From blame culture to learning culture

By Harley Dennett

August 6, 2018

Incident Investigation Report

How can public organisations strike the right balance between individual culpability and organisational responsibility?

That’s what UK policing think tank The Police Foundation and KPMG tried to find out after the latest inquest into the 1989 Hillsborough football match disaster in which 96 people died. After a near three decade delay because the chief superintendent in charge lied about mistakes, six people including police, a solicitor for the police and a club official have been charged, with five still awaiting trial.

Bringing together a group of senior police leaders and stakeholders with experts from the aviation and healthcare sectors, noting that disincentives to ‘speak up’ were not unique to policing, they tried figure out what policing can learn from other sectors. For instance, where is the sweet spot that encompasses strong external accountability to the public with an open culture in which people are willing to admit to and learn from mistakes? When should performance management be used instead of disciplinary responses?

According to Andy Higgins, Research Director at The Police Foundation, the key factors where police could seek to shift the dial towards learning and systemic improvement without surrendering the basics of a robust accountability framework, include:

  • Exploring a twin-track approach which separates and protects investigations aimed at facilitating learning and making organisational improvements, from disciplinary and conduct processes.
  • Developing and expanding the use of methods for promoting learning such as debriefing sessions, peer review, structured time for reflection, learning from mundane errors and ‘near misses’ and aiding investigations with human behaviour specialists.
  • Generating a learning environment by adopting the assumption that more numerous, less serious matters are dealt with via line management and HR within a performance management framework as opposed to discipline and professional standards channels.
  • Strong leadership to promote a ‘flatter’ hierarchical culture in which there is an expectation and requirement to speak out.
  • Public engagement and dialogue to better understand the kind of accountability the public actually want and expect.
  • Emphasising the importance to listening to complainants, developing individual and institutional empathy, and building greater trust.

From the aviation safety sector, they learned about the important role played by human behaviour specialists in identify the factors that led to mistakes and lapses in judgement. Much could be discerned from recording ‘mundane mistakes’ and breaches in procedure — “emphasised with one participant using the metaphor of ‘slices of Swiss cheese’ to describe the way that the alignment of otherwise trivial lapses or flaws, could occasionally result in catastrophic consequences.”

From the healthcare sector, they learned the value of having time to reflect: increasing the opportunities for practitioners to reflect and review their actions and decisions, including in a structured way and with supervisors, was essential for building a culture of learning and improvement. Higgins observed that while ‘reflecting more and learning more, not working more’ was ideal, there is a challenge for policing and public sectors lead to create the space and time to to put this into practice.

Sometimes harm is unavoidable

While there are some good reflective practices common in policing, like non-legalistic reviews, debriefings and peer review processes, attendees noted there can still be a tendency to revert to language like ‘things going wrong’ or ‘mistakes being made’ — even in instances where negative outcomes are unavoidable.

Several also urged the need to separate genuine misconduct from “well-intentioned mistakes, which often occurred within sub-optimal operating environments”, such as units where resources have been reduced and workloads increased. “Instinctively pragmatic police officers and staff were faced with little alternative but to ‘cut corners’ in order to ‘get things done’,” Higgins noted, with one attendee noting that leaders might turn a blind eye as long as these lapses in compliance keep business running.

Leaders, particularly in the increasingly common multi-agency/coordinated environment, would understand these operational issues better if they got closer to the work, some participants argued. In particular, that mid-level leaders in collaborating agencies needed to invest time in better understanding each other’s business and risks.

‘Journalistic outrage should not be mistaken for public opinion’

Public expectation of accountability and redress has driven much of the investigatory responses adopted within policing, the attendees noted, but the form of accountability expected by the public was poorly understood.

Higgins said there was agreement across the sectors that accountability needed to include listening to those who had come to harm during the matters under investigation, including their families.

“The imperatives for investigators and institutions to ‘put themselves in the shoes of others’, ‘truly listen’ to, and put those harmed at the centre of any process, was agreed by all. The experiences of attendees, gained across a number of high profile investigations in different sectors, identified a spectrum of nuanced expectations from victims and families; while there were often calls for justice and individual accountability the frequently expressed desire of those affected ‘to ensure this never happens again’ was also reported.”

The full report can be found on The Police Foundation website.

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