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Make Just Culture
just your culture
Dan Barker
@barkerd427
Just Culture started in
Hospitals and Aviation
@barkerd427
Always in a state of
failure
How Complex Systems Fail
@barkerd427
There is no
“root cause”
How Complex Systems Fail
@barkerd427
All actions are
gambles
How Complex Systems Fail
@barkerd427
Humans are the
solution
How Complex Systems Fail
@barkerd427
Just Culture is trust, learning, and accountability
What can you do?
@barkerd427
Change your
language
@barkerd427
I should have -> I
did x and expected
y, but saw z
@barkerd427
Blameless
Postmortems
@barkerd427
Timeline,
Just the Facts,
Learning
@barkerd427
Teach others
@barkerd427
How Complex
Systems Fail,
Westrum Model,
Just Culture
@barkerd427
Where will you fail?
@barkerd427
Patience
@barkerd427
Grace
@barkerd427
If you can’t change
your org, then
change your org.
@barkerd427
● https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1765804/pdf/v013p0ii22.pdf
● https://web.mit.edu/2.75/resources/random/How%20Complex%20Systems%20Fail.pdf
● http://sidneydekker.com/just-culture/
● https://danbarker.codes
Resources
@barkerd427

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