Yo yo! Today, we close out our 3-part series on systems thinking with this episode on psychological safety & just culture.

Part 1 (Episode 117) introduced systems thinking & high reliability organizations.

Part 2 (Episode 118) walked through resilience engineering, safety differently and synesis.

Part 3 (this episode) threads these topics together with psychological safety & just culture.

This three part series invites you to think about your home team and professional practice.

How does your team handle errors & mistakes? Are you safe to fail and be honest about mistakes & near misses? Are mistakes and mishaps talked about?

Do you usually take feedback well and look for ways to grow or get defensive and think it’s always someone else’s fault? What about the other folks on your team?

Psychological safety is about the freedom to speak up without fear of embarrassment or punishment. Psychological safety doesn’t just happen. Organizational leaders need to talk about it and normalize it – truly, make it part of your team norms. Psychological safety doesn’t skirt accountability. Accountability is a key part of a psychologically safe culture. We’ll talk more about it in the show.

Just culture extends the idea of psychological safety to the organizational environment and the team’s approach to errors and mistakes. Just culture encourages teams to look at systems factors for why things break down. People don’t make mistakes willfully. Willful harm with malicious intent is recklessness or sabotage. That’s not a mistake. Mistakes are always unintentional because people don’t show up to work planning how they’re going to accidentally drop the ball and screw things up. Just culture looks at mistakes from the standpoint that perhaps the system is broken and sets frontline staff up for failure. A systems fix is like a rising tide that lifts all boats. Just culture sees the systems as the usual point of failure, not the frontline worker. Front line workers are often the source of resilience and capacity within systems.

We talk about these things and more in the podcast as we thread all three parts of this series together.

As a reminder, I’ll be in Hilton Head, SC next month teaching with Encore Symposiums and back at the Cliff House in Maine this October with Encore. Come check us out if you’re looking for a great continuing education conference!

Your values build your system, your system creates your culture, your culture generates your results.

References

Batalden, P. a. C., E. (2015). Like Magic? (“Every system is perfectly designed…”). Institute for Healthcare Improvement https://www.ihi.org/insights/magic-every-system-perfectly-designed?utm_source=chatgpt.com

Conklin, T. (2025). PAPod 540 – Swiss Cheese Actually In PreAccident Investigation Podcast.https://podcasts.apple.com/us/podcast/preaccident-investigation-podcast/id962990192?i=1000702329202

Dekker, S. (2016). Just culture: Balancing safety and accountability. crc Press. 

Dekker, S. W., & Leveson, N. G. (2015). The systems approach to medicine: controversy and misconceptions. BMJ quality & safety, 24(1), 7-9. 

Edmondson, A. C. (2018). The fearless organization: Creating psychological safety in the workplace for learning, innovation, and growth. John Wiley & Sons. 

Edmondson, A. C. (2023). Right kind of wrong: The science of failing well. Simon and Schuster. 

Schein, E. H. (2010). Organizational culture and leadership (Vol. 2). John Wiley & Sons. 

Senge, P. M. (2006). The fifth discipline: The art and practice of the learning organization. Broadway Business. 

Weick, K. E., & Sutcliffe, K. M. (2015). Managing the unexpected: Sustained performance in a complex world. John Wiley & Sons. 

Willink, J. (2017, February 2, 2017). Extreme Ownership TEDx, TEDx Talks. https://www.youtube.com/watch?v=ljqra3BcqWM