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
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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)
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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%
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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
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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)
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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)
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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)
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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.
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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
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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 Welfare48Slide49Slide50
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.
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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.
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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
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“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