Our Approach


We believe human services agencies must evolve from outdated models of safety commonly used today. More advanced models of safety engage employees in safety related efforts, establish comprehensive approaches to analyzing adverse events and promptly act upon identified areas of improvement. These models have been championed by safety critical industries such as aviation, healthcare and nuclear power. The industries that use these updated models of safety depart from surface level understandings of how systems fail and seek out the complex interplay of systemic factors. When typical underlying systemic factors are addressed, an agency can begin to make critical advancements in promoting safe outcomes for children, adults, families, and employees. We believe in three primary transitions to achieve this.

From a culture of blame to a culture of accountability

The terms blame and accountability are too often conflated. When agencies blame and punish workers, they falsely believe that the agency and its employees are being accountable for their actions. Years of research have shown that blame may actually decrease accountability, since it inhibits the ability of the organization to learn and improve. Accountability engages frontline workers to be a part of the solution by providing their experience of how adverse events may have occurred and how they can be avoided in the future. Additionally, the agency is accountable to make improvements and to focus efforts and resources on becoming a more resilient and reliable organization.

From simple to systemic methods of learning and review

The methods in which agencies investigate adverse events strongly correlate with the lessons that may be learned and then acted upon. With simple methods and tools, organizations will be subject to a cycle of addressing the recurring issues. Agencies need to be equipped with the right skillsets and tools to adequately learn from failure and ultimately promote safe outcomes. Core learning systems such as a systemic critical incident review and a safety reporting system provide agencies with the ability to identify, track and respond to the issues affecting their capacity to provide safe outcomes.

From using quick fixes to addressing underlying systemic issues

In the wake of critical incidents such as deaths or serious injuries, it is tempting for human service agencies to use quick fixes such as firing employees, adding new policy or retraining employees. This leaves agencies with the false impression that a problem has been resolved. However, agencies are still left with the systemic constraints and influences that contributed to an adverse event. This is commonly seen as treating symptoms instead of the source of the illness. Instead, agencies need to track the underlying systemic factors that are present in many adverse events and are likely to be present in the future.