Culture of Safety Orientation

Charles YoungAric Gregg 1

Sara BeauchêneScott Schifsky

DHS, Disability Services

Welcome!

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Today’s presentation

• Introductions, WebEx logistics, poll questions

• Overview of safety science principles

• Systemic Critical Incident Review (SCIR) process• Use in DHS Disability Services

• How you might be asked to be involved

Person-Centered System – Levels of Change

Level 1: any change that results in a positive difference in lives of people who use services or in your own work life

Level 2: any changes an organization makes to it’s practices, structure or rules that result in positive differences in the lives of people

Level 3: any change in practice, structure and rules made at the system level. These changes have an effect on many organization, and therefore, many peoples’ lives.

Support Development Associates, Becoming a Person Centered System, April 2009

Critical Incidents: External Reports to DHS

Behavior Intervention Report Form

Adult Maltreatment

(MAARC)

Child Maltreatment

Serious InjuryDeath

245D Service Terminations

2960 Critical Incidents

Human Services across the U.S.

Media Portrayal

News article

Human Services across the U.S.

Common cycle

A common cycle

Budget Cuts

High Profile

Incident

Media Scrutiny

Staff is blamed or fired

Increased Funding

Florida

Incidents and System Responses in the Old View

Incident

System Response

Lead on the House Human Services Finance Committee: “…We need real reform and real accountability, not more excuses, slogans, and window dressing. I expect to hear from Commissioner Harpstead what steps specifically have been taken to hold those who failed to follow state law accountable."

Incident

System Response

Judge LeReverend said, “None of the workers addressed their minds to what needed to be done to save Kawliga. His death was a direct result of the fundamental failure of everyone connected with this child to do their jobs. No one followed the rules and procedures that were in place.”

Incident

System Response

Boulay said nursing staff failed to look beyond the room number to identify the patient. "This is nursing 101 — making sure that you actually verify the identity of the person you are giving medication to," Boulaysaid.

In the report, Boulay recommended that CISSSO direct staff to follow best practices on administering medication and develop a complete nursing treatment plan for each patient.

Incident

The 17 employees are charged with first degree falsifying business records, first degree endangering the welfare of an incompetent or physically disabled person and willful violation of public health laws.

System Response

Questions, comments….

Human Error

Old view and New view

Human Error in Old View

1. We believe that people are the cause of failure

2. Our learning ends with human error

3. Our safety interventions target people

4. We assume people should do better with what they have

5. We treat people as a problem to control

Sydney Dekker’s Bad Apple Theory

• Systems are perfect

• “Human errors” cause accidents

• Failures are unexpected

• Systems should identify the ‘bad apples’ and remove them

• Outcome bias: the worse the outcome, the worse the punishment

Time for something new?

To reduce critical incidents, we need to understand how our system influences decisions among those

operating our systems.

To do this, we must create an environment where staff are comfortable sharing how they operate and

make decisions.

Human Error in New View

1. We believe that failure is a consequence of deeper problems

2. Learning starts with human error

3. We understand that better system design promotes better outcomes

4. Our interventions target the environment or systems of which people work

5. We realize that people are why our systems work

Minnesota’s journey

• Minnesota’s high profile child death in 2014

• Governor’s task force (created 93 recommendations after this case)

• Culture of fear, defensive practice

• Need for healing

• Began our work with Collaborative Safety, LLC

Collaborative Safety Model

• Based in Human Factors and Systems Safety (Safety Science)

• Integrates Behavioral Analysis, Forensic Interviewing, and Trauma Informed Science

• Moves away from blame and toward a system of accountability that focuses on identifying underlying systemic issues to improve Human Service Systems

• Used by other Safety Critical Industries such as Aviation, Military, Nuclear Power, and Healthcare

• Systemic Critical Incident Review process is embedded within a larger framework to support and advance a safety culture.

Transitions to a Safety Culture

• Blame → accountabilityo Focus on the system rather than the bad

actors

• Applying quick fixes → understanding underlying features

• First stories → second stories

Blame actually decreases accountability

• Hold ourselves and our system less accountable

• Inverse relationship between blame and accountability

• Shuts down the learning process• Learning stops when the bad actor is found and removed

• Need to hear from those that experience the event

Applying quick fixes to understanding underlying features

• To make meaningful change and address the real problems

• Move away from immediate responses such as:

• More training

• More forms

• More policies

• Recommend that people “try harder”

• Step back and understand that there are features of our system support or do not support our work

First stories to Second stories

Dive beneath surface level descriptions of

events to understand the true

sources of failure and success.

Dive beneath surface level descriptions of

events to understand the true

sources of failure and success.

Incidents and System Responses in the New View

Minnesota – Incident in 2014

Minnesota: Old view response in 2014

Dayton called Pope County’s handling of Eric’s case a “colossal failure,” and said they should have followed through with the requirement to notify law enforcement of maltreatment reports.

“That’s just inexcusably and immorally negligent,” he said.

Minnesota – 2018 Lawsuit

Minnesota: New view response in 2018

"County child welfare workers work hard to protect children every day, and strive to meet the best interests of children and their families. It is frustrating when the public only hears one side of the story." said Minnesota Department of Human Services Commissioner Emily Piper in a statement.

"I can say with confidence that county child welfare workers are doing their best, day in and day out," Piper said in her statement. "It’s a difficult situation to remove children from their parents' custody and such decisions are not made lightly. The preference is to place children with family members when possible."

Arizona – Incident, 2016

Case: Three male children — ages 2 months old and 5 and 8 years old were found in a closet full of miscellaneous items.

• The youngest boy's body was in a suitcase.

• The children appeared to have been stabbed to death and parts of their bodies dismembered.

• DCS agency had multiple contacts with the family of the 3 slain boys

Arizona – Agency Response 1

Director Statement: "It is a sad day as we reflect on the gruesome nature of what occurred. We grieve as a community, trying to understand why three innocent souls have been taken. We grieve as an organization, suffering the loss of children whom we knew. When a child is murdered, it's common to ask if something could have been done to prevent such a tragedy. At DCS, we ask ourselves those questions because we take the responsibility of protecting children very seriously. But our powers are limited; we cannot predict the future; and people, can at times, do awful things. We offer our deepest sympathies to the family and pray for the peace of the departed. I ask all of us to respect, support, and commend the dedicated men and women of DCS and Law Enforcement who do the unimaginable. Who do, when no one else can or will. Who comfort the afflicted, protect the weak, and wipe the tears; who then go find a private place to shed their own.“

The story stopped that day.

Arizona – Agency Response 2

We’ve implemented what we call “a safety culture.” We’re not going to talk about people as failures as much as the systemic and process failures that lead to outcomes that we would like to be different. That’s had a huge impact. Our turnover rates are now in the mid-20s.

10 minute break

Systemic Critical Incident Review

Use of the model in Minnesota

• MN DHS, Disability Services• Eight counties (Blue Earth, Clay, Dakota, Hennepin,

Olmsted, Otter Tail, Polk, St. Louis)

• 245D licensed settings

• Incidents: elopement, medication error, service termination, staff sleeping, wheelchair safety, COVID, prone restraint

Critical Incidents: External Reports to DHS

Behavior Intervention Report Form

Adult Maltreatment

(MAARC)

Child Maltreatment

Serious InjuryDeath

245D Service Terminations

2960 Critical Incidents

Systemic Critical Incident Review Process

Critical incident Data collection

Identify learning points

Invite staff to Human Factors

Debriefing

Conduct the voluntary debriefing

Systemic mappingCreate narrative

Use scoring tool to identify

systemic themes

Review & make recommendations

from aggregate data

Human Factors Debriefing

• Voluntary 1:1 debriefing with staff involved

• Identify a learning point

• Purpose is to learn about local rationality

Local Rationality

• The “why” behind someone’s decision or actions

• Decisions are locally rational

• Highlights supporting features in how decisions become the best option

• Specifically captures:• Attentional dynamics (focus, environmental cues, “red flags”)

• Strategic factors (goal conflicts & competing contingencies)

• Knowledge factors (activation & application of knowledge)

Systems Mapping

• Uses technical case data and human factors data

• Create a clear and relevant picture of the event within context

• Allows for the exploration of any issues from a systems perspective

• Engages representatives from across our service system

DSD Map Example

Debriefing

systemic themes

from aggregate data

Narrative

• Create 1-2 paragraphs of detailed context

• Explains how identified influences played a specific role in the critical incident

• The map is used to create the narrative

• Includes first and second story

DSD Narrative Example

The crowd size, unfamiliarity with the State Fair and the person, impacted staff losing sight of the individual. When the staff lost sight of the person, his attention was divided between his 10-year-old son and the person. Staff brought their son along on the outing because the person offered for him to come along. The person likely offered because if staff was unable to work the person would be unable to go to the fair as the person overheard a conversation the staff had about his son not having childcare on the day of the Fair. The provider was experiencing a staff shortage and would not have been able to find another staff to go to the fair with the person.

DSD Narrative Example

Another contributing factor to losing sight of the person was that staff did not perceive a risk of losing the person because there was no elopement history. Therefore, staff felt comfortable bringing their son. Staff also knew the person’s high level abilities to be independent and capabilities to navigate the scooter, which further supported their decision to have divided attention between the person and their son.

Systems Analysis

• Identifies and captures relevant systemic influences and is designed to explain the complex nature of the work and many factors that influence the trajectory of care

• Aggregated and used to develop recommendations

• Regional Quality Council role

Systems Analysis Tool

Debriefing

systemic themes

from aggregate data

MN DHS, Disability Services Review

Case review by county & incident type

Elope.Med. Error

Serv. Term/Susp Sleep Wheelchair COVID Total

Hennepin 8 5 2 1 1 0 17St. Louis 6 6 5 2 1 1 21

Blue Earth 4 4 1 1 0 0 10Total 18 15 8 4 2 1 48

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