For one final example, let’s review the impeachment of Donald Trump. A democratically elected president makes a mistake and is taken to the wood-shed. A highly charged congressional process founders on the shoals of political partisanship. Where is the Just Culture here? Let’s review the facts.
I would argue that the Just Culture should be applied here. A sitting president should not be fired for a single mistake, no matter how egregious. He should be given the opportunity to admit his mistake, apologize for it, and convince the rest of us that it will never happen again. In a word: atone. After that, we should forgive the transgression and move on.
As everyone knows, that did not happen. Not only did Trump not apologize, he made false statements about his actions, denied that they mattered, and did everything possible to impede the investigation by prohibiting his own staff, State Department employees, and federal budget officials from even discussing the case with investigators, much less testifying under oath or submitting documents that could shed light on the incident. In other words, he become a non-cooperator, a saboteur, an obstructionist.
What happens in the Just Culture when an employee dissembles, hides facts, or otherwise impedes the RCA? That’s easy. We fire him. Immediately. Summarily. Without regret. The Just Culture is a two-edged sword, after all. So, in the case of Donald Trump, our first impulse should have been to seek his explanation, uncover the truth, and give him the opportunity to set things right – which he did not. Once he failed to do that, we should have lowered the boom without hesitation – which we did not. The unfortunate outcome is that the path toward the truth was thwarted and the Just Culture took another hit. Same old, same old.
From The Ailing Nation, Chapter Two: Forgiveness
One of the common misconceptions about the Just Culture is that there is no accountability. Nothing could be further from the truth. In the Just Culture, management assumes that the front-line staff are always trying to do the right thing, and that mistakes are the unintentional consequences of employees doing their best. As I have learned in a lifetime of medical leadership, most mistakes do stem from system defects, from imperfect processes that lead to unintended outcomes. In the Just Culture, we try to find those defects and mend them, so that our staff are not drawn into a future recurrence. The accountability in such a system lies with leadership, because it is our job to make sure our systems support our staff. But the Just Culture does not ignore malicious behavior. An employee who knowingly thwarts the rules or, even worse, obstructs our investigation of an adverse event, has violated the Just Culture and negates the right to continued employment. We fire them without hesitation.