October 30, 2019


Resilience is something a system does, not what a system has; creating and sustaining ‘adaptive capacity’ within an organisation (while being unable to justify doing it specifically) is resilient action; and learning about how people cope with surprise is the path to finding sources of resilience.

September 26, 2016

Just 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.