Over my four-decade career in child welfare I witnessed seemingly countless agencies and systems in crisis. These crises were often precipitated by tragic fatalities. But they also came about as a result of poor performance in critical areas of functioning.
Advocates pointed to numerous issues. The agency may have performed poorly on the Federal Child and Family Service Review. Children may be entering foster care at an exorbitant rate, staying too long, being abused at high rates while in care or not being adopted in a timely fashion, as examples.
When these circumstances arise two metaphors appear almost immediately. One is, “the system is broken.” The other is, “There is a need for reform.”
Both of these metaphors mislead well-intended professionals as to what needs to be addressed, and how to achieve sustainable change.
Why is this so? Merriam-Webster defines broken as “damaged or altered as if by breaking.” This suggests that key agency processes were once working well but became damaged or altered. This begs a critical question: Were they really ever working well or simply as good as it gets?
Tolerances are not well established in child welfare. There are three sources of standards for child welfare agencies. Two sources are the standards established by the Child Welfare League of America and the Council on Accreditation.
Neither of these contain output standards like maltreatment recurrence, timely permanency or improved well-being. Rather, they tend to establish standards for inputs, such as staffing, policies and procedures or services to be provided, with no established or known association of these with a level of outcome achievement.
The third source are measures established by the federal government contained within the Child and Family Services Reviews, a periodic assessment of state performance on certain safety and permanency measures. Though many of these standards are framed as outcomes, the actual outcome levels reflect norms based on what agencies are now achieving compared with other agencies.
This does not mean that an agency that meets these outcome standards is performing well, just that it is performing better than a percentage of the other agencies and systems across the country. After three series of these reviews, subsequent Program Improvement Plans and federal monitoring, no agency has of yet met all seven of the federal standards and there remains no evidence of significant improvement on federal outcomes across the totality of systems reviewed.
As mentioned at the beginning, child fatalities often trigger calls for system improvement. However, the low base rate of child abuse and neglect fatalities defies the consistent and precise measurement of any individual agency’s performance. As Daniel Kahneman points out, the problem with low numbers is the spurious nature of performance. A low number may be more an artifact of random timing than purposeful control of essential variables when it comes to human behavior.
The major problem with “broken” as a guiding metaphor for change is that the idea of something being broken ignores what was either never built in the first place, was an ineffective solution from the beginning, or a solution that was poorly implemented. It invites people to focus on a specific technical aspect or the problem and not include the environmental and systemic factors surrounding the problem that may have significantly influenced decisions and actions.
In many cases, poor agency performance reflects missing or inadequate infrastructure. Examples include inadequate staffing, poorly trained staff, data systems that count activities rather than monitor the application of critical agency processes, or shortages or absences of effective community services.
Additionally, poor agency performance frequently reflects ineffective processes. All organizations would prefer to operate with evidence-based practices and technologies, which can be defined as the practical application of knowledge especially in a particular area. When applied correctly, their presence yields a high rate of preferred outcomes. Airlines have achieved a very high rate of safety and reliability due to the existence of highly-refined technologies and safety practices.
Child welfare agencies often lack both. Instead they rely on what Yeheskel Hasenfeld and Richard English called “service ideologies,” or sets of beliefs about input and hoped-for outputs. Virtually every report I’ve ever seen following an assessment of a poor-performing child welfare agency suggests that staff need to be better trained. I have never even once seen a report that suggested that the agency needed more effective casework methodologies.
A potentially effective solution that is poorly implemented may come as close to fitting the “broken” metaphor as anything. Unfortunately, the solutions selected here are often symptom-relieving rather than true solutions. One popular solution: fire and replace the director. But how many times is the new director hired based on her or his vision of and ability to implement truly effective agency processes?
The complexity presented by the preceding factors too often results in a default to the second metaphor, “There is a need for reform.” One of Merriam-Webster’s definitions of reform is, “to amend or improve by removal of faults or abuses.”
Calls for reform often understandably follow the anger felt when the public feels its trust has been betrayed and seeks accountability from those responsible for this betrayal. But anger is rarely the best motivator for broad ranging systemic analyses.
Analyses that proceed from this perspective are often predicated on the concept of human error and are subject to hindsight and a range of other biases. They often result in rather shallow searches for people to blame, are non-systemic in their formulation, and commonly also ignore the environmental factors that influence the actions and decisions of people on the line.
Well-known business management author Peter Block once observed that problems always exist at two levels: the technical and the underlying. The technical problem is usually the symptom that tells us we are in trouble. The underlying problem has to do with how the technical problem is being managed. Solving problems so that they stay solved involves not only addressing the technical problem but the underlying problem as well.
The lessons of safety science, fostered by people like David Woods and Sidney Dekker, have much to offer the child welfare field about achieving lasting improvement and building organizational and system resilience. These approaches view human error as the starting place for analysis, not the end of inquiry.
Symptom-focused problem solving may gain relief for a while. But as we are witnessing in countless jurisdictions across the country, this strategy leads to a seemingly endless cycle: cries of a broken system, calls for reform and an inevitable return to crisis.
Tom Morton is the former president of the Child Welfare Institute, and former director of the Clark County Department of Family Services in Nevada.
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