Safe Systems Improvement Tool

Tennessee’s Communimetric Assessment for Understanding Critical Incidents

The 1st annual Safety Culture Summit gave attendees and their larger audience a glimpse of the work being done around safety culture. Along with the tools shared during the poster session at the summit, Michael Cull, Policy Fellow at Chapin Hall at the University of Chicago, and Tiffany Goodpasture, Director of Organizational Culture and Workforce Safety at TN Department of Children’s Services, had the opportunity to locally share the Safe Systems Improvement Tool (SSIT). 

What is the SSIT?

The SSIT is a multi-purpose information integration tool designed to be the output of an analysis process. The purpose of this tool is to support a culture of safety, improvement, and resilience. Much like other Transformation Collaborative Outcomes Management (TCOM) tools, completion of this instrument supports effective communication at all levels of the system. The SSIT contains twenty-one items and four domains. It is designed to support efficient and reliable event analysis and to foster data-driven recommendations.

Why was it developed?

Although child deaths are fortunately rare events in any system, the approach systems take to reviewing and learning from them can have an outsized impact on improvement and reliability.  For example, when a child welfare system’s response to a high-profile death results in blame, as is commonly seen, professionals in that system can become more conservative and less likely to trust reunification and preservation attempts. This can result in an increased number of kids in care as rates of removal and length of stay increase. By contrast, a child death review process that focuses on building up teams, identifying systems concerns, and promoting continuous learning can be an organization’s most effective improvement tool. To address these concerns, many have called for child death review innovations that apply safety science and support a safety culture.

How does it work?

Similar to how a barometer measures pressures in the atmosphere, the SSIT measures pressure existing within organizations and provides a frame for targeted quality improvement work. Each SSIT rating suggests a different systems influence on casework. There are four levels of rating for each item with specific anchored definitions and assessment prompts. These item level definitions are designed to translate into the following action levels:

“0” = no evidence, no need for action

“1” = latent factor

“2” = action needed to mitigate risk and avoid recurrence of non-proximal actions/decisions

“3” = immediate or intensive action required to prevent recurrence of proximal              actions/decisions.

How is it being applied?

The SSIT is an innovative tool that supports organizational learning and an improvement approach focused on human interaction in complex systems. The SSIT helps an organization identify and prioritize systems improvement opportunities.  The structure of the SSIT allows a system to uncover those threats/opportunities most proximal and likely to recur.  SSIT data contributes to professional learning at the individual case level and can be aggregated at any level of the system to support improvement and evaluate change over time. Classifying complex systems findings into a common language supports improvement discussions at all levels of the organization. Use of the SSIT in critical incident reviews reinforces important organizational values and shifts focus away from discussions of blame-worthy acts and simple cause and effect relationships. It supports efforts to create a culture of safety by increasing understanding of complex interactions in tightly-coupled systems.

For more information on the SSIT and how it is being used and implemented, comment below or contact Michael Cull (

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One Response

  1. This is a really exciting development. It’s great to see communimetric science being used in new and innovative ways. I particularly like how the action levels are being expanded upon for this unique question. I look forward to seeing the data on the impact of the use of this tool.

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