LEAD 6323 Module 5 Culture Change Plan Example

From Who Made the Error to What Allowed It: A Three-Year Culture Change Plan for a State Public Health Laboratory, Keeping Its Controls and Changing Its Assumptions

Student Name

American College of Education

LEAD6323: Organizational Behavior and Culture

Module 5 Assignment

Instructor Name

November 9, 2026

Introduction

Across four papers I have described the state laboratory I help run: a strong hierarchy culture with weak collaboration and innovation, scientists whose need for autonomy is frustrated, decisions centralized far from expertise and an outbreak team that broke apart over a dispute it had no way to resolve. Running through all four was one unspoken assumption, that every error is a personal failure. This paper sets out a three-year plan to change the culture, aimed first at that assumption, while keeping the controls that protect the public.

Why Culture Change Is Worth the Effort

Culture can seem too vague to justify investment. Braithwaite et al. (2017) systematically reviewed research on organizational and workplace cultures in health care settings and found that most of the 62 studies they included reported an association between positive cultures and better patient outcomes, such as lower mortality and higher patient satisfaction. A public health laboratory's patients are mostly invisible to it, but its results shape outbreak responses, water safety decisions and newborn screening. A culture that drives away skilled scientists and suppresses candor about errors carries real risk for those unseen patients.

What Must Stay

The plan begins with what will not change. Federal certification requirements, validated methods, document control for anything affecting reported results and the quality assurance office's authority over them remain intact. Staff in the established sections, whose quality-control subculture has kept the laboratory free of certification deficiencies for a decade, need to hear this first. Mannion and Davies (2018) caution that culture change in health care must work with existing subcultures rather than against them, and a plan that appeared to attack the microbiologists' standards would provoke the resistance it most needs to avoid.

Goal 1: A Just Culture for Errors

Dekker and Breakey (2016) argued that a just culture should achieve three kinds of justice after an incident: substantive justice, in which responses fairly distinguish blameless error, at-risk behavior and reckless conduct; procedural justice, in which the process for reviewing incidents is fair and transparent; and restorative justice, which repairs harm and focuses accountability on learning and future improvement. The laboratory's current response to errors, retraining and corrective action plans for individuals, addresses none of these well. Under the plan, every reportable error will be reviewed by a small team that includes a bench scientist, using a structured set of questions that begins with what in the system allowed the error, and individual corrective action will be reserved for at-risk or reckless behavior. The point is not to excuse errors but to learn from them, which requires that people be willing to report them. Restorative justice also means attending to the person involved: the technician from last year's specimen mix-up will be invited, if she wishes, to help design the new review questions, turning the incident that shaped the old assumption into the start of the new one.

Goal 2: Decision Rights Matched to Expertise

From Module 3: a two-track change process will separate validated reporting methods, which keep full review, from internal tools and development workflows, which unit leads approve with quality assurance notified. Every kind of decision gets one accountable person and a deadline for answering. This change addresses both the frustrated autonomy found in Module 2 and the centralization that slows innovation, and it is the most visible signal to scientists that the culture is changing.

Goal 3: Bridging the Subcultures

From Modules 1 and 4: the outbreak response roster, which meets quarterly, will become the main bridge between the quality-control and experimental subcultures. In addition, a monthly case conference will bring microbiology, sequencing and epidemiology staff together on one recent investigation, and new scientists will spend their first week rotating through sections other than their own. Leaders will tell the story of the outbreak team's breakdown and repair, with the participants' agreement, as an example of how disagreement can be handled. Couriers and administrative staff, who described themselves as outside both subcultures, will be included in the case conferences that concern their work, such as specimen transport delays.

Leadership Behavior

Schein and Schein (2017) emphasize that what leaders pay attention to, measure and reward, and how they react to critical incidents, are among the most powerful ways cultures are shaped. The plan therefore includes commitments by the director and me: to ask "what allowed this?" before "who did this?" after every incident; to report at each all-staff meeting one improvement that came from an error report; and to include bench scientists in decisions about their methods. These behaviors matter more than any policy, because staff will judge the plan by how leaders respond to the next error.

Anticipated Resistance

Resistance will come from several directions, each with a reason worth hearing. Some long-serving scientists will see the just culture process as lowering standards, because in their experience accountability meant individual consequences. The response is to show, with early cases, that the process still holds people accountable for reckless conduct and that system fixes reduce repeat errors. Some supervisors will see the two-track change process as a loss of authority; their role will shift from approving every change to coaching unit leads and auditing a sample of internal changes each month. And some sequencing scientists may expect faster change than the plan delivers and conclude it is another poster. The plan's first-quarter commitments, the first error review completed with a bench scientist and the first internal change approved within five days, are meant to give each group early evidence that something real has changed.

Resources

The plan needs little money and a good deal of time: training for twelve staff in just culture review, about forty hours of leadership time to design the process with staff, protected time for monthly case conferences and the cost of repeating the culture survey. The largest cost is attention, since leaders' consistency over three years is what will determine whether staff believe the change.

Timeline and Measures

Year one: just culture review process designed with staff and launched, two-track change process in place, case conferences begun. Year two: error review results shared quarterly, cross-section rotations for all new hires, first repeat of the culture survey. Year three: second repeat survey and evaluation of the plan. Measures include the culture survey's clan and adhocracy scores, targeted to rise toward staff's preferred levels; turnover in the molecular sections, targeted to fall from 24% to below 12%; the count of error reports, expected to climb in the first year once people trust that reporting is safe; and quality indicators, including proficiency testing and certification findings, which must not worsen.

Conclusion

Changing a culture means changing what people take for granted. This plan targets the laboratory's deepest assumption, that errors are personal failures, through a just culture process, while redistributing decisions to the people with expertise, bridging subcultures and changing what leaders pay attention to. It leaves intact the controls that protect the public, because the goal is not a looser laboratory but one where scientists can say what they see.

References

Braithwaite, J., Herkes, J., Ludlow, K., Testa, L., & Lamprell, G. (2017). Association between organisational and workplace cultures, and patient outcomes: Systematic review. BMJ Open, 7(11), Article e017708. https://doi.org/10.1136/bmjopen-2017-017708

Dekker, S. W. A., & Breakey, H. (2016). "Just culture:" Improving safety by achieving substantive, procedural and restorative justice. Safety Science, 85, 187-193. https://doi.org/10.1016/j.ssci.2016.01.018

Mannion, R., & Davies, H. (2018). Understanding organisational culture for healthcare quality improvement. BMJ, 363, Article k4907. https://doi.org/10.1136/bmj.k4907

Schein, E. H., & Schein, P. A. (2017). Organizational culture and leadership (5th ed.). Wiley.