The safety advancements in industries like aviation, nuclear power and healthcare have been nothing short of extraordinary. In many ways, these industries have become the shining examples of what safety should be. These areas are by no way perfect and have room for advancement but there is a tendency for progressive and innovative thinking to be specific to these industries. However, we have lost our way in thinking that these are the only agencies where innovation can occur. In many ways there has been an asynchronous evolution within safety critical industries and we have created a class system within the realm of safety. High profiting first class industries are where the money lies for consultants and where grants are funneled for safety research. Second class industries like public human service agencies and web ops have sparse funding for safety innovation or little attention to safety improvement and in many cases both.
One only needs to stay shortly in an industry other than aviation, healthcare or nuclear power before you realize the little support you have for safety improvement. For many second class industries, safety and quality improvement departments have not been ran by safety professionals. Instead they are staffed with domain specific professionals who have been promoted into the roles without formal training. In the human services industries, roughly 30% of quality improvement professionals have any formal training. In addition, they are given scarce resources to do the job yet handed all the responsibility of it. And the responsibility is daunting as it relates to the life and death of vulnerable citizens, the health of families and the security of web infrastructures. In spite of this, professionals in these second class industries are leading the charge to improve their respective industries. But for these industries such as human services or web ops, the growing pains have just begun.
In the past few years we have made progress in the area of child protection that currently model the growth of the new view thinking that has proliferated in first class industries. Not surprisingly, initial steps needed to address human error. First, we have implemented a blameless child death review that uses systems thinking. Specifically, we use an analysis model derived from Rasmussen’s AcciMap supported by Kleinian debriefing methods. Second, we passed law in Tennessee to protect the identities of frontline social workers that report into a safety reporting system. Third, we have begun to make movement on supporting the psychological needs of frontline staff involved in traumatic cases where they feel responsibility for the outcome. While making progress in the state of Tennessee, these initial approaches have been brought onto the national agenda, with recommendations that will be presented to US Congress in 2016. Even with initial success, we have only begun this journey into safety science and the realities of this endeavor are becoming increasingly apparent:
We cannot adopt the latest and greatest methods
As the interest increases in second class industries, leaders and advocates want to pick up where the first class industries have left off. We sometimes work under the assumption that we can take the latest safety technological and theoretical advancements and fit them into our systems. However, with this approach we would be imposing new safety features into a workforce that is not ready to adopt them. We can provide safety reporting systems to these industries, but there is little concept about how a blame culture can stifle its effectiveness. Additionally, we may add responsibilities to participate in safety related efforts onto an already burnt out and overworked workforce. Again, the returns may be diminished. From the frontline worker perspective, they have been given another task when they are already struggling to keep their heads above water to deal with the other bureaucratic responsibilities expected from them.
There needs to be a gradual evolution starting with a paradigm shift regarding safety. The organization and its leaders need to be brought into the new view of safety, a view of safety that challenges the design and effectiveness of older safety and risk models. For now we are reengaging the discussion on human error that gained traction in the second half of the 20th century. In essence, the groundwork needs to be laid for needed growth.
We have low funding and high responsibility
The funding for safety and quality improvement is constrained across industry. In second class industries, it is near nonexistent. This results in two sizeable issues. First, the industry becomes less attractive to consultants and safety industries because there is no monetary incentive. Agencies are less likely to pay out large contracts to safety professionals and are not attracting them to work within the industry due to low salaries. Second, there is less money funneled to support research innovation from within agencies or within the fields. I am yet to see a US federal grant that supports research into the decision making quality of social workers or caregiving professionals for older adults and those with disabilities.
There needs to be a renewed focus on improving quality and safety in these second class industries. Greater incentives need to be given to public agencies to place emphasis on safety improvement and high quality safety departments should be expected from oversight agencies. From a national perspective, there needs to be a research agenda that supports safety and quality improvement.
We want change
For the past few years working in public human service agencies I have experienced resistance to new view concepts on human error and systems thinking. But by far, the majority of individuals I encounter across the country are dedicated to change; in fact, they crave it. They intuitively grasp on to new view concepts and advocate for change. This makes progress seem dreadfully slow given all the industry professionals you want to reach out to.
Ultimately, champions for the new view in these industries need to stay motivated to see the change through. Pressure needs to be continuously applied to industry leaders and to political agendas. We need to continue to claw and scratch for every inch of progress against seemingly insurmountable inertia. Second class industries are currently experiencing a safety renaissance and the growing pains are ever-present. The concepts will continue to grow and take hold and will give rise to innovation and improvement.