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Following disastrous events such as Three Mile Island, the Challenger disaster, fatal airline crashes and unacceptable rates of fatalities in health care settings, the field of safety science expanded rapidly. And though it is credited with significant improvements in a number of enterprises, child welfare agencies have been slow to embrace and adopt principles from this body of work. That is unfortunate, because among public services, child protection is clearly a safety-critical enterprise.
Aside from notable examples of work by Eileen Munro in the United Kingdom on a systems approach to child death review and Scott Modell and his colleagues’ work in Tennessee on safety culture, the core principles and practices of safety science remain hard to find embedded in the daily routine of child protection agencies throughout the United States.
There are many lessons from safety science that might inform a child protection agency’s ability to build a stronger prevention and response system. We will discuss five of them that we believe are critical to address.
Build a strong safety culture
David Woods, a safety science pioneer, suggests that strong safety cultures are proactive. They learn before bad things happen. They are open to information even though the information may make you or your team look bad. They work to get beyond blame, and focus on how the system works rather than what makes it break.
Ultimately, they are driven by one question, “What will create safety?”
A resilient organization treats safety as a core value, not a commodity that can be counted. European safety expert Erik Hollnagel states, “The essence of resilience is the intrinsic ability of an organization (system) to maintain or regain a dynamic stable state, which allows it to continue operations after a major mishap and/or in the presence of continuous stress.”
Woods describes several characteristics that indicate a lack of resilience in organizations:
- Defenses erode under production pressure.
- Past good performance is taken as a reason for future confidence about risk control.
- Fragmented problem-solving clouds the big picture.
- There is a failure to revise risk assessments appropriately as new evidence emerges.
- Breakdown at boundaries impedes communication and coordination.
- There is a substantial gap between what upper management thinks is happening and what is actually happening at the front line.
- The organization cannot respond flexibly to (rapidly) changing demands and is not able to cope with unexpected situations.
Adopt a more dynamic view of risk
Woods also observes that “our responsibility is to create foresight about the changing nature of risk,” a concept sorely lacking in the standard management practice of child protection. Child welfare agencies generally treat risk and safety as a point-in-time marker condition. Risk may be higher or lower than an acceptable threshold when assessed. A child may be safe or unsafe at a given point in time. The agency may be assumed to be working well because nothing tragic has occurred yet.
Both risk and safety are dynamic. The conditions that determine both in families and organizational systems are fluid and constantly in motion. While many examples are possible, one of the most common tragic events for a child protection agency occurs when a child has been judged safe, remains at home as an intact family case, and then dies due to maltreatment.
A reliance on point in time measurements of safety may easily miss the dynamic changes occurring in conditions that determine safety. The safety instruments used by most child protection agencies were designed to assess present danger at a point in time when an allegation is made. The allegation provides a context and safety is judged as an artifact of the specific time the alleged maltreatment occurred.
But assessing the changing nature of safety requires sensitivity to and monitoring of changes in the intensity and frequency of risk and safety factors over time against the current strength of protective factors.
Look beyond human error
Sidney Dekker, founder of the Safety Science Innovation Lab in Australia, makes important distinctions between the old and new view of human error. The old view, he asks, “Who is responsible for the outcome?” The new view asks, “What is responsible for the outcome?”
The older view sees “human error” as the cause of trouble, whereas the new view sees it as a symptom of deeper trouble. Rather than focusing on what people failed to do, we should focus on trying to understand why people did what they did and why it seemed to make sense to them to do what they did.
This suggests a markedly different approach to post mortem fatality reviews than is the case in many jurisdictions when a child dies due to maltreatment after a case is opened. Current review methods are highly susceptible to hindsight bias, and the tendency to differently evaluate earlier processes and actions after one knows the outcome. The person looking forward down the tunnel has a markedly different perspective and ability to understand the future than does the person looking backward down the tunnel after an adverse outcome has occurred.
Learn from success
Most critical incident reviews look exclusively for instances of non-compliance and what went wrong. Rarely are reviews of successes undertaken that try to understand what went right and why. David Woods recommends examining successes in an attempt to tease out how success happened as a strategy for building safety.
Woods also suggests that a “component analysis” following failure very likely will produce a compliance culture. It forces a narrow look at what component failed and where were the rules violated. He asserts that this is inferior to a systems analysis, which looks at difficulties in the work, the role of uncertainty in shaping decisions and actions, the existence of weak indicators, the impact of workload and situations where limited action potential exists. A systems analysis seeks to understand how the work is done from front to back.
Be proactive
In reactive safety management, adjustments are made when unacceptable outcomes have occurred. In proactive safety management adjustments are made before something happens rather than after.
Erik Hollnagel observed:
“Safety management that follows rather than leads developments runs a significant risk of lagging behind and becoming reduced to uncoordinated fire-fighting.” In order to prevent this, safety management must look ahead and not only try to avoid things going wrong, but also try to ensure that they go right. Safety management must focus on how everyday performance usually succeeds rather than on why it occasionally fails, and actively try to improve the former rather than simply preventing the latter.
Don’t wait for a tragedy to build a safe system
The lessons of safety science extend well beyond the limits of this brief summary. A safety science approach builds the capacity of an organizational system to anticipate and manage risk effectively, and to ensure that its core functions are carried out in a stable and effective relationship with the environment.
The persistent turmoil of child protection agencies suggests the need to increase the resilience of these agencies. It is long past the time to end reviews of child protection tragedies that start and conclude by blaming human error. The number one priority of a child protection agency must be a constant drive to create safety in all aspects of its work.
Tom Morton is the former president of the Child Welfare Institute, and former director of the Clark County Department of Family Services in Nevada. Jess McDonald is the former child welfare director for the state of Illinois.
