By Dr. Michael Cull, associate professor in the Department of Health Management and Policy at the University of Kentucky and associate director for workplace health and safety in the Center for Innovation in Population Health

COVID-19 has changed the way we do work but it hasn’t changed the nature of the work. Our goals are the same. We want to get up everyday and do our best to help children and families. But “everyday” doesn’t look the same as it did before February. And we may need a new set of habits to ensure safety, reliability, and effectiveness.

Child welfare is not unlike the work done by professionals in a variety of high-risk, high-hazard, settings. In fact, like surgeons and pilots, child welfare professionals make complex and  high-consequence, decisions all day long. And like flying a plane or operating on a heart, we can’t learn by failing. For these reasons, it  makes sense to learn from other industries oriented around safety culture. It is likely that some of the same strategies that keep other professionals and those they serve safe might be effective for child welfare. But, strategies alone only get us part of the way there. We also need an organizational culture that supports our best laid plans.  

Other safety critical settings seek to develop a very specific kind of organizational culture focused on safety. According to the Agency for Healthcare Research and Quality, organizations with a safety culture:

  1. acknowledge the high-risk nature of an organization's activities and the determination to achieve consistently safe operations;
  2. create a blame-free environment where individuals are able to report errors or near misses without fear of reprimand or punishment;
  3. encourage collaboration across ranks and disciplines to seek solutions to patient safety problems; and
  4. commit resources to address safety concerns.

In a safety culture, professionals must also feel psychologically safe. That is, they need to feel accepted, respected and a part of a team that speaks up, avoids blame, and uses errors as opportunities to learn. Psychological safety is the cornerstone of a safety culture. It allows for continuous learning in a setting where professionals are comfortable pointing out concerns. 

An organization’s culture is formed by its habits and how it approaches problems. And culture defines the space we call work. Habits that promote safety are the building blocks of a safety culture. But developing new habits can be hard. 

In 2012, Vanderbilt University Medical Center took an interesting approach to developing habits that addressed two important patient safety concerns; 1) handwashing and 2) staff psychological safety. It is the case that washing hands reduces infection rates in hospitals. It is also the case – big surprise – not all doctors and nurses always wash their hands. Vanderbilt’s approach to this problem was to train all of its staff to feel empowered to challenge another professional (even the most senior surgeon) who did not wash their hands. They also trained staff to know that the only appropriate response to a challenge was to say “thank you.” 

Vanderbilt’s approach promoted hand washing while also promoting psychological safety – a broader organizational goal. Professionals need to be able to candidly speak up and give feedback independent of rank or status. And, importantly, the organization has to be able to support that behavior. If, for example, a nurse gives feedback to a physician and then the leadership fails to respond in support if/when that physician responds unprofessionally to the suggestion (yes this happens) psychological safety can be negatively impacted - making the system less safe. In Vanderbilt’s case, both handwashing and the organization’s culture change goals were improved by a new set of habits. 

Vanderbilt’s story makes for an interesting and timely example. Handwashing as a habit has taken on new importance both in our personal and professional lives. And the need for it to become habitual may be fundamental to our ability as a culture to get control of the virus and thrive again. But we also have opportunities to improve child safety and well-being through strategies that help us develop habits to directly improve our culture. 

A positive safety culture, whether in response to the pandemic or to preventing child abuse and maltreatment is a proven way to improve health, safety and to positively impact organizational goals. Fundamental to this approach are psychologically safe teams who challenge each other, feel confident raising concerns and promoting new ideas, and treat failures as opportunities to learn and grow. And just as it was not always comfortable for the nurse to take an interpersonal risk and challenge a physician’s decision, you can anticipate discomfort developing this new habit. 

Psychological safety is not about comfort. In fact, it is often very uncomfortable to have the brave conversations that are needed. And we know people avoid these conversations for all kinds of understandable reasons. We generally want to be liked and want to get along in the workplace. We may be concerned that there could be retribution with a challenge to a colleague or supervisor. And we also just don’t want to be wrong. But to achieve the kind of safe, reliable, and effective practice we all hope for we need to learn from places that do it well. A safe cockpit is one where a co-pilot is confident taking risks and sharing concerns with the pilot. We have an obligation in child welfare to support this approach to move away from punitive approaches to managing professional behavior and toward approaches that support learning and improvement.  

Dr. Michael Cull is an Associate Professor in the Department of Health Management and Policy at the University of Kentucky and Associate Director for Workplace Health and Safety in the Center for Innovation in Population Health. Mike has specific expertise in applying safety science to improve safety, reliability, and effectiveness in organizations. For more information, go to www.leadteamfirst.org.

This product was supported by cooperative agreement number 2019-V3-GX-K005, The OVC FY 2019 Reducing Child Fatalities and Recurring Child Injuries Caused by Crime Victimization demonstration initiative.