lipp scr masterclasses · dr. sheila fish, senior research analyst, scie sheila is a senior...

LiPP SCR Masterclasses

Masterclass 2:

The application of systems thinking to Serious Case Reviews and other reviews

Learning into practice: improving the quality and use of Serious Case Reviews

of 32

Learning into Practice: improving the quality and use of serious

case reviews.

LiPP SCR Masterclasses

SCR lead reviewers have a key role in producing high quality SCRs, which provide a good understanding of practice problems. There are currently limited opportunities for continuing professional development for reviewers. As part of the LiP Project, we are proposing that the activity of reviewing needs further professionalisation. To begin to test this concept, we have developed a set of “masterclasses” that bring knowledge from other domains in, to support reviewers to tackle various aspects of the role that are challenging. A number of bodies of knowledge and expertise exist that are potentially applicable to serious case reviews. These include

approaches to analysing data developed in the field of qualitative research

understandings of error and its causation developed in industry and engineering

ways of thinking about groups and their dynamics developed in social work and therapeutic methods

requirements from legal, coronial and criminal justice perspectives as well as other reviews All have potential for supporting the quality of SCRs but have not yet been applied systematically to SCR practice. The four LiPP masterclasses aim to introduce key ideas from these different fields and give SCR reviewers to consider their relevance. The material from these masterclasses is being published to assist SCR lead reviewers with their SCR practice. It should not be used to deliver training without seeking permission from Social Care Institute for Excellence.

of 32

Masterclass 2:

The application of systems thinking to Serious Case Reviews (SCRs) and other reviews

Date: Thursday 11th February 2016 Time: 10.00-16.00 Venue: Hilton London Euston, 17-18 Upper Woburn Pl, London WC1H 0HT

Introduction

The 2013 version of the statutory guidance Working Together to Safeguard Children contains two sets of principles that LSCBs are required to follow when undertaking reviews. This remains unaltered in the revised (2015) guidance. The first principles (paragraph 4.10) confirm that SCRs should take place as part of a continuous culture of learning and improvement and confirm the need for independence, the need to engage family and staff members and the requirement to publish reports. The second set of principles (paragraph 4.11) set out how SCRs and other reviews should be conducted, stating that they should:

• recognise the complex circumstances in which professionals work together to safeguard children;

• seek to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did;

• seek to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight;

• be transparent about the way data is collected and analysed; and

make use of relevant research and case evidence to inform the findings. This set of principles was drawn from an unpublished paper written by Professor Eileen Munro to assist the Department for Education. They embody, in a simple form that could be translated into brief guidance, her description of the minimum requirements of a systems approach to reviews.

The introductory sections of SCR reports prepared and published under this guidance (i.e. largely those published during 2014-15) invariably make reference to these principles in describing their methodology, though it is often less clear how they have been implemented during the course of the review. Many reviews now state that they have adopted a ‘systems approach’ or ‘aspects of’ this approach, though again it is not always clear what that means in practice. Often reports suggest a largely practical take on systems thinking, indicating that they have involved professionals and the family and not relied on ‘hindsight’.

Though a basic premise of systems thinking is that errors can only be understood by evaluation of the circumstances in which professionals work, summaries of SCR findings on the national repository rarely indicate that the focus of reviews has been on organisational influences on work. At first glance, recommendations of reviews remain largely focused on front-line professional practice.

This suggests that on its own the statutory guidance offers a limited starting point for the application of systems thinking to SCRs and that in order to improve reviews we need to engage in a more intellectual way with the development of systems thinking and develop a systemic model of ‘what causes errors’ which is relevant to multi-agency safeguarding activity.

of 32

If we can do this we will be able to access a range of models and tools which will improve reviews.

The workshop will combine presentations with opportunities for participants to consider if / how they find the content relevant to their practice. By its nature it will require the discussion of some complex ideas which will be assisted by some advanced background reading.

of 32

Learning Objectives

The aims of this class are:

1. To introduce participants to the basic theoretical approaches to understanding the causes of error in high risk fields such as aviation, engineering and health.

2. To give participants an awareness of some key concepts from these approaches 3. To encourage participants to make connections between some key concepts from systems

thinking and their own practice as SCR lead reviewers 4. To give participants the opportunity to consider what further support participants would

need in order to be able to apply systemic thinking in their reviews

Learning Outcomes

Participants who perform well in this module will be able to: a) Demonstrate knowledge of:

The basic theoretical approaches to accident causation,

Some key ideas from the systems literature and their implications for their own practice. b) Have developed the following skills:

The ability to make an informed choice about different accident causation models

The ability to understand the theoretical and methodological issues involved in providing explanations and findings/recommendations in SCRs

The capacity to critically reflect on the social and organisational factors involved in explaining why things go wrong

The ability to reflect on the enduring challenges to organisational learning.

Participant preparation for the Masterclass

Participants are asked to read the following article: Woods, D. D. and Cook, R.I. Nine Steps to Move Forward from Error. Journal of Cognition, Technology & Work (2002) 4:137–144

of 32

Programme outline

10.00 - 10.10 Welcome. Overview of the day, the premise of the day and timetable

10.10 - 10.45 Introductions from the group – brief biographies

10.45 -10.50 Input. Thinking about why things go wrong.

10.50-11.15 Small group exercise. Models of why organisational accidents happen. What are the explanations for why things go wrong, offered by these different models? How are these models similar and/or different?

11.15- 11.45 Feedback, discussion & clarifications from trainers

11.45 - 12.00 Coffee

12.00-12.15 Input. Key systemic ideas that can strengthen analysis in reviews

12.15 - 12.30 Small group discussion. Thinking back to reports you've written or read are these insights that are implicit or explicit in your reports? Do you think they apply? Would they improve our reports? What would be the barriers to implementing more ideas from systems thinking?

12.30-1.00 Feedback, discussion & clarifications from trainers

1.00 – 1.45 Lunch

1.45- 2.15 Exercise in small groups Looking inside professional practice and organisational systems: some examples from research How would you interpret this data? Are any of the key ideas from this morning relevant or useful?

2.15 – 2.45 Feedback, discussion & clarifications from trainers

2.45-3.00 Afternoon coffee

3.00- 3.20 Small group discussions. What do we need to do to take this forward? In what ways do these ways of thinking strengthen the analysis in SCRs? Are some structures/approaches to reviews more conducive to this kind of analysis than others? What kinds of understanding and skills would you and your co-workers need? What are the barriers to this kind of analysis?

3.20 – 3.45 Feedback, discussion & clarifications from trainers

3.45-4.00 Evaluation form & close

of 32

Presenters

Keith Ibbetson Keith Ibbetson began his career as a residential social worker in 1981 in Lambeth. He subsequently qualified and worked as a social worker in Hertfordshire and a safeguarding manager in children’s services in Islington. Between 1997 and 2000 he helped found, coordinated and taught on the innovative Child Studies MA at Kings College London. Since 1997 he has worked as an independent consultant and trainer in children’s social care and health services, specialising in child protection, service review, quality improvement initiatives and the development of preventative services. His interest in policy and practice on case reviews began in Islington when he worked with the Bridge Child Care Consultancy on the independent review Paul: Death through Neglect. It developed through work on reviews triggered by the deaths of Damilola Taylor and Victoria Climbié, attending the Climbié enquiry with staff from Ealing Council. In the last decade he has authored or chaired some 30 case reviews, as well as sometimes having his own practice scrutinised and challenged by reviewers. He chairs the standing Serious Case Review Group of Hertfordshire LSCB in which role he is heavily involved in the commissioning and publication of reviews. Keith’s main current areas of interest are in testing how systemic ideas can be used to review serious incidents; involving staff constructively in reviews; presenting and implementing the findings of reviews and in learning lessons from ordinary, positive, day to day safeguarding practice. History shows that – like most professionals who have worked for any length of time in safeguarding - he has made honest errors and some poor decisions. Dr. Sheila Fish, Senior Research Analyst, SCIE Sheila is a senior research analyst and Head of Learning Together at the Social Care Institute for Excellence (SCIE). Her main focus has been on developing a systems approach for case reviews, including serious case reviews (SCRs), of multi-agency safeguarding and child protection work. This has involved theoretical as well as practical collaborative development work, including developing, and providing, a training and accreditation programme in use of the Learning Together model. Her academic background is in social anthropology with a particular focus on children and childhood. She spent several years in Indonesia working in the field of child welfare as well as conducting ethnographic fieldwork. She retains a keen research interest in the use of ethnographic methods in the field of child welfare, particularly to explore interfaces between formal knowledge and professional practice.

of 32

The Learning into Practice

Project (LiPP):

The application of systems

thinking to Serious Case

Reviews

Keith Ibbetson

Sheila Fish

Lipp SCR Masterclasses

• LiPP assumptions:

• SCR Lead Reviewers have a key role in producing high quality SCRs

• Currently limited opportunities for continuing professional development

• Further professionalisation needed

• A number of bodies of knowledge and expertise exist that are potentially applicable

• To test this

• Developed a suite of master classes on areas of expertise that are not yet systematically applied to SCRs

of 32

Introductions

• Name

• Familiarity with systems literature

• SCR experience

Premise of the workshop

1. Extent to which systems thinking currently informs SCRs

• Working Together and the minimum requirements of a systems approach for

reviews

• Most SCRs now state they have adopted a systems approach but not clear what

that means in practice

• Often taken as involving staff & avoiding hindsight bias

• Focus remains on case specific details and ‘domain’ knowledge.

• Less routine exploration of organisational context of practice

2. SCRs would be strengthened if they made use of

• a systemic model of “organisational accidents” (James Reason)

• applying insights and concepts from accident investigation in other fields

of 32

Objectives & outline of the day

• an exploration of the value and relevance of ideas –about

thinking, introducing some new or not so new concepts

• would lead to a discussion about methods of review and tools to

assist in enquiry – but not today

• See Agenda

Thinking about why things go wrong

• Understanding why things go wrong inevitably

assumes a theory of causation

• Though this may not be explicit

of 32

Different approaches come from

different traditions

“traditional” (IMRs & Overview Report)

PolicySignificant Incident Learning Process (SILP)

PracticeRoot Cause Analysis

SCIE Learning Together

Systems thinking

causal models are more or less explicit

Models of why organisational

accidents happen

• SMALL GROUP DISCUSSION

• Handout

• What are the explanations for why things go wrong

that are offered by these different models?

• How are they similar and/or different?

• Does it matter which you use and if so why?

of 32

Why causal models matter

• The model you have of why things go wrong will shape the review

• Ideas about why this happened

• Focus of investigation

• Methods for gathering evidence

• Analysis undertaken

• Focus of the report and nature of the recommendations

• Will tie into your model of how organisations learn and improve

Different available models

• Linear or sequence of events’ model

• ‘Latent failure’ model

• Emergent or complex models

Always works in progress, evolving constantly

of 32

Complicated, determined

Complex, adaptive systems

The ‘quality broom’

of 32

Key concepts

Handout

• Complexity

• Tight coupling

• Normal accidents

• Latent and active failures

• A ‘just culture’

• Outcome and hindsight bias

A model of causation that fits

safeguarding must address…

handout

• These are “organisational accidents” not just individual errors

• Safeguarding is a “wicked” problem, i.e. one to which there is no final,

agreed solution

• Staff involved make unpalatable choices on the basis of imperfect

information

• Harm is usually caused to children by behaviour and conditions located

outside the professional system

• Knowledge of the risk posed by individuals varies enormously from case to

case, and is sometimes nil

• Every presentation has unique features

of 32

Coffee

A selection of systems concepts to help

making sense of front line practice

• Trade-offs

• Risks associated with

innovation and

organisational change

• Drift to failure

Handout

• Difficulty bringing knowledge

to bear in the work context

• Clumsy introduction of

technology

Discussion in small groups

• Thinking back to cases you have reviewed …

• Are these concepts potentially relevant?

• Are they there – implicitly or explicitly - in our reports?

• Would they improve our reports?

• Are there other relevant systems concepts?

of 32

Lunch

Exercise

Looking at an example of professional practice and

service provision

Presented with this data as part of an SCR…

What more would you want to know?

Are any of the key concepts to help make sense of

frontline practice relevant or useful?

of 32

A selection of systems concepts to help

making sense of front line practice

• Trade-offs

• Risks associated with

innovation and

organisational change

• Drift to failure

Handout

• Difficulty bringing knowledge

to bear in the work context

• Clumsy introduction of

technology

Discussion

of 32

Taking this forward?

• What are the benefits of these ideas for SCR analysis?

• Do some approaches/models accommodate them more

readily than others?

• What more would you need to feel confident to use these

ideas?

• What are the barriers to this kind of analysis?

Where are we now

• What SCRs are for, who does them and how they are carried out

is now contested

• Learning in Practice Quality Markers were developed in one

context but will have to work in another

• What combination of factors will guide the discussion?

• Policy considerations or professional knowledge and the best

ideas from the field of accident investigation?

of 32

Public enquiries and

local reviews

Family systems thinking

Evolving models used in industry and

transportation

Root Cause Analysis

and variants Reason OACM

Part 8 reviews and SCRs

(1991 – 2013)

Dissatisfaction

with SCR outcomes

‘Beyond Blame’

Production of working models

for health sector

Local approaches to learning from

practice

NPSA RCA

Vincent et al London protocol

Further refinement of systems approaches

Welsh model

Munro review

SCIE Learning Together

Working Together 2013 – 15

Significant Incident Learning Process

‘Blended’ and ‘hybrid’ approaches

Wales

Variety of methods, models and approaches seeking to comply with WT 2013, views of the

DFE and expert panel, borrowing from ‘Learning Together’ and other sources

Centralisation of some or all SCRs

Where next?

The best ideas from industry and health will continue to prove themselves to be of value. Will this, and what we know about how complex systems learn and improve, influence the centralised system for SCRs? Or will the focus be exclusively policy driven? For example focusing on the length and format of reports?

For more information

• Sheila Fish [email protected]

• Keith Ibbetson [email protected]

• LiPP Programme Manager, Jan Pickles, [email protected]

of 32

Handout 1: Models of organisational accidents

SCR Masterclass 2: systems thinking

Models of why organisational accidents happen

of 32

Handout 2: Models of Causation

of 32

Simple models of causation where an event or events, failure in a component or a significant error is seen as leading to a disaster

“Neil Garnham QC highlighted 12 missed opportunities to protect

Victoria Climbié in his closing evidence to the Laming inquiry this week.”

Community Care, 21 February 2002

But causation can only be linear in hindsight, because we can trace the path to the disaster.

No one can knows what would have happened

if a different course of action had been taken at any of these points.

These 12 episodes highlighted vulnerabilities in safeguarding arrangements.

“It is natural and nearly irresistible to

think of events as if they develop in a

step-by step progression, where one

action or event follows another…and

that there is a cause-effect

relationship between the two”

Erik Hollnagel

Manageable, mental models that

offer simple explanations.

Sometimes a series of ‘errors’

(sometimes linked, possibly

coincidental but unrelated) will be

seen as contributing.

Reflects and reinforces day to day

language and thinking

‘Cause’ and ‘root cause’

It was the product of …

This was the direct result of …

Component failure

Human error

One thing (inevitably) led to

another…

There was a domino effect

Complex organisational and

systems models inevitably rely on

a less everyday language, making

it harder to communicate findings

of 32

But is any better understood by treating it as a ‘missed opportunity’?

of 32

Complex causation of organisational accidents – many variations, used widely in accident investigation

Organisational accidents are distinguished

from the sorts of simple human errors

that happen in simple activities in

everyday life

The model acknowledges the complexity

of ‘organisational accidents’ and the

extent to which organisations now seek to

defend against them

It uses the technical language of

structure, alignment, defences, errors and

contributory factors. The term ‘latent

conditions’ borrows from the medical

notion of ‘latent pathogens’.

The weight attached to gaps in the protective measures put in place by modern organisations gave rise to the metaphor of a “Swiss Cheese”,

where holes align in certain instances to ‘allow’ an

organisational accident to happen

“For each individual unsafe act we need to consider what local conditions could have shaped

or provoked it. For each of these local conditions we then go on to ask what upstream

organisational factors could have contributed to it”

Reason (1997) Managing the risks of organisational accidents

of 32

Developments in the health sector from models of complex causation

Taylor-Adams and Vincent ,‘Systems Analysis of Clinical Incidents’ ,The London Protocol, Second edition (2000)

However there is an explicit focus on the value

of understanding and reducing future risk

‘… if the purpose is to achieve a safer

healthcare system, then it is necessary to go

further and reflect on what the incident reveals

about the gaps and inadequacies in the

healthcare system in which it occurred. The

incident acts as a ‘‘window’’ on the system—

hence systems analysis. Incident analysis,

properly understood, is not a retrospective

search for root causes but an attempt to look

to the future. In a sense, the particular causes

of the incident in question do not matter as

they are now in the past. However, the

weaknesses of the system revealed are still

present and could lead to the next incident.’

Charles Vincent (2004) ‘Analysis of clinical

incidents: a window on the system not a search

for root causes’, Quality and Safety in Health

Care

In its structural view of how incidents occur this model is structurally very similar to the previous one. Both seek to understand individual error in context.

of 32

More recent thinking on systems

‘This model sees accidents as emerging from interactions between system components and processes, rather than failures within them. As such

accidents come from the normal working of the system; they are a systematic bi-product of people and organisations trying to pursue success with

imperfect knowledge and under the pressure of other resource constraints (scarcity, competition, time limits)’.

Dekker (2006) The Field Guide to Understanding Human Error, p 81

Much modern industrial and commercial activity and public

service provision has become so complex that it is impossible to

specify exactly what action is required to obtain the desired

outcome i.e. procedures can’t be written for every situation.

‘When such systems perform reliably, it is because people are

flexible and adaptive, rather than because the systems are

perfectly thought out and designed’.

‘The variability of everyday performance is necessary for the

system to function, and is the source of successes as well as of

failures’. (EUROCONTROL, 2013)

The behaviours that get things done effectively most of the time

sometimes contribute to the development of poor outcomes and

major incidents. Thus accidents are “normal”.

‘Although it is still common to attribute a majority of adverse

outcomes to a breakdown of components and normal system

functions, there is (sic) a growing number of cases where that

is not so. In such cases the outcome is said to be emergent

father than resultant’

The diagram and all other quotes are from European Organisation for the Safety of Air

Navigation (EUROCONTROL) (2013) From Safety 1 to Safety 2 – A White Paper

Representing the idea of ‘transient

phenomena and emergence’

of 32

What would a model explaining organisational accidents for safeguarding look like?

As models of accident investigation have developed they have been tested, adapted and applied in different fields.

Woloshynowych et al (2005) tested parallels between industry, aviation and health and found that

‘aviation, nuclear power, chemical and petroleum industries are also complex, hazardous activities carried out in large organisations, by for the most part dedicated and highly trained people. The parallels with health care are obvious and it would be surprising if we could not learn from them….

(But there are also) many differences between industry and healthcare. First, healthcare consists of an extraordinarily diverse set of activities…environments and associated responsibilities…

Even with the most cursory glance at the diversity of healthcare, the parallels with the comparatively predictable high-hazard industries with usually a limited set of activities begins to break down….

Healthcare is in large part also routine but in certain areas healthcare staff face very high levels of uncertainty. ….

Unlike industry tolerance for uncertainty on the part of healthcare staff, and indeed the patient is vital. Hence the nature of the work is very different from most industrial settings.

NB

Patient safety and quality initiatives in the NHS have not historically encompassed safeguarding

There are no significant references to safeguarding in the systems literature

The SCIE ‘Learning Together’ model built on the root cause analysis and early systems models used by the NHS to find a model that could be applied to safeguarding

A model for safeguarding needs to continue to assert that children’s deaths result

from “organisational accidents” rather than individual errors

It must recognise that safeguarding children is a “wicked” problem, i.e. one to which there is no final, agreed solution, subject to competing,

changing policy and societal priorities and demands

Staff involved make unpalatable choices on the basis of imperfect information

Harm is caused to children by behaviour and conditions located outside the professional system (except in the rare

cases of professional abuse)

In some respect, every presentation is unique Knowledge of the risk posed by individuals varies enormously

from case to case, and is sometimes nil.

Models that take account of ‘transient phenomena’ and treat cases with very poor outcomes as a bi-product of pressurised normal working are well suited to capturing

the complexity and unpredictability of safeguarding work.

of 32

Handout 3: Glossary of terms

LiPP SCR Masterclass 2: Systems thinking

Glossary of terms

A selection of systems concepts to help making sense of front line practice

Trade offs. Organisations, teams and staff may have shifting or incompatible objectives and priorities. Sometimes these arise from external pressure (time and resources); often trade-offs are inherent in the task or function itself. New arrangements or working methods that create new vulnerabilities or ‘pathways to failure’. We introduce new approaches and arrangements with a view to improving an aspect of service (usually quality or efficiency). Even innovations which are designed with safety and quality in mind will contain new pathways to failure (often hidden and difficult to anticipate) Drift to failure. Serious organisational accidents can often be shown to have been influenced by a gradual shifting in priorities which led to quality and safety being treated as lower priorities. Organisations sometimes find it difficult to spot early signs of deteriorating standards, especially if senior managers are perceived as being unreceptive to bad news Difficulties of bringing knowledge to bear in context. Accident investigations have considered many aspects of this including: 1) what knowledge is relevant? 2) is that knowledge accessed? 3) is the situation being oversimplified? 4) Are those involved aware of the limits of their knowledge? Clumsy introduction or application of technology. How does the introduction of technology shape tasks? How does it affect the ability to access and apply relevant knowledge?

of 32

Handout 4: Glossary of terms

LiPP SCR Masterclass 2: Systems thinking

Glossary of terms

A selection of concepts

Increasing complexity of working arrangements can increase risk, especially when complexity is linked to tight coupling and interdependence of functions. The quest for efficiency drives growing division of labour and increased complexity. This is shown to increase the risk of error (especially when parts of the system are separated by time and place and controlled separately). The source of errors is more opaque and it may be harder to recover when something goes wrong Tighter coupling of operations. In a tightly ‘coupled’ system, functions rely on one another, strongly influence one another or must happen in a given sequence or window of time. This may increase the scope for error or miscommunication. The impact of an error in one function may adversely affect other functions and tasks. A tightly coupled system may find it harder to recover from an error in one part of the system Normal accidents No organisation can specify the practice response to ever set of circumstances in detail. Organisations rely on staff ‘at the sharp end’ to adjust their activity in order to manage pressures, unusual circumstances and new or unexpected workload pressures. Front line staff usually ‘create safety’ but in some circumstances the things that usually work contribute to failure. Latent and active failures. Front line staff are seen as the inheritors of problems caused by the poor design of procedures and arrangements. Potential shortcomings remain hidden until a particular set of circumstances arises Existence of a ‘just culture’ as a precondition for investigative neutrality and learning and improvement Working Together states that “professionals must be involved fully in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith” (WT 2015 Section 4.10). But that begs the questions, ‘What is good faith?’ and ‘Who is to judge?’ Organisational approaches recognise that 1) activity and outcome do not necessarily correlate – there is not necessarily an error to uncover 2) errors are common place in complex high-risk activities 3) if errors are uncovered they mark the starting point for the investigation, not its end point. Errors will be described and understood, but it is not the role of the SCR to determine whether those who were involved acted in ‘good faith’ or not. Outcome and hindsight bias Have you ever caught yourself asking, ‘How could they not have noticed?’ How could they not have known?’ Then you are reacting to failure. And to understand failure you first have to understand your reactions to failure. Sidney Dekker, The Field Guide to Understanding Human Error (2006)

of 32

‘Looking back, the situation faced by the clinician is inevitably grossly simplified’ Charles Vincent, (2010) Patient Safety, 2nd edition We are naturally swayed by the outcome to imagine that everything that ‘went wrong’ contributed in some way to the final tragedy or might have (if something different had been done) prevented it. In reality professionals working in safeguarding are frequently faced with a range of unpalatable choices which they must make on the basis of incomplete or incorrect information. After we know the outcome of a case history the range of apparent choices appears to be much narrower and the implications of each of them is perfectly clear. None of the people involved in the care of Victoria Climbié wilfully ‘missed an opportunity’ to save her because none of them knew that she was going to be killed. In context very different pressures and reasoning shaped their actions.

lipp scr masterclasses · dr. sheila fish, senior research analyst, scie sheila is a senior...

Documents