In an effort to improve child safety and prevent the estimated 1,500 deaths due to child abuse and neglect that occur every year in America, child welfare leaders representing 15 jurisdictions and states have formed The National Partnership for Child Safety (NPCS), a quality improvement collaborative.
The collaborative was formed in partnership with Casey Family Programs, a national operating foundation focused on safely reducing the need for foster care and building Communities of Hope. Casey Family Programs hosted several safety convenings since 2011 aimed at improving safety and preventing child maltreatment fatalities and has supported efforts to implement safety science principles in child welfare in several jurisdictions through peer visits and technical assistance from consultants with expertise in the safety science field. In January 2018, child welfare agencies from 20 jurisdictions participated in the Tennessee Safety Culture Summit in partnership with Casey Family Programs and the Tennessee Department of Children’s Services at Vanderbilt University. The summit was focused on applying safety science in child welfare to improve safety and prevent child maltreatment fatalities and served as a launching point for ongoing collaborative work among interested jurisdictions.
The federal Commission to Eliminate Child Abuse and Neglect Fatalities recommended in its final report that safety science be explored as an approach to better understand and prevent 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. This is certainly not true in the airline industry, where safety is paramount and commercial airline crashes are never seen as inevitable.”1
Other safety critical industries have recognized that a culture of fear and blame does not promote learning from error, and it can result in decreased organizational effectiveness and compromised safety. The approach that systems take to responding to and learning from critical incidents can have a crucial impact on quality improvement and services reliability. Safety cultures strive to balance individual accountability with system accountability and value open communication, feedback, and continuous learning and improvement.2 For example, when the public, the media, policymakers and the child welfare system’s response to a high-profile death results in blame, staff can become more risk averse and fearful, leading to increased removals of children and delayed reunifications. In addition, when policymakers react by passing new laws and the system institutes more procedures in response to critical incidents without fully considering the unintended consequences, they add to the complexity of an already overwhelmed system. The result can be increased workload and high staff turnover. Overall, these reactive responses can make the system less effective in keeping children safe.
Although progress has been made by implementing various strategies in child welfare such as evidence-based interventions, their effectiveness is limited by their application to systems with pervasive workforce instability and the related absence of effective learning systems. In addition, current quality improvement reviews are primarily retrospective after incidents occur. New strategies and tactics informed by safety science, such as prospective instead of retrospective quality improvement processes similar to other safety critical industries, are needed to improve outcomes in the complex, interdependent work of child welfare.3
- Commission to Eliminate Child Abuse and Neglect Fatalities. (2016). Within our reach: A national strategy to eliminate child abuse and neglect fatalities. Washington, DC: Government Printing Office. Accessed at http://www.acf.hhs.gov/programs/cb/resource/cecanf-final-report.
- Chassin, M. R., & Loeb, J. M. (2011). The ongoing quality improvement journey: next stop, high reliability. Health Affairs, 30(4), 559–568.
- For example, New York City is implementing a just-in-time proactive quality review system for CPS.