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Culture of Safety

The Westlake Story: Building a Just Culture for our Nation's Police Officers

About the authors:  Kevin Bielozer is Chief of the Westlake Police Department (WPD) in Westlake, Ohio.  David Huntsman, Ph.D., is a research scientist with The Just Culture Company.  They have coauthored this article to summarize WPD’s Just Culture implementation journey.

Success at the Westlake Police Department

Do law enforcement officers deserve a more just workplace culture?  One that encourages event reporting? One that better balances system and individual accountability?  Absolutely.

Just Culture principles protect officers’ mental well-being and ensure high policing standards, fostering trust between the community and law enforcement.  In 2023, the Westlake Police Department (WPD) implemented the Just Culture in an effort to enhance accountability and safety for its officers by establishing a more uniform and fair approach to events. To date, 85% of WPD personnel have received formal managerial and staff training. Positive results from implementing Just Culture at the Westlake Police Department in Ohio affirm its efficacy.  

WPD adopted the Just Culture philosophy using an algorithm we received in Just Culture managerial training that helped us evaluate deviations from policy. The algorithm’s structured approach allowed managers to consistently and clearly evaluate policy deviations, and assess whether the deviation was justified.  This, in turn, promoted accountability, in both the design of policies and procedures, and for officers who now have transparency in how policy deviations will be evaluated.

David Kenney (WPD Special Operations Division) first introduced the concept of high reliability organizations (HROs) to our department. During our research and training with the Joint Commission, we found an article by David Marx that convinced us that a critical part of workplace justice in high reliability organizations is looking at the decisions that were precursors to mistakes.

Prior to our implementation of Just Culture, disciplinary outcomes were often viewed as subjective and inconsistent, reliant not only on individual interpretations and judgments, but having multiple layers of supervisors further complicating the process, often resulting in disagreements and reputational risks that affected the consistency of disciplinary decisions. The seeming arbitrariness and confrontational nature of traditional disciplinary methods exacerbated tensions, especially in cases where employees lacked commitment or faced challenges in their roles.  Strong union protections added a layer of defensiveness, making it difficult for officers to admit to errors and hindering the resolution of performance issues.

The Just Culture algorithm provided transparency and clarity for officers to understand how their decisions and behaviors would be addressed and allowed us to objectively assess officers’ performance, minimizing ego-driven disciplinary decisions.  For example, in one incident, WPD applied the algorithm to an event involving an initial foot chase in a busy business district, during which a wanted felon fled to his car sparking a vehicle pursuit. While officers need supervisor approval for maneuvers to stop fleeing cars, known as precision immobilization techniques (PIT), real-time events sometimes require decisions to deviate from protocol.  In this case, one officer attempted a PIT without clearance and was rammed by the suspect, escalating the situation. Another officer, witnessing this and anticipating further escalation on a busy street, decided to ram the suspect’s vehicle, targeting the rear tire to minimize bystander danger. The suspect was stopped and arrested without additional incident. Officers, however, were concerned about potential repercussions for deviating from protocol. Using the algorithm to assess the officer’s decisions ultimately supported the officers’ actions for prioritizing public safety and operational readiness.

In another example of the shifting culture at WPD, a supervisor felt safe to report an error and then implement system improvements to prevent future occurrences. This approach not only earned respect for the supervisor but also led to organizational learning and development.

Overall, the disciplinary process prior to Just Culture implementation lacked a structured framework and consistency, making it difficult to address performance issues effectively and professionally. The implementation of Just Culture provided clarity and transparency, resulting in fair and consistent accountability in response to events.  Given the progress we’ve made, the State of Ohio has approved and validated the “Just Culture for Managers and Influencers” course for continuing professional training (CPT) credit.  The course, now known as 24CPT917, offers four hours of CPT, further incentivizing police departments across Ohio to engage with Just Culture principles.

Supported by Data Importantly, we needed to measure the effect, if any, Just Culture has had on our department. While Just Culture has consistently increased reporting of errors across many high-consequence industries, and enhanced organizational learning leading to continuous system improvements, no empirical evidence demonstrating Just Culture’s benefit in policing exists. To get at this data, Westlake Police personnel agreed to take the Just Culture Improvement Index (JCII), a short survey designed to evaluate an organization’s baseline across nine critical behaviors: open reporting1, peer-coaching2, search for causes3, system design4, transparency5, non-punitive response to errors6, accountability7, lack of severity bias8, and equity9 across seven organizational values tied to successful Just Culture Implementation including: customer service, customer safety, employee safety, data privacy, financial stewardship, environmental protection, and diversity/equity/inclusion (DEI).

Aggregate Findings Over 75% of WPD personnel completed the JCII (N=62). We analyzed the data and compared our JCII scores to a nationally representative U.S. police benchmarking sample. The graph below shows the percent agreement scores for each behavior averaged across the seven values to be protected.10  As shown, WPD’s scores (dark blue bars) are significantly higher (p<.001) than those of U.S. police generally (light blue bars), indicating that WPD’s performance is stronger around learning, justice, and safety culture compared to other police departments in the U.S..  Of the nine, the most significant differences are seen in lack of severity bias (WPD M=81% vs. U.S. police M=52%) and non-punitive response to errors (WPD M=54% vs. U.S. police M=26%), where WPD performs nearly 30% better than the national police sample. Among the remaining seven benchmarks, the results show that WPD is stronger on transparency (+14%), system design (+12%), open reporting (+10%), search for causes (+10%), equity (+10%), peer-coaching (+5%) and accountability (+4%) as compared to U.S. police as well.11  For context, a 5-10% agreement difference is often sufficient to jump 1-2 percentile categories in large benchmarking datasets.  This is a major achievement for any organization measuring its current state or improvement.  A percentage difference of 30% in lack of severity bias and non-punitive response to errors significantly distinguishes WPD from its law enforcement peers. Moreover, when comparing data from additional measures in the JCII, WPD personnel reported significantly higher camaraderie (+24%: WPD M=84% vs. U.S. police M=60%) less burnout (-35%: WPD M=19% vs. U.S. police M=56%), fewer turnover intentions (-8%: WPD M=0% vs. U.S. police M=8%), and fewer safety concerns (-6%: WPD M=14% vs. U.S. police M=20%).  While not shown in the graph, WPD performs stronger on all nine behaviors when comparing against other high-risk industries in the United States including healthcare, aviation, emergency medical services, as well as against policing data from the United Kingdom. The data from WPD demonstrates that a more fair and just workplace culture is achievable as measured by improved reporting and transparency, reduced punitive response, severity bias, and burnout. WPD’s ratings are significantly higher compared to the national average of U.S. police departments.  In 2024, WPD will further expand the Just Culture initiative by training all personnel and will re-administer the JCII12 to measure additional improvements over time.

Support from the State of Ohio

The State of Ohio recognizes the benefits of Just Culture training for its police officers.  In addition to validating 24CPT917 (the Just Culture for Managers and Influencers course) for four hours of CPT credit, the Ohio Peace Officer Training Commission will reimburse the officer’s agency for four hours of wages while officers take the Just Culture training (all officers in Ohio are required to take 16 hours of elective CPT in 2024).  

The Just Culture Framework

The Just Culture framework serves as a blueprint for high-risk systems and institutions while recognizing the complex and often dangerous nature of police work.  Rather than removing accountability, Just Culture seeks a balance of accountability between individuals and the organization for safe outcomes, and it prompts leaders to consider the systemic issues and behavioral choices within these systems that contribute to errors.  A Just Culture encourages the reporting of errors without fear of punishment, while holding the organization accountable for system design issues.

References

Cite as: Bielozer, K, and Huntsman, D., (2024).  The Westlake Story: Building a Just Culture for our Nation’s Police Officers. The Data Series, (1), 1–2. www.justculture.com

  1. Open Reporting: The reporting of hazards, errors and near misses
  2. Peer-Coaching: Peers coaching peers when they see risky behavioral choices 
  3. Search for Causes: The investigation of hazard sources and near miss events to identify any system or behavioral contributions
  4. System Design: The continuous evaluation and improvement of the systems and processes in which team members work
  5. Transparency: Appropriate transparency within work groups, so that all team members can learn
  6. Non-Punitive Response to Errors: Refraining from disciplinary sanction as a de-facto response to human errors and at-risk behaviors
  7. Accountability: Little tolerance for behaviors that deliberately and unjustifiably compromise the mission or protected values
  8. Lack of Severity Bias: Rejecting no harm, no foul (removing severity bias) as a risk management practice
  9. Equity: Being fair and equitable in response to less-than-desired behavior across disciplines and work groups
  10. Scores for the nine behaviors are much higher when analyzing them in the context of customer service, customer safety and/or employee safety issues (e.g., open reporting on customer safety issues is 97% in Westlake vs. 90% in U.S. policing generally) as compared to an average of the seven values, as service and safety tend to be prioritized more than environmental, financial, DEI, and to a lesser extent, data privacy issues.
  11. The scores for these nine behaviors are in the context of all seven organizational values, but the above differences between Westlake Police and U.S. police look similar in terms of effect size regardless of the organizational value specified in the analysis.
  12. The Just Culture Benchmark Survey is a device for evaluating workplace culture using nine key behavioral markers tied to seven generally universal organizational values: customer service; patient/customer safety; employee safety; financial stewardship; data privacy & protection; environmental protection; and diversity, equity and inclusion.  We use the survey, and its associated Just Culture Improvement Index, as key measurement tools aiding organizations’ implementation of Just Culture.