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Building quality and safety in service delivery

11 August 2020 at 7:00 am
Alan Hough
What is a just culture and how can it benefit an organisation? Alan Hough, from Purpose at Work, explains the approach and highlights some soft skills that can help executives in their communications with the board.

Alan Hough | 11 August 2020 at 7:00 am


Building quality and safety in service delivery
11 August 2020 at 7:00 am

What is a just culture and how can it benefit an organisation? Alan Hough, from Purpose at Work, explains the approach and highlights some soft skills that can help executives in their communications with the board.

The first article in this series identified the increasing expectations on boards and executive teams of human service organisations for promoting human rights and for improving the quality and safety of services. Last week’s article outlined seven steps that organisations can take. In this article, I want to explore the benefit of organisations adopting a “just culture” approach and identify some soft skills that will assist directors and executives in their boardroom interactions.

Just culture

Just culture is a term coined by Emeritus Professor James Reason, who is probably the world’s leading authority on safety. A just culture is one where workers have confidence that they will not be blamed for errors which are more within the control of the organisation than of the worker. Reason notes the paradox that the safest organisations often have high rates of incident reporting. Indeed, safe organisations want “near misses” reported, because they provide the basis for learning. However, in order to encourage reporting, employees need to have confidence that they will not be unfairly blamed for mistakes. 

Reason asks: “By what means can we set about transforming an average safety culture into an excellent one? The answer, I believe, lies in recognising that a safe culture is the product of a number of interdependent sub-cultures, each of which – to some degree – can be socially engineered. An informed culture can only be built on the foundations of a reporting culture. And this, in turn, depends upon establishing a just culture… The other elements of a safe culture – a flexible culture and a learning culture – hinge largely upon the establishment of the previous two.” 

Diagram showing A safety culture

The term just culture is sometimes known as a “no blame culture”. This is not entirely accurate, because Reason distinguishes between acts which are not the fault of individual employees and lie with the organisation’s systems on the one hand, and acts which involve the wilful breaking of rules or acts of negligence on the other. A worker is not responsible for the first category of incidents but is accountable for the second category. Workers having confidence that they will not be unfairly blamed will promote reporting and thus the opportunities to learn and to improve.

Soft skills for executives and directors

Just culture principles apply equally to the interaction between directors and the CEO, or a board and executive managers. CEOs and executive managers should be open in their communication with the board. If there is important bad news, it is vital that this is shared with the board and shared on a timely basis. Managers should welcome the interest of directors in service delivery. They should accept and allow for the fact that not every question by a director will be fully informed. Sometimes CEOs and executive managers wish for a black-and-white distinction between governance and management, but in reality there is a grey zone for mutual exploration. 

From the director side of the discussion, an attitude of genuine curiosity can also assist the deliberations of the board. Adopting such an attitude will help in creating a learning culture because a curious – rather than an accusatory – tone of voice, will result in less defensive and more expansive answers by management. There is no more likely way for a board to shut down communication lines than to have a reputation for “shooting the messenger” in the event of bad news.

Another way that directors can encourage open and honest conversation is to provide the opportunity for the CEO to “think out loud” about service delivery. Even in situations where the CEO has technical expertise but the directors do not, allowing the CEO to talk about issues of concern enables the CEO to share these concerns and to think through the issue at hand. 

Even directors who lack deep knowledge of service delivery can ask useful questions. Sometimes the simplest questions are the most powerful, e.g., “What do the clients want?”, “What are the root causes of these incidents?” and “If this incident occurred in this part of the organisation, could it occur in other areas?” These questions can be asked by anyone, including those with only a general understanding of service delivery. 

If directors and executives observe these behaviours, then their dialogue is likely to be both more respectful and more robust. Ultimately, we all need to have such conversations in order to provide a basis for reflection, to increase learning and to improve service delivery.


To learn more about the program Right on Board: Governing for Human Rights, Quality and Safeguarding visit or email


See also:

Boards need to be concerned about human rights, quality and safeguarding

How do boards and executive teams promote human rights, quality and safeguarding?

Alan Hough  |  @ProBonoNews

Alan Hough is a director at Purpose at Work.

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