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Make Just Culture just your culture

Dan Barker

@barkerd427

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Just Culture started in Hospitals and Aviation

@barkerd427

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How Complex Systems Fail

Always in a state of failure

@barkerd427

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How Complex Systems Fail

There is no

“root cause”

@barkerd427

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How Complex Systems Fail

All actions are gambles

@barkerd427

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How Complex Systems Fail

Humans are the solution

@barkerd427

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Just Culture is trust, learning, and accountability

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What can you do?

@barkerd427

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Change your language

@barkerd427

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I should have -> I did x and expected y, but saw z

@barkerd427

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Blameless Postmortems

@barkerd427

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Timeline,

Just the Facts, Learning

@barkerd427

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Teach others

@barkerd427

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How Complex Systems Fail, Westrum Model, Just Culture

@barkerd427

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Where will you fail?

@barkerd427

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Patience

@barkerd427

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Grace

@barkerd427

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If you can’t change your org, then change your org.

@barkerd427

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Resources

@barkerd427