Creating a Just Culture in Policing

“A just culture balances the need for an open and honest reporting environment with the end of a quality learning environment and culture.”

The issue of police use of deadly force continues to remain a point of non-discussion in most communities. Rather than actively working to reduce these tragic events, many hope the matter simply blows over.

It won’t.

Instead, I suggest we look at the problem of police use of deadly force in light of a “just culture” approach. It may produce an acceptable solution and reduce the number of our citizens (especially those of color) who die at the hands of those who have sworn to “serve and protect.”

Years ago, we in Madison started to adopt the teachings of Dr. W. Edwards Deming with regard to system improvement and customer needs along with Prof. Herman Goldstein’s method of Problem-Oriented Policing and Robert Greenleaf’s concept of Servant Leadership.

These creative ideas helped us make a good police department great. Now, how can these learnings be applied to today’s problems? The “Just Culture” principles seem to have incorporated many of their teachings about systems improvement and problem solving.

For example, in Madison we established twelve Principles of Quality Leadership (our driving values) that addressed this new learning. Six of them directly apply to today’s problem concerning police use of force:

  • (2) Be committed to the problem solving process; use it and let data, not emotions, drive decisions.
  • (6) Have a customerorientation and focus towards employees and citizens.
  • (7) Manage on the behavior of 95% of employees and not on the 5% who cause problems.
  • (8) Examine processes before placing individual responsibility when problems arise.
  • (10) …be tolerant of honest mistakes.
  • (11) …develop an open atmosphere the encourages providing and accepting feedback.

One thing that is greatly needed in the field of policing is creative thinking. That’s why I continue to stress the important of a college education and a commitment to life-long learning by police — both personally and organizationally. (See Peter Senge’s work on this.)

The medical field has begun to use “Sentinel Events” and a “Just Culture” approach to solving their often life-threatening problems that affect  a person in their care. The object of both determining Sentinel Events and establishing a Just Culture is not to shame practitioners, but fix and prevent the problem from happening again. Could this thinking be applied to policing?

In 2013, an article in the Ochsner Journal, “Just Culture: A Foundation for Balanced Accountability and Patient Safety,” outlined the process for developing such a culture:

“A just culture balances the need for an open and honest reporting environment with the end of a quality learning environment and culture. While the organization has a duty and responsibility to employees (and ultimately to patients), all employees are held responsible for the quality of their choices. Just culture requires a change in focus from errors and outcomes to system design and management of the behavioral choices of all employees.”

“While the concept of developing a Just Culture may be new to healthcare—spurred by publication of Errors in Medicine in 2000—the Just Culture environment has been imbedded in other industries for many years. The industries of aviation, train transportation, and nuclear power have been accepted as highly reliable and safe. For aviation, frequently compared to healthcare, these principles and their foundation span 45 years. Nonetheless, within these just culture industries are examples of errors, failures, and accidents that are insightful and address human behavior in complex systems…”

Think about this idea and how it might apply to your police department. Shouldn’t police be as concerned as health care professionals when what they set out to do resulted in someone’s death? And after experiencing such an event, why wouldn’t police be just as concerned about preventing the event from happening again?

Think about it.

  • Learn more about creating a “just culture” HERE.


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