Safety culture

....the next big challenge for child protection

Think of an industry in which professionals make high-risk decisions every day. They can’t afford mistakes, can’t “learn by failing,” because a failure might lead to a death. When something goes wrong, the results might be catastrophic.

What industry were you thinking of? Airlines? Nuclear Energy? Neurosurgery? How about child welfare?

Child welfare is what Dr. Michael Cull wants us to think about when we think about “safety culture.” As in aviation or nuclear energy, our social workers make tough calls every day, balancing the risk to a child against that child’s biological and emotional need to be with his or her parents. Facts have to be separated from allegations. A wrong decision made in good faith could result in a child’s death. Just as in aviation or nuclear energy, there’s very little room for error.

Child welfare might even be tougher. Airline pilots train for years before they’re ever put in the cockpit, and they regularly go through simulations of mechanical and other failures so they’ll know how to react. As a result, being on a plane is one of the safest places you can be.

But case managers? We often hire them right out of school, put them through a few weeks or months of training, then expect them to go make life-and-death decisions about child safety. And if they do make a mistake, our system is great at Monday-morning quarterbacking. Reviewers comb through the record, find that one issue the case manager missed, and take disciplinary action.

Cull says that culture needs to change: “We aren’t going to fire our way to better child welfare,” he told me.

Instead, Dr. Cull and his colleagues at the University of Kentucky are working with child welfare agencies in 26 jurisdictions to implement safety science in child welfare. Taking a page from healthcare and other high-risk industries, these jurisdictions are building an organizational culture in which we look at system weaknesses, not individual mistakes. He uses a visual of a winding sidewalk across a park with a bare “shortcut” path that walkers have made. Instead of demanding that folks not walk on the grass, perhaps the better solution is to straighten the sidewalk.

To implement safety culture is to implement a system in which everyone in the organization is empowered to speak up when they see problems that might lead to mistakes. In the healthcare context, it means the orderly has not only the authority but also the responsibility to call out the physician who’s not washing his hands between patients. In child welfare, it means case managers should be free to speak up without fear of retaliation.

Safety culture also requires organizational accountability when things go wrong rather than finger-pointing. As we’ve seen for many years, there are many mistakes made in child welfare practice, but few of them actually result in tragedy. So rather than blame the case manager or supervisor who are involved in a case with a bad outcome, it’s better to focus on creating a system with checks and safeguards so that fewer mistakes are made. And when they are made and a tragedy results, we should focus on improving the system rather than finding “the” person responsible for the mistake.

In collaboration with Casey Family Programs and the University of Kentucky, the National Partnership for Child Safety is promoting this cultural change across the country. If you’d like to know more about how your agency can improve its culture, let me know. It’s an issue I love to talk about and present on.