(Photo by Bill Pugliano/Getty Images)

In announcing the "brutally tough" and "deeply troubling" results of the investigation into the ignition switch catastrophe at General Motors, CEO Mary Barra on Thursday laid out the changes the company is making to overhaul its bureaucratic culture.

She's named a vice president of safety, added safety investigators, and introduced a program to recognize employees who report safety issues. She's restructured the decision-making process for safety issues so that they are raised to the highest levels of the company. And she revealed the company has terminated 15 employees — more than half of whom were executives — and is disciplining five others.

She also said GM would be implementing recommendations from the harshly critical report, which was led by attorney Anton Valukas and made public on Thursday. The report had a dizzying list of more than 90 recommendations, which include suggestions for changing the company's organizational structure, its supplier interactions and its communications with regulators. Yet the ones that fall under emphasizing a safety culture and individual accountability may be the most important, and the most difficult to do.

As Barra noted in her remarks in an employee town hall, simple structural moves aren't enough. "To excel — to truly build the best auto company for customers — we have to change our behavior as well," she said. "If we think that cleaning up this problem and making a few process changes will be enough, we are badly mistaken."

This is the slippery, nebulous work of culture change. It's hard to identify, tricky to implement, and tough to measure how an organization goes about changing its ways.

Creating a new leadership position is easy to do. Databases can be improved and training programs can be launched. Setting up meetings or reports that get different departments talking to each other is concrete enough that it can be observed. But getting people to take ownership of a problem, or hold themselves responsible for something that's long been seen as someone else's job, is far more difficult.

That's why a few of Valukas's recommendations stand out in particular — either for how much of an impact they could have, or for what more they could say. Perhaps most interesting is his recommendation that employees certify annually that they have reported any safety issues of which they're aware. Assuming he is referring to all of GM's 220,000 employees, this is no small matter. It would turn reporting safety issues into a requirement, rather than something employees are encouraged to do (akin to dropping a note in a virtual suggestion box). It would become a matter of honor, professional integrity and perhaps even job security.

Another one that stands out is his recommendation to widely publicize the company's new Speak Up for Safety program, which encourages employees to raise safety issues and recognizes those who do so "in bulletins and newsletters." In fact, Barra should go one step further, and give whistleblowers the ultimate kind of employee recognition: promotions.

She could take a page from her crosstown rival, Ford, where incoming CEO Mark Fields famously endeared himself to retiring chief executive Alan Mulally by being willing to deliver bad news. As the story has been reported, Fields was the only executive in a meeting early in Mulally's tenure who was willing to hold up a red box revealing technical problems that would require an expensive delay in a vehicle's launch. Fields wasn't penalized; he was promoted, eventually all the way to CEO.

Valukas hints at this in another recommendation, where he suggests making the identification and elevation of safety issues part of employee performance reviews. While that would likely help to reward the right behavior, Barra should also be wary of unintended consequences if she makes this change, especially since performance evaluations are often tied to what people are paid.

Sometimes, a program designed to encourage good outcomes can result in actions by employees that no one wants. Look no further than the controversy at Veterans Affairs to find another example of a sprawling bureaucracy with an entrenched culture where top leaders were unaware of big problems going on below the surface. At the VA, incentives designed with the right goals in mind — to reduce wait times for veterans' appointments — may have had the opposite effect, potentially playing a role in motivating staffers to fudge the numbers for better bonuses.

Finally, Valukas suggests the company regularly communicate with employees about safety and "reinforce the tone at the top," sharing the safety message via "regular bulletins" or through columns in employee newsletters. But what matters just as much as how often leaders talk about safety or where they communicate it is how the discussion about safety is framed.

Back in April, when GM announced its Speak Up for Safety program, Harvard Business School professor Amy Edmondson told me that the best safety cultures actually reframe the discussion around failures as inevitable. They don't take for granted that employees know this. Rather, they explicitly communicate that things will go wrong again at some point. The message, she said, should be "it's not because people screw up, but because of the immense complexity of what we do. The phenomenal number of interacting parts, interacting people and continuing changes in technology mean that we will always have failures, full stop."

Talking about safety problems that way doesn't excuse them. But it could help to take away much of the stigma that keep people from bringing them up.

Read also:

Getting GM employees to speak up about safety

To change a culture, follow the money

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