What is the role of managers in a Just Culture?

Managers set clear expectations, respond calmly to bad news and ensure that reports are investigated independently and expertly. They first ask what happened and what circumstances played a role before drawing conclusions about people. They also free up time, people and budget for improvement measures and provide feedback on what has been done with reports.

Their own actions must also be able to be investigated. If only executive employees are addressed and choices about workload, resources or unclear goals remain out of the picture, the culture is not fair. The AHRQ Guide to System-Based Incident Investigation emphasizes both leadership support and fact-finding rather than blame-finding.