trying to achieve, and just, you know, everything you’re there, all the complex factors that go into it, I think all the stakeholders on the back of that were then able to understand where we were trying to get to, with the stress, just culture methodology, in going then outside to talk to this individual individual, some months later, he was extremely appreciative of, you know, their learning review that had taken place, which was in direct contrast to perhaps what may have happened in in the past. And that then reverberated through that work area, because they could now see, well actually hang on a second. There’s some safety professionals here who are actually really quite interested in what it’s like for us in our day to day work, and they actually want to help, and they’re actually genuine and authentic when they say that they want to learn. And so that was hugely valuable for the organisation. So that was a real lightbulb moment for me to see this, you know, in practice, and seeing the flow on effect that it had throughout the organisation. I think the challenge was, though, was that some stakeholders, you know, who were invested in this system, and they you know, and rightly so, given, you know, the role that they played in the organisation in HR IR, you know, just that ongoing, genuine concern about the methodology and how it was being used? I guess that fear for them that perhaps it meant someone was going to get away with something. So is that just that consistent approach to working with them understanding their stakeholder needs and bringing them on that journey? But I think another big lightbulb moment for not just myself, but for the safety team that I worked with, was just on the back of these learning reviews and opinions guys would walk out of these reviews and say that was the best investigation I’ve ever been involved in. When’s the next one? You know, I’ve never heard that in my career before. So, you know, I think that for me, it’s those anecdotal stories when things like that happen that you know, you’re really starting to make a difference when you’re hearing it from from the horse’s mouth, so to speak.


Nippin Anand  49:44

Brilliant, and which goes back to the reason I’m glad I asked the question because it goes back to the Clive’s point, which is who gets to draw the line. And this is what I was trying to come to terms with. I think I guess I have two points here who gets to draw the line is an important one. because often people in positions of power and authority, it is very difficult for them. So to, to be to be convinced by this idea of multiple perspectives and, and different views, you know, the higher up you go in the organisation, the more black and white is the view of most most people. And it’s, it’s, it’s a paradox in its own because as you go up in the organisation and you become a leader, you should actually have be a more visionary person, but doesn’t always happen that way. But I guess the more important question for me is that, and I think this is what you were alluding towards, which is that, you know, give me the context, give me the rich information, which will help me to empathise with the person and what my experience so far has been came as that. I think, yes, you can give me I mean, I can never forget that that moment, I was in Singapore, and I did a workshop on the Costa Concordia case, I did a very, very rich story. And four o’clock in the afternoon, I get waved by one of the attendees, and he says, I want to meet you in the in the coffee room before you leave. And he asked me the question. Yeah, I’ve heard the whole story. It’s, it’s, it’s, it’s very convincing. But I want to ask your question was an alcohol test done on the captain at the time when he were met with the accident. And the point being that meaning making is very, very individual to us, you can give me all the context in the world, you can give me a lot of hard data. But I want to believe in what I want to believe in. And this is where I find it very, very challenging. But I think that there is also an element of what you said that, yes, there are instances where people see a lot of information, and that brings a change within them. And they want to see and they are interested to see things differently. But I think that’s again, down to the the idea of power and authority, are people in positions of authority wanting to be moved or not, but brilliant articulation. Thank you very much for that. I’m glad I asked the question. Jay, over to you now, what is what is learning in your view EG and how does or is the idea of, or the notion of just culture desirable for learning from your perspective, let’s start with what is learning from your point of view first.


jay banerjee  52:15

So learning for an individual is is you know, either could be just giving you knowledge, but ideally it should be talking about professionals, ideally, should be new knowledge that is then put to a new use to improve performance. So improve the quality of care I provide my patients. So anything that allows me to improve is a learning experience. Adjust culture does not have to be a mandatory thing for learning. I have been in the healthcare long enough to know when there wasn’t anything called adjust culture. And we have still learned. So personal motivation, intrinsic drivers are of course really important. But but at the end of the day, the key question, I suppose is learning to serve what purpose and if I say actually, the learning really should be to serve the purpose of the customer, in this case our patients to provide them better care, then surely it is much more meaningful for the organisation to learn so the system can deliver better quality care for a lot of patients rather than one individual to learn. So, the day may or may not consistently deliver a better informed care in the future. So, in order to get the system to improve learning has to be a daily exercise. So unless we know how we perform our tasks on a daily basis, we will never be able to have a just culture because the whole notion that this performance lies outside which I referred to the norm, the outcome is such a powerful driver of that in the absence of data, that unless we get better at measuring on a daily basis, our performance or the way I look at it, the reflection of our learning is our performance, we will not be able to improve on it without understanding what is the normal function, what is the wrong function. I think this whole thing about you know, somebody does not give antibiotics to a patient for three hours and the patient dies and then we complete dependent on an individual completely ignores the fact that chances are in a busy system in a busy organisation, the norm for delivery of antibiotic could well be two hours and 30 minutes with two standard deviations right between three hour 30 minutes and one hours and unless we know that performance, how can we in a just way really say that what you did was something abnormal, but actually it is completely within the realm of normal performance. So so to me, learning cannot happen improvement cannot happen. Unless we absolutely get better at measuring. What is it we do on a daily basis? What is the work? We actually do? versus the work we think we do. Data is the only way to know the work we do. And you know, and the more data we have, from more parts of the system, more understanding we have over the complexity of what we try to create.


Nippin Anand  55:19

Is there anything else you want to say?


jay banerjee  55:22

It’s a long journey, and it will be a constant battle. I don’t think we will ever get there. But there will be a lot of joy learning and how to get there.


Nippin Anand  55:30

Yeah, yes, I learned something really powerful here. Jay, you don’t use the word fatality, you use the word death. Right, which may be very unique to the to the to the healthcare world, I don’t come from that world. And I think that’s fundamental to what you’re saying here. Because in a way, you have been able to manage that expectation that the outcome of what we do, could also result into a debt. And people enter into that implicit contract, when they are availing services, from professionals like yourself, we have been in many other in many of the professions, we have not been able to get into that implicit contract, that fatality is okay. It’s okay to have a fatality. So I think that was very, very powerful, what you say, and I want to think about that a little bit more, and come back to you maybe at a legacy. But I also wanted to challenge you a little bit on the notion, and I think some some others also had this view. And I hear that a lot that is learning always about change and improvement. The reason why I say that is that learning is a gamble. Learning is always a gamble. Because you’re you’re you’re working with uncertainty, there’s a huge amount of uncertainty, whenever we do something, we want to learn something. Training is different schooling is different. Gaming is different. But learning is a gamble. So I’m not sure if learning will always result in improvement and change. So and how do you then manage that expectation that when when learning does not result in improvement and change? When something untoward happened quite the opposite of it? How is the organisation going to deal with that?


jay banerjee  57:13

So I think I clarified that from a professional perspective is different. So learning is all about, you know, doing better, I don’t have to do anything with that. Read millions of books and learn, I don’t have to use that knowledge anywhere. It’s unimportant. But if I’m a professional, paid by the public, funded by the taxpayer, that my learning absolutely has to be tied to improving the carrot gift to the public. And that is the accountability question that should always be raise, I’m paying you for this. You were doing this 10 years ago, you’re still doing this now, what has changed, why hasn’t things improved, why hasn’t done better. And I think the best we should be doing that is why data is important, is capturing our efforts on a daily basis on what is it we’re trying to learn and how we are trying to learn. So that when learning does not happen, ie improve care is not delivered, you can absolutely demonstrate the process through which you tried to, but you failed. And I think the public will be okay with that. Any rational person will be perfectly alright to know that you are learning from a duty performance you’re trying to improve yourself. But within the constraints of the context, this is the best you can do. And that is okay. But not capturing any information is not okay. And in the midst of this, we’ll never anaesthetise a human being and come out of theatre an hour later, let’s say we started with a blood pressure of 120 We finished with a blood pressure of 120 The patient must be fine. Actually, the patient will be very brain dead and all of that because he had no other data, they will never do that. So you cannot work in a system without measuring daily performance to understand if you are on the right trajectory, or even not.


Clive Lloyd  58:56

Can I put forward an alternative point of view?


Nippin Anand  59:00

Please, please do. Yes. Yes.


Clive Lloyd  59:02

That’s what obviously, obviously J different industry. So so different approach. But again, what if I’m working in the construction industry here in Australia, for example. And what I learn is I work for a contracting company. And of course, we’re always chasing the next job. And this is going on a lot here. And what I find out is part of how clients select their contractors, one of the criteria is their safety record, which is usually based of course on lag indicators, lifetime injury rates. What I know is we run a very honest company, and we report everything. What I know is I’ve just seen a company who I know don’t do safety as well who’ve got a lower LTI rate only because they don’t report them. I’m a professional I run a company, I’ve got people to employ, I’ve got people to pay. But what I’ve learned is, if we report less LTI, I’m way more likely to get the contract with that client. That’s also learning.


Nippin Anand  1:00:14

Indeed, I’m just conscious of the time we’re coming to the end of the hour. It’s been a wonderful discussion with so many different views on both just culture and learning. And I would like to thank all the panellists for for being so kind, some, some even working outside of their hours of work, and very odd time. So to share their perspectives I cannot be more grateful for for this. So thank you very much, everyone, and thank you to those who have joined us, we’ll obviously turn it into a recorded video and also a podcast later on. And hopefully, get this to people who were not able to be present for the session. But any parting words very, very quickly from anyone before we wrap up, I’m quite okay to go for a couple of minutes if there’s any burning desire or a question or comment in your minds.


Kym Bancroft  1:01:09

Nippin just to say, thank you, it’s such a valuable conversation that you’ve opened up over the series. And certainly I’ve taken away a lot of learning. And I’m now keen to go away and look at how we understand normal work, and how this fits into our whole just culture process, based on what Jay was saying, that’s a real insight for me, and how can we just expand this out even more, I think there’s just such an incredible opportunity with the synergy between those two things. So thank you, Nippin. It’s been fantastic.


Nippin Anand  1:01:38

Likewise, as anyone else wants to say anything.


Clive Lloyd  1:01:43

Zero Kim, and it’s been lovely to see you again to Kim. But everybody, I’ve really enjoyed listening to you some very different perspectives. My final thought would be why why would we limit just culture to only after an incident? Yes. Why wouldn’t we just implement just culture as a way that we actually do work for thought? Thank you, Claire. It is


jay banerjee  1:02:07

absolutely, absolutely echo that, which is why I’m so insistent on measuring daily performance. Because without that we can never say when our investigation starts, if that was truly just because we don’t know what the norm was.


Nippin Anand  1:02:22

Thank you, Jay. Daniel, anything from you


Daniel Hummerdal  1:02:24

know, just thank you, Nippin. This has been inspiring many ways. Thank you,


Nippin Anand  1:02:29

likewise, and thank you to all the participants. Thanks, everyone for joining us, we will see you again for the sixth and final part. I will end the broadcast now. But you can stay online for a few minutes if you don’t mind talking to me for a few seconds. As always, these smart people have left us with more questions than answers. For instance, how can a framework of just culture that is based on understanding what has happened in the past? And more specifically, what went wrong? serves the purpose of learning about the future? Should it surprise us that a lot of discussion about just culture sets us on a path towards accountability? Now we learn from Virginia sharp in a book that accountability can also be forward thinking, not just who screwed up, but also who in the organisation can address the problem, and hence the term looking ahead, forward thinking. How helpful is this concept of forward accountability? If the leadership does not understand the value of being comfortable with not knowing everything? Can we really speak about curiosity, humility, vulnerability, without questioning and understanding our relationship with uncertainty? That is a question we need to ask ourselves. Also, many organisations turn towards seeking someone to blame doesn’t matter upwards or downwards, whenever they’re faced with an accident of serious consequence, or commercial loss or reputational setback? Is that surprising? We hear that blame fixes nothing. But from Kim, as I was hearing her, I learned how hard it is to live up to this slogan, in the face of an accident have serious consequences.


Nippin  1:04:27

Maybe, maybe blame does fix a few things. For example, it allows the organisation to move forward by giving some kind of meaning to a mishap and accident.


Nippin Anand  1:04:42

How’s that different from the Aztecs of Mexico and the Zandy of South Sudan. Blame for those primitive people was about creating social order. As we also learned from the French philosopher Rene Girard, the British anthropologist Mary Douglas, the edge case notes such as Guy Claxton, and many other serious thinkers, that blaming and scapegoating keeps an entire society from collapsing in the face of crisis. You know, in certain societies blaming even brings social conflicts to surface and helps us resolve them in a constructive manner. Therefore, a more appropriate question maybe to ask, what is the intent behind blaming someone or something? It may be that we need to think about this question more critically. When we say blame fixes nothing. We need to also think about this logon, we can only blame or learn we can never do both. Because that is precisely what we do. Most of the times in most organisations. We try and find that sweet spot between blaming and learning. And we move forward. But I think, to understand this delicate balance, we need to define what learning really means to us. In this series, so far, I’m still struggling to answer that question. And I haven’t received a satisfactory answer to what do we mean by learning? How do we define learning? And answering this question is fundamental to the series? Because if you want to justify any investment in designing and implementing adjust culture, and if you’re a competitive organisation that wants to to make profit, then looking for return on investment, is a very, very reasonable question. Then we hear that just culture can also be can only be as effective as the politics in the background of the process? No, I think that’s a very interesting thought. We seldom speak about the politics of processes and systems. For example, as Clive said, who gets to draw the line? How can a process work effectively in isolation from politics, history, ethics of the organisation and the regulator, again, something to think about? Finally, and one of the most powerful things that I learned in this podcast was how the culture of healthcare sees debt as a normal outcome that is so different from every other industry and culture where mortality is not normal. And when we think about just culture, from this perspective, from these lenses, of a notion of the fallible person who works in the healthcare sector changes fundamentally. Because we think that that can be a normal thing. We’re less focused on the outcome, and more on the cultural and social context in which the healthcare community operates. Forgiveness, understanding, trust, love, empathy, justice, learning, almost immediately, inevitably will follow. But ideally, and this is a topic on its own, that Jay has gifted us to think about. But then if we look at it slightly differently, how do we explain the case of the former nurse in United States Redonda Ward, who was sentenced to three years of supervised probation, after being found guilty of homicide for injecting a 75 year old patient with the wrong drug. And it turns out that the fear of mortality and the retributive sense of injustice that follows is as pervasive across other industries. As with health care, at least from this example. The answers are not so straightforward. Well, I hope I gave you enough to think about and I leave you with those thoughts. I am Nippin, the founder of novellus. And you will listening to my podcast embracing differences. If I’ve made you think I have achieved my purpose, and I would love to hear your thoughts, especially if you don’t agree with me. There is no better way to learn than understanding and embracing our differences. If we do so in a respectful manner. My work is mainly focused on helping leaders becoming a little bit less sure about themselves a bit more curious, and organisations organization’s achieve cultural transformation. We at novellus facilitate a series of leadership and cultural programmes both online and in person on a weekly basis. If you want to learn more about my work, please visit our website novellus.solutions. If you enjoyed this podcast and you want to learn more about our work at novellus You can also write to me at Nippin.Anand@novellus.solutions. Thank you for wanting to learn more than you knew yesterday. I wish you all the best.