At the end of the message I prepared I indicated I don't have an instruction manual on how to change or fix a culture. The culture, however you want to define it, very much needs to reflect on the fact that, again as I said in the message, even though we are operating in a world that has many different types of controls in place already, which have been designed to prevent this type of thing and many of those controls probably were put in place in response to past Auditor General reports when we identified significant issues, somehow those controls did not work to prevent Phoenix from happening.
The first step is a general awareness within the culture that just following the form, I suppose, of policies is not going to prevent incomprehensible failures. There needs to be a real understanding of what the goals are, what the results are that departments are trying to achieve, and that they are focused on those things, and that when something looks like it's going off the rails, they feel they can and do bring those problems forward.
I don't have the answer to the problems with the culture or how to fix those problems. I was trying to raise awareness, and if there's at least some awareness about that, then perhaps that can contribute to preventing this type of situation in the future.