Why safety science is an essential tool to reducing critical incidents in child welfare

by Jodi Hill-Lilly, Chip Spinning and Michael Cull

March 23, 2023 @ 12:01 am - Ct. Mirror

There is nothing harder in the work life of child welfare professionals than the loss of a child. While much of the work in child welfare is marked by success stories, thanks to the tireless efforts of those in the child welfare field who care deeply about the safety and well-being of children and families they serve, the reality is that no system or combination of systems can prevent all tragedies.

This is true for other systems, such as transportation and health care, but these systems have adapted to address critical incidents utilizing evidence-based, safety disciplines to mitigate future occurrences and create a more trustworthy system of transportation or health care delivery.

Today, the child welfare field is working toward a similar goal to implement safety science by better understanding system risks and how to reduce deaths from abuse or neglect.

How does this work in practice?

The Connecticut Department of Children and Families (DCF) is one of 35 jurisdictions working to answer that question by adapting safety science in child welfare. As part of the National Partnership for Child Safety (NPCS), a quality improvement collaborative formed in 2018 to reduce child maltreatment fatalities through the application of safety science and shared data, Connecticut’s DCF is joining with state, county and tribal child-serving agencies from across the nation to strengthen families, promote innovations, and foster a public health response to reducing and preventing child maltreatment and child fatalities.

As an evidence-based field of discipline, safety science expands the scope of learning beyond an individual case to a systemwide comprehensive analysis. This process reinforces that empowering and supporting families does not rest solely with the child protective services agency – but the entire child welfare system – of which the state agency is a part.

In the context of child welfare, it utilizes a standardized critical incident review process, coupled with data analysis across multiple jurisdictions to identify systemic challenges that serve as barriers to child safety.

In essence, safety science provides a framework and processes for child protection agencies to understand the inherently complex nature of the work and the factors that influence decision-making. Most importantly, it also provides a safe and supportive environment for professionals to process, share and learn from critical incidents to mitigate the potential for future tragedies. That is why, in Connecticut, we have implemented a “Safe and Sound” culture across all levels of the DCF where staff openly express their views in an honest and straightforward manner regarding casework decisions to create an authentic learning environment.

A safety science approach must also be cultivated throughout the agency — from top to bottom — and with external partners, including constituent partners and those with lived expertise, to promote learning. Tools are created to collect data and identify and understand systemic barriers to child safety, and to guide recommendations to effectuate change.

Data sharing across jurisdictions is another important tool in safety science. When each jurisdiction looks at its own data in isolation, the numbers are small and less informative. Having a national collaborative approach to data collection allows for the identification of meaningful trends and patterns, enhancing the visibility of areas for child safety improvements.

In Connecticut, we have already begun the data exchange process with other jurisdictions, both locally and nationally. Our data is collected as part of a Special Qualitative Review (SQR) process that we initiate after a child fatality or near fatality to assess all components of our case practice, adherence to policy and strengths. We then extrapolate major themes across the data to help generate a learning forum to examine outcomes and make recommendations for practice and systematic improvements.

All of these efforts and strategies reflect many of the recommendations of the federal Commission to Eliminate Child Abuse and Neglect Fatalities, established by Congress as part of the Protect Our Kids Act of 2012. In its groundbreaking 2016 report, the commission emphasized that fatalities are preventable and identified three fundamental components to improving our child welfare systems based on a public health approach: 1) leadership and accountability; 2) decisions grounded in better data and research; and 3) multidisciplinary support for families.

This concept integrates a broad spectrum of partners and systems to identify, test, and evaluate strategies to provide upstream, preventative, and earlier intervention supports and services that can strengthen the building blocks of healthy families. It represents a system that is focused less on a child protection response to abuse and neglect and more on building the well-being of all children throughout our communities.

As many child welfare systems are working toward a more preventative, upstream approach, safety science enables child welfare staff and leaders to work within jurisdictions and across the sector to build a learning community around safety science, shared data and the application of a standardized platform for critical incident review.

This work will help to strengthen families, promote innovations in safety culture, and, most importantly, reduce the potential for future tragedies from child maltreatment.

Jodi Hill-Lilly is deputy commissioner for the Connecticut Department of Children and Families and executive committee co-chair of the National Partnership for Child Safety. Chip Spinning is executive director of Franklin County Children Services in Ohio and executive committee co-chair of the National Partnership for Child Safety. Michael Cull, Ph.D., is Associate Director, Center for Innovation in Population Health; Associate Professor, Health Management and Policy, University of Kentucky, College of Public Health, and technical assistance provider to the National Partnership for Child Safety.

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