Charles A. Gruber, MS, Chief of Police (ret.), South Barrington, Illinois, Police Department, and IACP Past President; Scott Griffith, MS, Partner, SG Collaborative Solutions, LLC, Westlake, Texas; and Steve L. Whatley, PhD, Sergeant (ret.), Shreveport, Louisiana, Police Department
olice chiefs can obtain better outcomes in law enforcement by employing improved strategies developed in other high-consequence industries. Although law enforcement may appear very different from these industries, the underlying fundamental elements remain the same: the combination of the systems designed by law enforcement and the human behaviors within those systems will determine the outcomes.
Similar to physicians, engineers, firefighters, and pilots, police officers are highly trained professionals operating in complex environments where the consequences of failure can be disastrous. However, unlike these other endeavors, the profession has been slow to recognize the science behind predictable organizational outcomes. In other words, the systems law enforcement designs, including the policies, procedures, and equipment, when combined with human behaviors, lead to predictable outcomes. In most cases, these components, especially police officers’ decisions (i.e., behavioral choices), are considered only when the outcome is negative. Often, for the near misses or close calls, little or nothing is done in terms of reviewing these systems or the behavioral choices regarding their contributions to those negative outcomes. No harm, no foul, right?
For example, what is the typical reaction to a situation when an officer trained to not reach inside of a driver-occupied vehicle, does just that and is dragged down the street? The reaction likely focuses on the outcome of the event rather than the behavioral choice of the officer. Often, the focus is on the assailant’s and not the officer’s actions, especially if the officer is uninjured and has “safely” apprehended the assailant. For another example, what about multiple officers giving chase to several fleeing suspects individually, leaving their partners exposed to one or more assailants? Would the result have been better if the officers had stayed together and focused on the apprehension of one assailant? Would “safety in numbers” on the part of the officers have resulted in a lesser degree of force, with a higher likelihood of avoiding injury or fatality? Shouldn’t the investigation start with an examination of the expected procedure to be followed in this situation, and understand if a breach was justifiable or not, and then turn the attention to the officers’ behaviors?
In general, a more thorough, scientific approach would start with examining departmental procedures and officers’ behaviors before assigning blame to anyone for the outcome, good or bad. Again, the reaction to a situation is likely based on whether or not the outcome is undesirable. When the outcome is tragic, there is often external pressure to show a disciplinary response, which sometimes leads to the impression of simply “throwing the cops under the bus.” However, the same types of behavior without a tragic outcome would go virtually unnoticed in most agencies.
Focusing on Systems and Behaviors
To continuously improve, law enforcement agencies must see new opportunities to manage both systems and behaviors that they have traditionally missed. Many of the methods employed in present-day law enforcement culture were derived from military command and control principles. Likewise, in today’s police organizations, the primary methods of controlling behavior within the department have been punitive. But just as the success in keeping the peace within communities has evolved beyond use of force to include a variety of effective community policing strategies, the approach to managing within the department must evolve as well. Most importantly, this includes the potential to reduce the number of unintended and, at times, harmful outcomes, including sustained citizen complaints from rudeness to excessive force, preventable vehicle crashes, false confessions, unlawful arrests and wrongful convictions, and civil rights violations, to name a few. If law enforcement is to improve outcomes in these and other areas, it will require a deeper understanding of risk management and socio-technical systems.
|Figure 1: The Socio-Technical Pyramid and the Central Focus on System Design and Behavioral Choices|
Figure 2: A Balanced Approach to Workplace Fairness
The term “socio-technical” refers to human beings operating inside technical systems. These systems are comprised of departmental policies, procedures, training, and equipment. Managing the risks of socio-technical systems involves an understanding of the complex relationship between people and those systems (see Figure 1). In other words, the systems designed by law enforcement should depend, in large part, on an understanding of the capabilities of officers to react in risky situations; conversely, the actions and decisions (i.e., behavioral choices) of officers will often depend on their knowledge, skills, and abilities in utilizing the tools that have been given to them. The success at preventing undesirable outcomes will depend on the design and ability to hold to the socio-technical system encompassing policies, procedures, and equipment, as well as police officers, accountable for both the good and the bad outcomes.
An effective organization will recognize that system design provides the framework for success, but that it can do no better than the limitations that are inherent in those designs. Success in building and operating a nuclear power reactor requires multiple layers of barriers, redundancies, and recovery strategies to ensure acceptable levels of risk. Yet many organizations outside of the nuclear industry often expect employees to be perfect without recognizing the importance of these system design strategies. In the fields of nuclear power and aviation, success starts with procedural and engineering controls, including human factors design, that are essential to achieving positive outcomes.
So what role does human behavior play? In essence, officers are critical components within the systems, and system design and human behavior are interconnected. That is, a relationship often exists between the two that can be mutually supportive—or, at other times, can lead to complacency. In a perfect system, neither mechanical parts nor humans would fail; however, if mechanical parts are expected to eventually wear out and sometimes malfunction, shouldn’t the limitations of officers be considered as well? A machine might not get fatigued, forgetful, distracted, rushed, overstimulated, or frightened, but an officer may go through these states of consciousness on any given day.
By necessity, officers remain central to how risk must be managed. Within police departments and in certain high-risk situations, law enforcement has built complex systems to manage risk, but, ultimately, risk management must continue to rely on the good judgment and experience of the professionals employed and trained for these situations. While officers continue to perform in ways no computer has been able to match, officers fail in predictable ways: distractions, fear, fatigue, drift, low-risk perception, and a lack of situational awareness all contribute to undesired outcomes. Systems engineers in other high-consequence professions predict human variability in critical circumstances. In policing, it is essential to realize that law enforcement is comprised of imperfect systems interfaced with predictably fallible human beings. Even highly trained SWAT teams that use specialized equipment never deploy without risk of operational failure. The challenge is to not rely on the officer to be perfect, but to identify where the systems and people are vulnerable and work to optimize reliability in those areas.
Well-designed, high-consequence organizations recognize the vulnerability of their systems being one human error or at-risk behavior away from causing harm. In law enforcement, it could be an officer making an arrest using force who mistakenly draws a lethal firearm instead of a less lethal tool. Just as important are personal performance shaping factors, where both external and internal influences on human resources and their reliability are examined. Finally, the personal perception of risk involved in a specific behavior will, in many cases, determine how well the officer performs.
In the past, the mistaken thought has been that holding humans accountable for their outcomes through punishment will ensure that they never make a mistake or drift into at-risk behaviors. For example, all agencies have policies that prisoners being transported to any destination will be seat belted in the rear seat of the squad car. Yet how many officers adhere reliably to this policy? Minor crashes might not raise a red flag, but when a prisoner sustains serious injuries after not being properly seat belted, the officer would likely be disciplined or their employment terminated. Organizational accountability requires an understanding of system design, human behavior, and how to achieve reliability within each.
Learning Systems—Our Ability to See Risk Clearly
Human beings’ perception of risk with respect to behavior is directly related to their perception of the consequences of their actions. Immediate and certain consequences provide strong motivations; vague and uncertain consequences are weak; and rules and procedures are often the least effective of the influences on behavior. For example, most adults understand the risks associated with maintaining a speed limit at all times, yet people often choose to drive a little over the speed limit because of the perception that it saves time or that “everyone else is doing it.” However, when a citizen sees the police officer parked along the side of the road, they slow down, at least temporarily, until they drive out of sight and resume the at-risk behavior.
This illustration is meant to show that of the three possible incentives to drive at or below the speed limit, rules and the possibility of causing a collision often take a “back seat” to the higher likelihood of receiving a ticket, if only temporarily. In this respect, police officers are no different than other people in society. Everyone slows down or follows the rules when being watched and then often drifts back into habit patterns when it is perceived safe to do so (i.e., when the potential consequences are less immediate). Take, for example, an officer who chooses to activate the siren on a routine call or makes an arrest without following proper procedure when handcuffing a suspect. Would the officer be likely to engage in these at-risk behaviors in the presence of the chief or supervisor?
Recognizing this fact about human beings, how does it affect law enforcement’s ability to manage the socio-technical system? The answer is that “what we fail to inspect, we shouldn’t expect much of in return.” In other words, behaviors beyond the supervisor’s line-of-sight are most likely to be risky. To manage the socio-technical system well, organizations must be able to see risk clearly and be able to learn from both positive and negative experiences of their officers. Often, the only way to do this is to understand and learn from the day-to-day perspective of officers. However, to do this, officers must feel that it’s safe to come forward or to admit mistakes and at-risk behaviors.
Workplace Fairness—A Balanced Accountability
At the heart of this approach to producing better outcomes lies a fundamental workplace fairness issue: what system of accountability best supports the goals of the department and its charge to protect the public? In the real world of law enforcement, neither a “blame-free” nor a “punitive” culture is optimal. The answer lies in a balanced, collaborative approach to workplace fairness, where both systems (i.e., policies, procedures, training, and equipment) and individuals are held appropriately accountable—an approach often referred to as “just culture.”
A just culture model refers to a safety-supportive system of shared accountability where organizations are accountable for the systems they have designed and for responding to the behaviors of employees in fair and just manners. Employees, in turn, are accountable for the quality of their choices and for honest reporting of their actions, omissions, errors, and system vulnerabilities. This model is designed to help change an organization’s culture by placing less focus on incidents, errors, and outcomes, and more focus on risk, system design, and the management of the behavioral choices of its personnel. In this model, errors and outcomes are the outputs to be monitored; system design and behavioral choices are the inputs to be managed.
The field of human factors psychology has been integral to advancements in managing human behavior. Based on these scientific advancements, collaborative organizations recognize three major categories of human behavior and the importance of responding appropriately to each:
Human Behavior Category 1: Human Error
A human error occurs when an individual inadvertently does other than what should have been done; a slip, a lapse, or a mistake.
When a human error occurs, the response is to console the humans who made the mistake; work with them, when appropriate, and assist them in making better choices that will lower the likelihood of error; and consider redesigning the system to better manage the risks involved. Organizations that practice just culture examine the human error rate of other individuals in these circumstances, and seek to learn from reports, audits, and near misses before an accident occurs.
Human Behavior Category 2: At-Risk Behavior
At-risk behavior involves making a choice that increases risk where risk is not recognized or is mistakenly believed to be justified.
The response to at-risk behavior is similar to the response to human error, yet here exists the opportunity to more closely examine the choices themselves. When at-risk behavior occurs, the response to those involved is to coach them around their awareness of risk, remove the barriers or disincentives to compliance with rules and procedures, and promote incentives that produce the desired behaviors. Just culture examines norms, both individual and group, and what role these may have played in the behavioral choice. Why not simply punish people who demonstrate at-risk behaviors? Because actions such as rewarding outcome-based performance or looking the other way when no harm occurs may have contributed to the presence of these at-risk behaviors. In addition, punishing at-risk behavior serves to drive admission or reporting of these choices below the surface. If punishment is the likely consequence in an organization, then such behaviors are reported only when they cannot be hidden.
Human Behavior Category 3: Reckless Behavior
Reckless behavior is a choice to consciously disregard a substantial and unjustifiable risk.
The just culture response to reckless behavior is to punish or discipline the person who consciously disregards a substantial and unjustifiable risk, regardless of the actual outcome. It’s necessary to recognize the outcome bias and demonstrate a fierce intolerance for the reckless choice before actual harm occurs.
Avoiding the Outcome Bias
The outcome bias affects everyone on an individual, organizational, and societal level, and while people’s initial reaction to adverse events might be emotional, rational experience can guide them to a better result. Addressing the quality of the system design and behavioral choices, and not the actual outcomes of events and behaviors will lead to improved results. Producing better outcomes requires commitment and consistent response to both systems and behaviors, and avoiding the outcome bias is a crucial component of that success.
Most of the time, risky behaviors will lead to successful outcomes. (Most people who engage in at-risk behavior by talking on their cell phones while driving don’t have car crashes every time they use their phones.) When the accident does occur, however, people are often surprised at what should have been a predictable result. The stakes can be even higher when it comes to reckless choices. Drunk driving causes roughly 12,000 deaths each year in the United States alone. Yet, some states allow individuals to be arrested up to five times for driving under the influence of alcohol before imposing a criminal penalty, unless there is a fatality. The average drunk driver has driven drunk 80 times before his or her first arrest.1 If reducing the number of these preventable deaths is a serious endeavor, should it take until the fifth occurrence to impose a significant deterrent? If so, then why would it be a surprise when the drunk driver with multiple offenses eventually does run a red light, killing an unsuspecting family?
Similarly, if law enforcement is to manage the risk of unintended outcomes within police departments, as well as the risk inherent in policing the community, then the task is to recognize the outcome bias and avoid it at all costs. The result will be a more fair and learning-centered department with better outcomes.
Collaborating Better Outcomes in Law Enforcement
In law enforcement, the challenge is to learn from other professions and to embrace the science of effective risk management. Policing in the 21st century must incorporate improved scientific methods of managing both systems and human behaviors, rather than rely on outcomes to direct the response to adverse events, as seen many times in the past. This must be done within the department—as well as within communities. The key to putting all this together is enhanced collaboration. A collaborative approach has proven to be the most effective and sustainable foundation that science and the law can provide. Law enforcement has the opportunity to re-define accountability in clear, practical terms that can produce better outcomes for all. Establishing a collaborative foundation will produce safer outcomes for officers, departments, and the public. As those who have accepted the duty to serve and protect, law enforcement agencies and officers should offer nothing less to those who entrust them with their lives. ♦
|Benefits of the Socio-Technical Collaborative Approach|
Benefits for Officers
- Officers and administrative staff work in a just system that is neither punitive nor blame free, but a system of shared accountability between labor, management, and departmental oversight officials.
- Officers and staff have an objective framework for fair and constructive response to errors and events.
- Chiefs and supervisors have a practical tool to guide consistent, objective, and fair evaluations of behaviors leading to errors or events.
- Individuals have a framework to evaluate their own behavioral choices.
Benefits for the Department
- An environment of transparency around risk is created.
- The department has reduced risk and prioritized interventions. This is possible in organizations with open, fair, and learning cultures, and in facilities that design safe systems and manage the behavioral choices of everyone working in and for the department.
- It provides a framework for proactive management of system design and management of behavioral choices.
- When adverse events occur, the organization has an objective framework for a fair and constructive response to errors and events.
Benefits for the Public
- Improved risk management leads to better outcomes across all primary values for the public.
- Communities are safer when protected by a department with a learning culture, treating all officers and administrative staff in an open and fair manner. The public benefits from an organization that designs safe systems and manages the behavioral choices of everyone in the organization.
- There are clear expectations of what should happen when things go wrong and an understanding of how best to hold the organization and individuals accountable.
1Centers for Disease Control, “Vital Signs: Alcohol-Impaired Driving Among Adults — United States, 2010,” Morbidity and Mortality Weekly Report, October 4, 2011, http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6039a4.htm (accessed April 1, 2014).
|Charles “Chuck” A. Gruber is past president of the International Association of Chiefs of Police and the Illinois Association of Chiefs of Police. Chief Gruber is a decorated law enforcement executive with a distinguished career in law enforcement spanning four decades, with 32 years as a chief of police. He is the recipient of numerous awards including Law Enforcement Officer of the Year by the U.S. Marshals Service and the International Association of Chiefs of Police Civil Rights Award.|
Scott Griffith is a partner and principal collaborator at SG Collaborative Solutions, LLC. He is a former international airline captain and director of corporate and flight safety at American Airlines. He is the recipient of the Admiral Luis de Florez Flight Safety Award for his outstanding contribution to aviation safety. Over the past decade, he has pioneered the concepts of collaborative just culture improvement in numerous high-consequence industries beyond aviation, including health care, nuclear power, the fire service, and law enforcement.
Steve L. Whatley, PhD, is a retired sergeant and police administrator with over 20 years’ experience in the Shreveport, Louisiana, Police Department. Steve has presented and is published in the field of Human Resource Development and is a certified Just Culture Champion. Over the past several years, Steve has transitioned into other high-consequence industries and has been a principal improvement champion in the health care setting.
Please cite as:
Charles A. Gruber, Scott Griffith, and Steve L. Whatley, “Better Outcomes in Policing,” The Police Chief 81 (March 2014): 26–29.