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Improving Child Protection With Safety Science Improving Child Protection With Safety Science

Improving Child Protection With Safety Science - PowerPoint Presentation

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Improving Child Protection With Safety Science - PPT Presentation

  Michael Cull PhD Deputy Commissioner Child Health Tennessee Dept of Childrens Services 1 My plan Describe S afety Science Safety Culture and High Reliability Organizations Explain how principles of HRO can be applied to support a Traumainformed Resilient Child Welfare sy ID: 534311

culture safety percent amp safety culture amp percent high positive child system trauma systems support managers teams work children

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Slide1

Improving Child Protection With Safety Science 

Michael Cull, PhDDeputy Commissioner, Child HealthTennessee Dept of Children’s Services

1Slide2

My plan…Describe Safety Science, Safety Culture and High Reliability Organizations Explain how principles of HRO can be applied to support a Trauma-informed Resilient Child Welfare systemDiscuss some of the tools and tactics we’re applying in TennesseeSlide3

Trauma-informed?3Slide4

ResilienceTraditionally, resilience has come to mean an individual's ability to overcome adversity and continue his or her normal development. What doesn’t kill me makes me stronger…4Slide5

Or…“If you managed to survive, and were fortunate enough to spend time recovering and reflecting within a robust support structure, you may, despite your weakened state, glean some helpful insights.” 5(Sexton, 2014)Slide6

An Engineering ApproachAdaptive capacity: Properties change to meet demands of unanticipated events and then return to normal operations. 6Organizational

IndividualSlide7

How can Safety Science help?7Slide8

Safety Culture A safety culture is one in which organizational values, attitudes, and behaviors support a safe, engaged workforce, and reliable service deliveryLeaders within a safety culture:Balance systems and individual accountabilityValue open communication, transparency, and continuous learning and improvement8Slide9

High Reliability OrganizationsHigh-risk, high-consequence, organizations that function in hazardous, fast-paced, and highly complex technological systems essentially error-free for long periods of time. Organizations that operate continuously under trying conditions and have fewer than their share of major incidents.

(Roberts, 1990; Weick & Sutcliffe, 2007)Slide10

HRO CharacteristicsPrinciples of AnticipationPreoccupation with failureReluctance to simplifySensitivity to operationsPrinciples of ContainmentDeference to expertise

Resilience

(

Weick

& Sutcliffe,

2007)Slide11

HRO ExamplesUS Air Traffic Control SystemPower Distribution GridsNuclear PowerAircraft Carriers & SubmarinesInternational BankingWhere’s Healthcare (our close

cousin)?Slide12

12

Total lives lost per year

Dangerous(>

1/1000)

Ultra-Safe(<

1/100K)

HealthCare

Mountain Climbing

Bungee Jumping

Driving

Chemical

Manufacturing

Scheduled Airlines

European Railroads

Nuclear Power

Regulated

Chartered Flights

Numbers

of

encounters

for each fatality

Adverse Event

Rates: US

HospitalsSlide13

Do we face similar challenges in Child Welfare?Society?13Slide14

Deaths from Abuse and NeglectThe CDC reports 14 % of children suffer abuseNationally estimated 1560 children died from abuse and neglect in 2010 or 2.07 children per 100,000 children in the general populationThis is an average of four children dying every day from abuse or neglect14Slide15

How does a Child Welfare system advance a safety culture?Pursue a new lensBias, behavior, fallibility and system interactionAsk new questionsWhat and why? Not, who and how?Expect different preconditions for your workSafe, engaged workforce with the tools to do their job15Slide16

Professionals are supposed to get it rightBad things happen because people make mistakesPeople/Organizations that fail are badBlame motivates being careful

(Dekker, 2008)

The Old View

16Slide17

Serenity Deal17Slide18

Risk of failure is inherent in complex systemsRisk is always emergingNot all risk is foreseeablePeople and systems are fallible Well-prepared professionals are crucial

The New View

18

(Dekker, 2008)Slide19

A New View of Human ErrorNo longer seen as a causeSeen as a Symptom

Not the end of our inquiry The Beginning

Not a random or isolated event

Emergent Property from the SystemSlide20

20Human LimitationsSlide21

How do we develop this new way of thinking AND learning?21Slide22

Tennessee’s ApproachBest practices have been identified that support a safety culture:Enhanced surveillance(e.g., event reporting, accident analysis, safety culture survey) Better communication(e.g., teamwork, professionalism, child/family engagement)

Reliable systems(e.g., bundles, predictive modeling, staffing models)

(

Hickson

et.

a

l., 2012; Singer

&

Vogus, 2013

)

22Slide23

Child Death Review: An Accident Model23Slide24

Measuring Our Safety CultureAssessment of DCS’s safety culture supports communication. Our survey strategy will:Create a language to drive culture change Raise staff awareness about safetyIdentify opportunities for improvementAllow us to track change over time

(Edmondson, 2004; Kessler, 2013; Cull et. al., 2013)

24Slide25
Slide26

What was our process?Survey Construction41 Item instrument consisting of 5 dimensions made of previously validated measuresResponse RateDistributed system-wide to case managers, team-leaders and team coordinators 70% response rate26Slide27

(n=1365/354)27Slide28

37.5 Hours

Standard full-time work week

28

(n=

1365

/

354

)Slide29

(n=

1719)

High performing: percent positive > 90%

Problematic: percent positive < 60%

29Slide30

(n=

1719)

High performing: percent positive > 90%

Problematic: percent positive < 60%

30Slide31

High performing: percent positive > 90%

Problematic: percent positive < 60%

31

(n=

1365

/

354

)Slide32

(n=

128/27)

High performing: percent positive > 90%

Problematic: percent positive < 60%

32Slide33

(n=

1719)

High performing: percent positive > 90%

Problematic: percent positive < 60%

33Slide34

Interplay of Stress and Fatigue34Walker et. al., Current Biology, October 2014"The emotional centers of the brain were over 60 percent more reactive under conditions of sleep deprivation than in subjects who had obtained a normal night of sleep,"Slide35

35Slide36

Preliminary FindingsHigh-levels of staff engagement/interest Response rate well above typical response for organizational surveys (40 – 50%*).604 respondents provided comments.Understanding risks associated stress and fatigueCase managers and supervisors report working on average 44 and 45 hours/week respectively. 56% of case managers and 54% of supervisors do not recognize the role stress and fatigue play in performance

. Organization of teams to anticipate and learn from unexpected events62% of case managers and 59% of supervisors do not think their teams operate in a way that supports rapid detection and correction of errors and unanticipated events.Psychological safety

58%

of case managers and

57% of supervisors do not believe team

members are accepted,

treated with respect, or

safe to take interpersonal

risks.

Supervision model supporting system safety

44%

of case managers and

53% do not believe their supervisor is interpersonally or professionally supportive or fair and unbiased in their decision-making.

43%

of case managers and

57% do not believe the organization’s climate supports workforce engagement and quality care.

(*

Brauch

& Holton, 2008)

36Slide37

(n=1719)37Slide38

Focus AreasPsychological Safety Supervision modelTeamwork and Communication 38Slide39

Why Promote Teams in Child Welfare?

39Slide40

40Slide41

Other things we are doing…Safety Culture integrated into CANS trainingHuddle, briefs, and debriefsSafety RoundsNew supervision modelsSimulationLEAN Process improvement41Slide42

Questions?michael.cull@vanderbilt.eduwww.mc.vanderbilt.edu/coe42Slide43

Teams vs. TeamingTeams are social constructions defined by:Common goal and a game planDiverse roles that synergizeAgreed upon behavioral normsAgreed upon attitudinal normsTeaming is the active process of:Relating

to othersListening to others’ points of viewMaking shared decisionsRemaining vigilant of others needs, roles and perspectives

(

Edmundson

, 2012)

43Slide44

What Properties are Found in Effective Teams?Shared mental modelA mental picture or sketch of the relevant facts and relationships defining an event, situation, or problem. Collective mindfulnessThe ability to rapidly detect and respond to unexpected eventsSituational awarenessThe state of knowing the conditions that affect one's workPsychological safety

Team members feel accepted, respected and safe to take interpersonal risks (Henrickson et. al., 2008; Edmundson

, 2012)

44Slide45

What Behaviors Support Effective Teams? Plan forwardTimeouts, Briefings, Huddles and ChecklistsReflect backScripted DebriefingCommunicate EffectivelyClear, concise, comprehensive and congruent (words match body language and expression)Active listeningUse tools (SBAR, Repeat-back)Promote Professionalism

Accountability and Critical Language (Hickson et. al., 2011; Frankel, 2011)

45Slide46

Survey DimensionsStress Recognition: The recognition that stress and fatigue impact performance. Psychological safety: The shared belief that team members are accepted, respected, and safe to take interpersonal risks. Leader-member exchange

: The two-way relationship between supervisors and subordinates that influences subordinates' responsibility, decision influence, access to resources, and performance. 

Safety Climate:

Perceived organizational attributes related to safety

which may be induced by

policies

and

practices.

Safety Organizing:

The described preconditions that support rapid detection and correction of errors and unexpected events.

46Slide47

Safety OrganizingPreoccupation with failure: Chronic wariness of the unexpectedReluctance to simplify interpretations: Questioning assumptions and received wisdomSensitivity to operations:

Up-to-date knowledge of where expertise residesCommitment to resilience: Deliberate learning from experience

Deference to

expertise:

Migrating

decision-making to person with most expertise, not most authority

Vogus & Sutcliffe, 2007

47Slide48

Could I be burned out?You try to be everything to everyone You get to the end of a hard day at work, and feel like you have not made a meaningful difference You feel like the work you are doing is not recognized You identify so strongly with work that you lack a reasonable balance between work and your personal life Your job varies between monotony and chaos You feel you have little or no control over your work You work in Child Welfare48Slide49
Slide50

Are you Trauma-informed?Trauma-InformedNon-Trauma-InformedRecognition of high prevalence of trauma

Lack of education on trauma prevalence & “universal” precautionsRecognition of primary and co-occurring trauma diagnoses

Over-diagnosis of Schizophrenia & Bipolar Disorder, Conduct Disorder & singular addictions

Assess for traumatic histories & symptoms

Cursory or no trauma assessment

Recognition of culture and practices that are re-traumatizing

“Tradition of Toughness” valued as best care approach

Power/control minimized—constant attention to culture

Keys, security uniforms, staff demeanor, tone of voice

Caregivers/supporters––collaboration

Rule enforcers––compliance

Address training needs of staff to improve knowledge & sensitivity

“Patient-blaming” as fallback position without training

Objective, neutral language

Labeling language: manipulative, needy, “attention-seeking”

Transparent systems open to outside

parties

Closed system-advocates discouraged

SAMHSA

Developing

Trauma Informed

Systems

that can

Support People

in the

Community,

Tim

Tunner

, PhDSlide51

What do these tragedies have in common?Turkish Air flight TK1951 received erroneous information from the plane’s radio altimeter system. The crew’s response resulted in a fatal crash that claimed the lives of 4 crew members and 5 passengers.A 2 y/o girl is left unattended by her foster parents and drowns in the family’s swimming pool.

51Slide52

System SimilaritiesPublic trustPublic oversightHigh risk decisionsHigh consequence outcomesHigh profile52(Cull, Rzipnecki, O’Day & Epstein, 2013)Slide53

Let’s revisit these two cases?Turkish Air flight TK1951 was given incorrect information from the planes radio altimeter systems. The crews response resulted in a fatal crash that claimed the lives of 4 crew members and 5 passengers.A 2 y/o girl is left unattended by her foster parents and drowns in the family’s pool.

53Slide54

Expert FindingsThe length of B737 type training at THY, as well as procedural compliance at THY, appear to at least match industry standard. The Captain had close to 11,000 hours on the Boeing 737 alone. This combination of training standards and experience is apparently not enough to protect crews from the subtle effects of automation failures during automated, human-monitored flight. The documentation and training available for flight crews of

the Boeing 737NG leaves important gaps in the mental model that a crew may build up about which systems and sensor inputs are responsible for what during an automatically flown approach.

(Dekker, 2009)

54Slide55

Expert FindingsIt is indisputable that OKDHS was well aware of the hazard associated with the pool. The home should never have been approved without a specific and shared understanding between OKDHS and the foster parents about the pool. The pool should have been removed or a suitably protective fence should have been placed around it. No children should ever have been placed in the home before one of these things happened.

By failing to ensure that this hazard was either removed or mitigated, OKDHS violated CWLA and COA standards and its own policy.

Goad, 2011

55Slide56

“documentation and training available for flight crews leaves important gaps in the mental model that a crew may build up”vs.“Indisputable”, “should never “, “should have”, “failing to ensure” 56