When the federal Commission to Eliminate Child Abuse and Neglect Fatalities released its 2016 report, Within Our Reach, Commission Chair David Sanders sought to challenge the notion that we cannot prevent all maltreatment fatalities.
“Child protection is perhaps the only field where some child deaths are assumed to be inevitable, no matter how hard we work to stop them,” he wrote in the report’s prologue. “This is certainly not true in the airline industry, where safety is paramount and commercial airline crashes are never seen as inevitable.”
The health care sector is another that utilizes evidence-based, safety disciplines to mitigate critical incidents and create a more trustworthy system of health care delivery. So what can child welfare systems adapt from these to reduce deaths from abuse or neglect?
We submit that the primary lesson to be learned is the value of incorporating and embracing safety science as a North Star for child welfare. It is fidelity to this practice that has led to a safety revolution in aviation and health care. And with many child welfare systems working toward a more preventative, upstream approach, there has never been a more important time to weave this into the fabric of the field.
As an evidence-based field of discipline, safety science aims to improve systems by expanding the scope of learning beyond an individual case to systemwide comprehensive analysis. In the context of child welfare, it utilizes a standardized critical incident review process, coupled with data analysis across multiple jurisdictions to identify systemic challenges to child safety.
Safety science provides a framework for professionals to process, share and learn from critical incidents to prevent additional tragedies.
Child welfare systems are incredibly complex. Safety science provides a framework guided by data sharing and critical incident review (CIR) processes for child protection agencies to better understand the inherently complex nature of the work and the factors that influence decision-making. Health care, aviation and other safety-critical fields have all demonstrated approaches that prevent harm and reduce risks and can serve as a model for national quality improvement efforts focused on child welfare.
What does this look like in practice? In January 2018, child welfare agencies from 20 jurisdictions came together to answer that question by participating in the Tennessee Safety Culture Summit.
These efforts culminated in the formation of the National Partnership for Child Safety (NPCS), a professional learning collaborative supported by Casey Family Programs that focuses on applying safety science in child welfare. To date, the NPCS has grown to include 29 jurisdictions nationwide that serve more than 800,000 children who are subjects of an investigation by child protection services annually.
As co-chairs of the NPCS, we are working within our jurisdiction and in partnership with other NPCS jurisdictions to build a learning community around safety science, shared data and the application of a standardized platform for critical incident review. Our shared goals are to strengthen families, promote innovations in safety culture, and reduce and prevent child maltreatment and fatalities through a public health approach.
One of the important elements of the partnership’s work is sharing data across jurisdictions. Having a national collaborative approach to data collection allows for the identification of meaningful trends and patterns, enhancing the visibility of areas for child safety improvements. Sharing data across states also makes it possible to disaggregate and examine the data by race/ethnicity to track disparities at different decision points, potentially identifying larger issues, such as implicit bias, that can be used to inform systemic or policy reforms that advance racial justice.
By implementing more proactive rather than reactive strategies, we hope to enhance quality improvement, reduce the current rate of workforce instability, and address the cycle of blame that occurs in response to critical incidents — a cycle which often leads to changes in leadership rather than needed systems change that would prevent future tragedies.
When the Family First Prevention Services Act was signed into law in 2018, it set forth requirements that each state provide a description of the steps it is taking to collect information about child maltreatment fatalities and implement a plan to prevent them. This presents an important opportunity for states to improve the quality of the critical incident review process and utilize it to improve child safety and prevent future deaths.
Implementing a standardized critical incident review process grounded in safety science is a vital step toward fulfilling these requirements and reimagining child welfare systems as child and family well-being systems that put child safety first.
By working collaboratively across multiple jurisdictions, NPCS hopes to identify a road map to a culture of safety in child welfare and to share our findings broadly, both within child welfare and intersection communities and systems, to help other jurisdictions navigate the shift to a more preventative child welfare system.
