New York Times, April 8, 2011
The death of Marchella Pierce, a 4-year-old girl in Brooklyn who was beaten, malnourished and tied to a bed, has again aroused anger over child welfare in New York City. Her mother stands accused of murder, and a caseworker and a supervisor were charged last month with criminally negligent homicide.
Reading about Marchella's death in September brought back painful memories. When I was the director of child welfare in the District of Columbia I often woke up at 3 a.m., fearing all that could go wrong. During my tenure, there were increases in adoptions and speedier investigations, and more children went to live with foster families rather than in institutions. But substandard care and terrible cases also continued.
Because there is so much to fix, improvements and calamities can happen simultaneously in long-troubled child welfare systems. In Washington, where I took over from a court-appointed receiver, the work ranged from reducing caseloads to overhauling information technology, contracting, licensing and personnel systems. On good days, we reminded ourselves that it was all worth it. But when a child was hurt or killed, we often reacted defensively, fearing that a misdirected public outcry could undercut our plans for reform.
After I left that job, I kept looking for solutions. For ideas, I examined institutions like airlines and some hospitals that have reduced deaths and injuries. Through rigorous data analysis, they have developed systemic approaches to safety, focusing on clear communication, minimum-staffing requirements and “fail-safe” strategies to reduce the consequences of inevitable human error. Such strategies - including checklists and passing on information at crucial moments like shift changes - can be applied to protecting children.
Findings from the Institute of Medicine, the Commonwealth Fund and other organizations point to several lessons from safety initiatives in these fields:
- You can’t fix a systemwide problem by simply blaming or retraining individuals. When systems are broken, workers respond in counterproductive ways. They try “workarounds,” as when a nurse guesses at a doctor’s unreadable handwriting on a prescription because she is afraid to ask. Or they withhold information to avoid responsibility, wanting someone else to make a decision even if it is wrong. Blaming individuals can also make it harder to recruit and keep the most qualified employees. (In child welfare, talented caseworkers too often give up on investigating troubled families and gravitate to handling adoptions.)
- You can’t learn what’s wrong with the system from just one case. Understanding what to fix requires analyzing many cases, including deaths, injuries and “near misses.” That is why airline safety analysts collect information about maintenance problems and planes that come too close to each other on the runways or in the air, and why hospitals study medication errors. Looking just at Marchella’s death focuses attention on the caseworker, while looking at more cases gets us closer to understanding trends and patterns.
- You can’t understand problems and fix them unless you create a culture in which employees share information without fear. The Department of Veterans Affairs increased reporting of potentially dangerous errors by promising hospital staff members they would not be punished unless the mistake was intentional or criminal or involved substance abuse. Pilots who anonymously report an unsafe episode receive a number they can use in an investigation to show that they made a report, shielding them from punishment in most circumstances.
These insights can yield simple fixes. In 2005, for example, the Illinois inspector general found that a failure to identify parents’ mental health and substance abuse problems was a common feature in child deaths. Harried caseworkers who had to substantiate a complaint of abuse or neglect didn’t have enough time to thoroughly investigate whether drug addiction and mental illness were involved. When state forms required them to choose yes or no in those first hectic days, they chose no - and often no one came back to help the families. So the inspector general urged the state to give workers another option, one that would indicate a need for continuing assessment in these in-between cases.
But we need to aim even higher. The Department of Health and Human Services should create a national commission to review deaths and serious injuries to children from abuse and neglect. Among other things, it should examine practices in sectors with strong safety records; look at deficiencies in access by parents to drug counseling and psychiatric care; and recommend procedures for caseworkers to report mistakes anonymously without getting blamed.
For too long, we have had a stalemate: Child welfare experts, worried that anger over high-profile deaths often leads to the unnecessary removal of children from their homes to an overloaded foster care system, are reluctant to talk about systemic safety improvements. Meanwhile, the number of children who die each year from abuse or neglect in the United States - an estimated 1,770 in 2009, or 2.3 deaths for every 100,000 children - has been rising.
There is a way out. Making sweeping policy changes and scapegoating individuals are not the best way to enhance safety, but rather, clear-headed, evidence-driven examination of the resources, conditions and communication that guide decision-making in the workplace. That way Marchella’s death will not become just another example of the cycle of outrage and failure.