Monday, 13 July 2009

Learning Lessons

After a child protection tragedy we are frequently told that "lessons will be learned". An obvious source of learning appears to be the Serious Case Review (SCR). But OFSTED and academic researchers have been critical of the quality of some SCRs. There are concerns that they often take too long to prepare, and that they are sometimes formulaic and defensive.

I'm sure that it is possible to improve the quality of SCRs and some useful suggestions have been made, such as placing more emphasis on understandinging systems' weaknesses and less emphasis on identifying individual failures.

More important, however, is to recognise the inherent limitations of SCRs. Any learning process which relies on time consuming investigations and the circulation of written documents will be slow to deliver results. Learning will only be partial because edited summaries of the findings, and not the full reports, are available to most practitioners, so important details will not be apparent. Highly generalised recommendations - such as "better information sharing", "more inter-agency co-operation" - inevitably have a hollow ring.

Another problem with SCRs is that they focus on circumstances in which things have gone very wrong indeed. Disasters usually result from a rare combination of individual and systems failures. Concentrating only on these rare cases can be misleading - they are unrepresentative of everday practice. Improving the quality of child protection work depends on understanding, mitigating and reducing routine, everyday errors and mistakes, which only infrequently combine to cause a tragedy. Thus the most pressing need is for workplace learning in which practitioners engage on a routine, even daily, basis.

If we look at the literature concerning management of quality, we find that some of the most successful quality improvement programmes are based on workplace learning. Back in the 1950s and 1960s Japanese engineering companies, such as Toyota, developed continuous improvement methodologies, often based on employee suggestion systems. These have come to be known as Kaizen (the Japanese word for improvement). Crucial to these systems is the involvement of every employee in addressing quality problems. Workers are encouraged and expected to investigate their working environment to discover the potential sources of failures and defects and to make suggestions about how these can be removed. Managers accept their responsibility to treat employee suggestions with respect and to implement viable improvements quickly. The emphasis here is not on large scale, discontinuous change. Rather it is frequent, small, incremental steps which are important. Cumulatively these have been found to have profound effects on both quality and efficiency (which tends to increase as re-work due to quality problems diminishes).

Can Kaizen be applied in child protection? The answer is that it can, but only if important cultural changes are recognised and embraced. Central to this type of approach is an acceptance by all concerned that the causes of workplace error reside not in the individual failings of particular employees but in the way in which working practices and systems are designed. Accordingly workers who report and reflect on their own errors are to be congratulated rather than blamed. They have uncovered an "error trap" which can now be the subject of further investigation and re-design.

Continuous improvement methodologies, such as Kaizen, require management to resist the temptation to impose improvements top-down, but rather to develop systems which promote and encourage bottom-up communications and ideas. The prevailing performance management culture of many public sector organisations - with externally imposed targets and PIs - may not be the most promising starting point, but without this sort of cultural change high relaibility systems in child protection are unlikely to develop.