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Culture of Safety Orientation
Charles YoungAric Gregg 1
Sara BeauchêneScott Schifsky
DHS, Disability Services
Welcome!
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As you join, please complete three poll questions. After answering the questions, click submit.
For the location question, use the map to the right to select a region.
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
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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
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Critical Incidents: External Reports to DHS
Behavior Intervention Report Form
Adult Maltreatment
(MAARC)
Child Maltreatment
Serious InjuryDeath
245D Service Terminations
2960 Critical Incidents
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Human Services across the U.S.
Media Portrayal
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News article
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News article
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News article
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Human Services across the U.S.
Common cycle
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A common cycle
Budget Cuts
High Profile
Incident
Media Scrutiny
Staff is blamed or fired
Increased Funding
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Florida
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Florida
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Florida
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Florida
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Florida
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Incidents and System Responses in the Old View
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Incident
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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."
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Incident
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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.”
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Incident
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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.
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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.
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System Response
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Questions, comments….
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Human Error
Old view and New view
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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
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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
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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.
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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
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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
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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.
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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
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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
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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
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First stories to Second stories
Dive beneath surface level descriptions of
events to understand the true
sources of failure and success.
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Dive beneath surface level descriptions of
events to understand the true
sources of failure and success.
Incidents and System Responses in the New View
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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.
Questions, comments….
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10 minute break
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Systemic Critical Incident Review
Model
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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
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Critical Incidents: External Reports to DHS
Behavior Intervention Report Form
Adult Maltreatment
(MAARC)
Child Maltreatment
Serious InjuryDeath
245D Service Terminations
2960 Critical Incidents
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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
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Human Factors Debriefing
• Voluntary 1:1 debriefing with staff involved
• Identify a learning point
• Purpose is to learn about local rationality
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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)
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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
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DSD Map Example
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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
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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
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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.
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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.
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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
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Systems Analysis Tool
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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
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Questions, comments….
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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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Category
MN DHS, Disability Services Outcomes (48 cases)
Prescribed PracticeCognition
Procedural DriftDemand-Resource Mismatch
Teamwork/CoordinationService Availability
Production/Efficiency Press.Knowledge Gap
Fatigue
MedicalDocumentation
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Supervisory SupportEquipment / Tools / Tech.
Systemic Theme Definition Examples
• Prescribed Practice: when policy or work expectations are absent, conflicting, not clear or does not support the work
• Cognition: not understanding a situation due to focusing on beliefs and past experiences or focusing on way one to do things when there are other options
• Demand-Resource Mismatch: the agency does not have resources available to help staff do their work or the resources available is not enough or does not support their work
• Procedural drift: staff change how they do work (make shortcuts or workarounds) because of challenges (staff shortages, what worked before doesn’t now), co-workers suggestions, or because the new way worked or was successful 68
MN DSD - Reoccurring systemic influences
• Conflict between health, safety and welfare requirements and promoting self determination
• 245D & Positive Support Rule
• DWRS > RMS > DHS 6790
• MnCHOICES
• Guardians – especially when a person is their own guardian
• ‘Gray areas’ in the decisions and documentation of supervision
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Competing contingencies
Health, Safety & Wellbeing
Person-centered/Dignity
of risk
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Safety vs. Autonomy
Provider/Staff penalized for
restricting autonomy
People are given more autonomy
Injury/Incident happens
Provider/Staff investigated/
penalized
Safety weighed over
autonomy/rights restricted
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Competing contingencies II
Promotion of Informed Choice
Reducing options available to a
person
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Competing contingencies III
Serve people with challenging
behavior/high medical needs
Emphasis on a critical incident-
free system
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When exploring systemic influences, consider using the 5 A’s…
All perspectives are valid
Avoid counterfactuals > Focus on what did happen and not about what should have happened
Avoid blame > Assume good intentions
Analyze the system > Don’t try to fix the incident
Allow yourself and others time to listen and reflect
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Integrating safety science into everyday work
Remove “error/mistake”
• Attributed “after the fact”
• Retrospective attribution
• Focus on negatives
Instead:
• Explain decision making
• Provide explanation and context
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Importance of language II
Remove “cause”
• Simplistic
• Incompatible with complexity
Instead use:
• Influences
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Importance of language III
Remove “failure”
• Retrospective attribution
• Focus on negative
Instead:
• Provide explanation and context
• Use ‘adverse event’
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Importance of language IV
Remove “should have/could have/would have”
• Counterfactuals - don’t actually know if they would have, etc.
• Inhibits learning
Instead:
• Provide explanation and context
• Look for what happened and why
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Awareness of bias
• Hindsight bias: outcome knowledge, not in real time
• 3 reasons why the decision may have made sense
• Severity bias: same decisions different outcome
• Proximity bias: close to the outcome
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Discussion & reflection
• Thoughts and reactions about safety science (old view & new view)?
• Old view (human focus – incident, fixes)
• New view (system focus – deeper trouble, fixes, learning)
• Questions, feedback?
• Collaborative Safety videos and resources: https://www.collaborative-safety.com/videos
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Closing
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