Placing People at the Center of Quality Reviews in Child Welfare Work: A Person-Centered and Psychologically Safe Systems Approach to Improvement

by: Dr. Tiffany Lindsey, LPC-MHSP (she/her)

Assistant professor at the Center for Innovation in Population Health at the University of Kentucky

Think back to a challenging time in your life – a time when you felt vulnerable and needed help, maybe even professional help. What was most memorable to you – the procedural actions of the helpers themselves, or that your circumstances actually got better (or didn’t) and your needs were met (or weren’t)?

It’s the latter, right? It likely is for all of us. Accessing professional help is especially hard, even under the best of circumstances, and we remember its worth as directly related to how much a program or support helped or didn’t help us. This is even more true for families served by public and private child welfare agencies, as families can be in crisis and connected to us in ways that are – and at minimum feel — involuntary, inequitable, intimidating and punitive.

Traditional quality reviews are an important component to creating and sustaining consistent work products, but how often do our reviews assess whether or not our efforts had person-centered value? A review less focused on whether we checked all the boxes and instead asking if families’ needs were really met. Traditional quality reviews tend to guide toward increasing our level of action and documentation. Things like taking diligent and reasonable efforts and adhering to our institution’s procedures. The type of review I’m suggesting focuses less on effort and adherence and more on value and outcome.

Traditional quality reviews have their place. Audits help us share accountability across agencies for doing the things we say we’ll do e.g., timely home visits, checking well-care appointments, engaging all household members, and making collaterals all part of family assessment practice. Those tasks are required and funded because they are important, and our systems need to be accountable for completing them. But when quality reviews start (or worse, end) by simply considering compliance and departures from policy or expected practice, the learnings are limited at best and dangerous at worst. Why is that?

Because we can’t assume our agencies, systems, institutions, laws, etc. — broadly referred to as the “system-at-large” — are designed to best meet youth and family’s needs. In other words, we can’t assume doing work-as-prescribed actually leads to meaningful help being given. It’s possible, even likely, professionals depart from policy in the hopes of better meeting people’s needs. From caseworkers to senior directors, we all want to have a positive and meaningful impact on the lives of those we serve. We can’t assume anchoring quality reviews to departures from policy will get us to the systems-level transformational work that truly helps families be safe, connected and thriving. In fact, doing so may mean we unintentionally reinforce or double-down on practices that hurt the families.

Picture of a happy Family at a Picnic
Picture of a Happy Family - Photo by Migs Reyes

Think about your experiences serving children and families. Have there been times when you worried “doing it right” by policy actually meant “getting it wrong” for the people you were trying to help?

For those of us in public child welfare, consider times when we completed investigative or assessment tasks and – by policy – substantiated or otherwise classified maltreatment. In each of these circumstances, were children and families likely better off for having known us? Did we help?

If not, it may be that professionals did the job the way the system was designed to work – even if the result was more hurt than help. And there are lots of systemic barriers to how these challenges exist. Repairing these problems will take work, yet often we do not have the data to drive the conversation.

No stories without data and no data without stories

This is the reason we need a person-centered approach to quality reviews and – broadly – systems improvement work. In TCOM, we use the Safe Systems Improvement Tool (SSIT) to provide a supportive systems framework to understand how families’ needs can go unmet through the course of agency involvement, particularly as it relates to a critical incident.

Centered in the SSIT, the inquiry of a review begins by assessing what is known about the youth and family’s needs. With all available knowledge at hand, how do we understand the family?

After assessing what is known of the families’ needs, two follow-up questions emerge:

1) were any needs unassessed; and/or

2) were any needs unmet?

To both questions, engagement with those who provided care is the necessary next step. Helpers can give us a systemic lens on what professionals most need to do the family-centered work they intend. Akin to a root cause analysis or other systems-focused review, the SSIT’s collection of items serves as a framework for assessing and recording all the systemic themes (e.g., cognitive biases, resource mismatch, community support gaps, rigid statutes) which contribute to a work-as-prescribed that’s not help-as-intended.

Placing Families’ Needs at the Center of Quality Reviews

A Safety Culture is a workplace culture where values, attitudes, and behaviors are consistently oriented toward safe, effective, reliable care. More than free from harm, it’s about the presence of belonging and connection. It’s not only about keeping children safe from historical or potential maltreaters. It’s about families experiencing safety with us. To draw from the wisdom of Katherine Stoehr, First Deputy Commissioner in the New Jersey Department of Children and Families, it is that fundamentally we – our system – are safe and coordinated to help.

Safety Cultures value open communication, balance individual and systems accountability, and commit to learning and improvement. Psychological safety is core to a Safety Culture, where professionals have permission and even the expectation to be candid – able to disclose mistakes, problems, and divergent points of view. It’s perhaps a vulnerable and brave mission for public child welfare agencies to embrace a Safety Culture during a time in history when our public institutions have been so pervasively scrutinized and shamed. In spite of the many challenges, public child welfare still exists and has so much potential and good intent to draw upon, so we must do all we can to continue to transform.

Picture of Dr. Tiffany Lindsey, LPC-MHSP (she/her)
Dr. Tiffany Lindsey, LPC-MHSP (she/her)

Dr. Tiffany Lindsey, LPC-MHSP (she/her) is an assistant professor at the Center for Innovation in Population Health at the University of Kentucky. Her work focuses on quality improvement and system reform efforts in child welfare jurisdictions. Lindsey has specific expertise in applying safety science to improve the safety, reliability, and effectiveness of organizations. Lindsey is co-author of two tools within the Transformational Collaborative Outcomes Management (TCOM) framework — the Safe Systems Improvement Tool (SSIT) and TeamFirst: A Field Guide for Safe, Reliable, and Effective Child Welfare Teams. With the support of Casey Family Programs, Lindsey supports the National Partnership for Child Safety — a member-led, member-owned quality improvement collaborative of 33 public child welfare agencies. Lindsey also has a strong clinical background working with vulnerable populations.

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