FBI agents interviewed a Boston man to see if he was a threat to society. They decided he wasn't. He was.
Prosecutors weighed the exceptionally sparse evidence against five young men in a high profile rape case. They decide they can convince a jury they are guilty. They are not. (Watch the movie).
The social service version of this happens daily. A child protection worker determines that a child is safe and she is not. A juvenile officer decides that a child is ready to leave a treatment facility and live in the community. He hurts someone.
Guilty - Innocent. Safe - Unsafe. Ready - not ready.
The rush to blame someone or something for last week's Boston Marathon blast is on. Depending on what you read, it is the fault of President Obama, Alex Jones, the U.S. government (I refuse to link to an Alex Jones site), the bombers' parents, Islam, the sequestration, the FBI, immigration policy, and yes... wait for it... gay marriage.
But unlike some other tragic events of the past few years, it is evidently not the fault of those of us who work in social service systems. Evidently, the two brothers did not drift from foster home to foster home. Nor were their obvious mental health issues left untreated in an uncaring juvenile justice system. They evidently were not even seduced away from the sedentary life of welfare dependency by the excitement of evil. Although the younger brother was in college, I can't even find reference that someone is blaming the university's student counseling center for a failure to hospitalize a freshman who might have harbored an urge to blow up a city as revenge for his poor grades in political science. If the young man's friends didn't see this coming, the reasoning seems to be, you can't blame the professionals for not picking up on it either.
The current issue of Quality and Safety in Healthcare contains an incisive editorial by Kaveh Shojania and Eric Thomas about why the QI field has not been able to demonstrate widespread improvements in patient safety as a result of their efforts. To show such an improvement, they write, would require three achievements:
- "Identification of interventions that reduce common types of adverse events.
- Dissemination of (some of ) these effective interventions into routine practice.
- Development of a tool to measure improvements in patient safety problems.
Unfortunately, none has occurred. We have few effective patient safety interventions. Those that may be effective have not been widely adopted (or not adopted in an effective form). And, the gold standard instrument for measuring patient safety problems is probably too blunt to detect changes over time."
Lack of money and time. Lack of buy-in. Competing demands. Lack of training and skills. Lack of authority. Lack of research capacity. Ever-changing requirements from accreditors, funders and licensing bodies.
These were the major challenges reported by 16 quality professionals working in social service agencies in St. Louis. The findings are from a qualitative interview study published this week in the journal with the bad name, Administration and Policy and Mental Health Services Research.
Some places are in need. Some places are in real need. Some places are in crises like we only see in war. The Englewood neighborhood of Chicago is one of these.
The recent series on Harper High School in Englewood that last month aired on This American Life, NPR Morning Edition and WEBZ radio is a blockbuster. Anyone interested in violence, urban America, schools, or guns needs to listen.
Since I first heard it, I have been debating whether to post one of my more visceral reactions. As part of the series, Alex Kotlowitz hung out in the social work office at Harper High, where social workers faced the effects of violence every day. One youth profiled in the series accidently shot his younger brother while they played with a found gun. He seeks refuge in the social work office and develops a touching relationship with a caring young social worker.
And it struck me all wrong.
Accreditation is sold as a marker of quality social service, but amazingly little is known about the effects of accreditation on quality in any field, including the social services. A new paper by Madeline Lee of Tulane University sheds some light on what it is like for social service agencies to go through the accreditation process. Dr. Lee studied five social service organizations as they underwent their initial COA accreditation. Some agencies found it a struggle, not just to prepare the COA self-study, but also to establish the Quality Improvement processes that COA requires for becoming accredited. Two kudos here: 1) for Dr. Lee undertaking a research agenda on accreditation. It is much needed. 2) For COA sticking to their guns and requiring solid QI processes of all agencies they accredit. The study, in my biased eyes, also points to the need for widespread training and coaching for social service agencies on quality improvement. Too many small agencies, especially, are clueless about what QI can offer them and their clients.
The study was published in Families in Society. Academic readers may be able to access the article here.
A recent post noted how little training in quality improvement appears to have made it to the quality improvement workforce in child welfare. Why is that?
Return on investment (ROI) is the holy grail of quality work, not just in the social services. It was heartening to read this week of a research study (also look here) showing ROI on providing quality mental health services in the foster care system. In this study, 90 youth with PTSD in foster care in Delaware who received state of the art trauma treatment cost the state $167,000 less in the subsequent year than a matched sample of youth with PTSD who received treatment as usual. That comes out to about $1800 a year in savings per kid.
Rarely does the public get a glimpse into the working of quality improvement systems in place in a public social service. In 2012, the National (Child Welfare) Resource Center on Organizational Improvement (NRCOI), conducted semi-structured phone interviews with 31 state child welfare quality improvement leaders. NRCOI has now published a number of reports from these interviews on their website. They suggest a quality improvement workforce with expertise in child welfare, but not in quality improvement.
Good ideas need champions and the New York Times is the champion of positive deviance. They followed up articles from 2008 and 2009 this week with a reminder on the power of the positive deviance approach. While some think of positive deviance as a community development strategy, through our lens it is a quality improvement and implementation strategy of nearly unlimited potential.
In this approach, look for where things are going right in places where lots of things aren't going right. Then, investigate to find out what people are doing differently there. Then, try to replicate. Tufts maintains a website on positive deviance. You can also check out the well-regarded article in F@st Company that helped spread the word.