Tuesday, 24 September 2013

Sixteen principles for better and safer practice [1]

Sometimes it seems that there is something about child protection that defies all attempts at improvement. The case of Daniel Pelka, and the uninspiring report into his tragic death, only serves to deepen frustrations. In the wake of the tragedy it is not surprising if people are asking yet again: what do we need to do to improve the child protection system?

The short answer is that I don’t know and neither does anyone else. There are lots of suggestions: mandatory reporting, more information sharing, computer systems, surveillance of children and their families, early intervention, named-persons, lead professionals, more training, different recruitment initiatives, assessment frameworks, harsher punishments for perpetrators, public education…. The list just goes on and on.

And it is so easy to lapse into an argument for or against making this particular change or that. I do it myself….

But the bottom line is that in September 2013 we really do not have the information that would allow us, with any degree of confidence, to make the improvements necessary to reduce the probability of another child dying like Daniela Pelka did. In many ways we are just as ignorant now as we were when we all agonised about Maria Colwell’s death in the 1970s.

History is littered with examples of how people in England have tried to improve the system only to be faced with yet another tragedy a few years later. Child protection procedures were introduced in the 1970s and 1980s, to be followed by assessment frameworks in the 1990s and 2000s. In the 1990s attempts were made to re-focus practice on need rather than simply looking at the question of whether or not abuse had occurred. The benefits of information sharing and the contribution of IT were endlessly and uncritically touted in the early 2000s. The Common Assessment Framework (http://www.education.gov.uk/childrenandyoungpeople/strategy/integratedworking/caf) was also introduced, amid unrealistic claims about what it could achieve.

And, of course there were still unacceptable failures. Some children who should have been protected died and many more have suffered re-abuse. 

I believe that we need to approach this problem in a different way. Rather than concentrating on specific suggestions for change we should instead focus on helping people who are responsible for safeguarding and protecting children to learn more in general about how to improve their practice and how to improve the organisations in which they work. 

That would not result in any quick fixes but, if we were able to make the organisations that safeguard and protect children better at learning and improving, then in the long run the quality and safety of services would get better and progressively fewer children would die or suffer continued abuse and neglect.

Below I sketch out some of the principles [2] that I believe should be applied by organisations that protect and safeguard children and that want to improve. The list in not exhaustive, but it is a start.

The first principle is proceed with caution. Primum non nocere – ‘the first thing is to do no harm’ - is a principle of medical ethics. It states that before doing anything we need to be sure that we are not risking causing more harm by acting, than we would be by doing nothing.

In the world of developing services it may not always be possible to apply such a principle rigorously – because the effect of changes may be unpredictable – but we can minimise the possibility of harm flowing from change by trying to ensure that change is modest and reversible. We should be most sceptical about grand scale changes which are irreversible or difficult to reverse.

 Application of this precautionary principle suggests that many improvements will have to be small scale; they will be cautious. This does not mean that their cumulative impact will be small. That is a point to which I will return below.

The second principle flows from the first. There must be no more grand-scale top-down quick fixes. Politicians, civil servants, ‘experts’, policy wonks, management consultants, newspaper editors and interest groups must not be allowed to railroad change top-down. Politicians and civil servants in particular need to understand that their primary responsibility is to ensure that organisations are focused on broad goals and are learning how to achieve them. They should not tell them in detail what to do or what they should learn. Organisations and professional groups should be held accountable for achieving the broad goals and for creating and sustaining learning and improvement in their organisations and in their practice.

More of the impetus for change needs to come from those who deliver the services and from those who receive them and from objective evidence about what changes will be most effective. We must never again experience the irrational dash for change driven from ‘the top’ that was so evident in the Every Child Matters agenda [3].

The third principle of improvement is to create a learning culture. No sensible change can occur unless we make learning and improvement the priority - not rule-following or slavish adherence to ‘big’ policies and shiny initiatives or to mundane procedures and regulations.

Associated with that is the fourth principle which is about removing barriers to learning. We need to drive out fear and develop a just culture [4], in which people are empowered to learn from their errors instead of being forced by fear of disapproval, discipline or other sanction to conceal them.

That leads on to my fifth principle; that is to have the correct attitude to human error. We need to accept that errors are inevitable and to be expected. Error is an opportunity for learning if we deal with it correctly. Discipline, rather than retraining, is only required where established safety rules and procedures have been deliberately flouted for the wrong reasons, such as personal gain.

We need to have an appropriate model of how organisational accidents occur. The best available model is Reason’s Swiss Cheese model [5] and Reason’s BMJ article [6] provides an excellent summary of this approach.

The sixth principle is to give people space to learn and to reward them for doing so. There is no point exhorting people to understand the consequences of their actions and then give them no time in which to reflect. Surprisingly the amount of time required is not great. A few minutes everyday, in which people reflect on what has gone well and what has gone wrong; and why. A short formal de-briefing, at the end of a significant piece of work, is often sufficient to produce useful information that can be taken forward to make practice safer.

It is vitally important to realise that people who are overworked find it difficult to be reflective learners. The idea that people are only working properly if they are staggering under the weight of unmanageable caseloads is part of the fallacy of work-hard-not-smart. Overburdened employees seldom produce work of high quality and often do not work safely. Interestingly they are not more productive, because frequently re-work is necessary to correct mistakes and quality shortfalls. A vicious spiral can occur in which overwork results in poor quality which results in rework which results in more overwork which results in poor quality etc etc. When such spirals occur they have to be disrupted by management action.

When I say to we should reward people for learning, I do not mean ‘financial reward’. Rather I am thinking of recognising and congratulating people who think constructively about error and improvement and valuing and using their contributions.

The seventh principle is to give people the tools with which they can learn and improve. They need to understand the business and professional processes that deliver the service and their effects. An analytical approach is required. We need to ask why we are doing things in a particular way and whether we could do them better. Management needs to carry out research to understand the resource requirements of business and professional processes and their effects. Could we be doing this at lower cost or at higher quality or both?

People need to understand how they do things well and how they screw-up. A Human Factors approach [7] gives practitioners and managers an intelligent perspective on human error in the workplace and how it can be avoided, reduced or mitigated. Learning how to de-brief following a significant piece of work can be a very effective way of capturing what went right and what went wrong.

Once members of a team understand Human Factors they can be ‘consciously competent. In other words they will be right by design not by luck. They can self-debrief and move towards error-proofing from within the team. 

Confidential Critical Incident (or Near Miss) Reporting [8] helps everyone in the organisation understand more about what happens when things go wrong, but not disastrously so. It is a way of gaining ‘free-lessons’ about how to practice more safely. 

Continuous Improvement Systems (Kaizen) [9] are ways in which the suggestions for improvement made by front-line practitioners can be turned into practical developments. They are a way of capturing the experience and expertise of those who actually deliver the service.

The eighth principle is to listen to and learn from children and young people, especially those who have suffered abuse and neglect and who have received safeguarding/protection services.  Conducting panels, surveys and focus groups requires special skills and can be expensive, so perhaps it needs to be done centrally at national level. It needs to be done by people who know how to engage with and listen to children.

Children and young people should be asked about their experience of services and they should be asked for their suggestions about how the quality and safety of services can be improved.

The ninth principle is to communicate learning. Textbooks and academic articles and research reports are often a slow and cumbersome way to spread knowledge. Brief simple electronic reports can be made available more frequently and cheaply with much wider circulation.

The tenth principle is to stop pretending that inspectors know best – they don’t. We need gradually to reduce reliance on inspection. We need to design quality and safety in, through progressive improvement in the design of services, rather than hoping to inspect it in. A positive learning culture works best when nobody is looking, or indeed needs to look.

The eleventh principle is to get rid of targets and target driven management. We need to measure the right things, not just those that are easy, convenient or politically expedient to measure. For example re-abuse following intervention is an absolutely vital measure which is not routinely collected, while at the same time fat statistical reports detail a great deal of data of questionable relevance. We need to use realistic outcome measures to understand the impact of professional and business processes – not proxy measures. Data needs to be used to understand and improve services, not to drive them.

The twelfth principle is to help managers to become supportive rather than directive. The focus of management should be on promoting learning not on telling people how to do the job. A complex professional service cannot be managed like a fast food restaurant. Managers have to listen to and support those people who actually do the work.

The thirteenth principle is to learn from elsewhere – indeed anywhere and everywhere - especially from other safety critical industries. Child protection professionals need to think laterally about how to improve the services they deliver. The defensive this-is-the-way-we-do-it-here stance is the kiss of death. We should be able to learn from pilots and surgeons and nuclear power station technicians and from bomb-disposal experts. There should be no horizons or limits. Protecting children successfully is too important for professional or occupational boundaries and rivalries.

The fourteenth principle is that of incremental and cumulative learning. When I outlined Principle 1 I said that improvements need to be cautious, but this does not mean that their cumulative impact will be small. Making lots of small improvements all the time can have huge cumulative impact. One improvement every working day amounts to more than 200 a year or 2,000 in ten years. And that may be what we could expect from a single team! Where continuous improvement has been introduced into manufacturing businesses it has made a huge cumulative impact.

The fifteenth principle is to recruit and RETAIN people who can and will learn. The ability to learn and receptiveness to new ideas should be necessary requirements of everybody who wants to work in a role in which they will have responsibilities for safeguarding and protecting children.

The sixteenth, and last, principle is to minimise distractions, especially unnecessary bureaucracy and administration. We must try to ensure that most of the scarce resources go to the most essential parts of the process – protecting children from abuse and neglect and learning how to do it more effectively. 


[1] I am grateful to Trevor Dale for his helpful comments on an earlier version of this article. The remaining mistakes are all mine!

[2] These principles are by no means original and have been distilled from a variety of sources. In particular I have always been greatly impressed by the fourteen principles for quality improvement that were outlined by the American engineer and statistician, Dr. W. Edwards Deming, in his 1950 lectures at the Mount Hakone Conference Centre in Japan.

The lectures were attended by some of Japan’s leading industrialists at the time and are often credited with kick-starting the Japanese industrial revolution. Obviously the sixteen principles outlined in this paper lack the originality of Deming’s principles! Indeed, some of mine are directly inspired by his, for example my fourth (which resembles Deming’s eighth) and my tenth (which resembles Deming’s third).

[3] https://www.education.gov.uk/consultations/downloadableDocs/EveryChildMatters.pdf 

[4] See Dekker, S.  Just Culture: Balancing Safety and Accountability, Farnham: Ashgate 2007.

[5] http://patientsafetyed.duhs.duke.edu/module_e/swiss_cheese.html 

[6] Reason, J. “Human error: models and management” British Medical Journal 2000; 320:768 http://www.bmj.com/content/320/7237/768 

[7] See Flin, R et al Safety at the Sharp End: a guide to non-technical skills Farnham: Ashgate 2008

[8] See Mills, C. and Vine, P. “Critical Incident Reporting - an Approach to Reviewing the Investigation and Management of Child Abuse”