Serious Case Reviews: How much are we really learning?

16 Jul

Question marksI went to an event where they asked this question and my response is, we are good at learning lessons. I think the reviews themselves are quite good at pointing out where there need to be improvements. Where we go wrong is what we do with this information once we have it. I am not speaking, necessarily, of the local authority where the incident happened. It appears that, when it comes to local authority services, all the learning from others is very much externalized. Executives and senior management recognize the importance of the key themes but don’t really make internal changes based on the reports from the case reviews from other authorities. Most have internal quality assurance process and case audits but it isn’t until something tragic occurs in the particular local authority that systems/processes are checked and/or reviewed for failings.

We need to learn from the mistakes of others. I think serious case reviews should prompt internal mini reviews. Take the learning from the case reviews and do a mini internal review to ensure mistakes are not being replicated locally. The review may not raise any issues about replicating mistakes. However, it may highlight issues in other areas.

The Individual

I tend to be of the opinion that if as you (as an individual worker) are committed to your work, quality assurance will be a critical part of your overall practice. Not just token quality assurance – coming from a perspective of political agendas, but from a point of doing the absolute best and delivering a high standard of services. In this way you can catch any mistakes before they become tragic events. You won’t be able to account for absolutely ever eventuality but it is inevitable that you will be able to catch a few things before they escalate. Of course, a big part of this and good practice in general is evidencing the work you’re undertaking. So, if there is ever a time when something tragic does happen, there is documentation of the actions you took to do all that you could with the information available to you as a practitioner.

The Organization

It is the responsibility of management to convey messages from serious case reviews in terms of how this will impact the way of working within the local authority and what changes are coming. This is where I believe there is a gap.

Change management programs are not managed as well as they could be from what I have seen. They all start with recognition of a need for change. It is then discussed at the executive and senior management levels (which also happens to be where the final decisions are made); and may include one or two staff consultations though I am not sure to what degree these are considered in the final decision making. Then, the change program starts. It is almost like the decision is a target holding practitioners over a dunk tank and senior management have the ball. The final decision is the ball hitting the target, dropping everyone sinking into the water.

If we look at change programs in the private sector you can see why they are successful. Two of the more popular change models are Kurt Lewin’s model and John Kotter’s model. Both models emphasize the importance of a staged change program. “Change needs to understood and managed in a way that people can cope effectively with it.[1]” Management need to ensure if they cannot get complete agreement from their staff that their staff at least understand the need for change. It is suggested to use workshops to achieve understanding, involvement in plans, measureable aims, actions and commitments. It is the responsibility of management to manage change. It is their responsibility to facilitate and enable change.

Within social care, it appears that there are lots of reflection and lots of thought, work groups etc. that get established as part of change programs. What’s missing is the lack of work to embed learning and help practitioners internalize lessons learned from serious case reviews. Without this any change management programs that need to occur will not be as effective as they could be. Embedding only works when the lessons are internalised by frontline staff; that is, they need to understand how it applies to them and the work they are doing.

One possible reason for this is the lack of space for practitioners to understand the lessons and assimilate it. They are busy trying to manage the day to day that they don’t get much time to take on new ways of working. It would help for management to give staff the same space they are afforded to think about lessons and any possible changes that could be made to assimilate the new knowledge into practice. I think there need to be designated practitioners to be part of management meetings who are tasked with taken messages back to staff in workshops where they are given space to come up with some solutions that they believe would work on the ground. They could then own the change instead of having changed imposed upon them. Involving staff will also give the message that they are valued. Allowing them to drive the change on the frontline will empower them to make changes. It will give them confidence to speak up and give them a voice so they can identify areas that need to be changed before these issues come to light in serious case reviews.

Management needs to help staff understand what is in the real m of possibility. Staff need to understand the limitations present so when they are a part of the change process they can make informed decisions. Fore warned is fore armed.

Going forward

1. I think it is crucial that managers’ institute staged change management programs with thorough plans to feedback to stakeholders to alleviate any fears about drift and avoid being pushed into quick change programs that produce token change at best.

2. Involving frontline social care staff is another part of the process that will yield longer term change. If they are involved from the start in the readiness evaluation, planning and implementation it is a change they can own; a change in which they are invested. Critical to this is that staff understand the why and the how.

3. Annual reviews of improvement and quality assurances frameworks which include frontline staff. It is important that staff understand the standards against which they are being judged. It is important for them to understand why this process is important, what it is and what it isn’t. I believe involving staff in these processes gives them a better understanding and demystifies anxiety provoking processes. It also helps with their ability to do individual quality assurance. They are more aware of what is being scrutinized.

4. Anticipated or planned changes can be incorporated in the learning and development strategy for the local authority. Internal audits can produce a wealth of information that would be invaluable in terms of courses needed to ensure that staff are prepared to do the job for which they were hired. Change management programs can inform strategy by informing management what new skills their staff may need or skills they may need to develop.

5. Even though we can recognise that senior management are getting better at identifying themes and reviewing performance from serious case reviews, but they cannot ignore the need to make sure frontline staff are on board because the culture of the organisation may need to change and this means changing the way they work. As I have already mentioned this is important because if they are able to own some of the changes it is more likely to be embedded into practice and become a lasting change.

6. I mentioned this previously but we need to make sure that not only the messages from serious case reviews are filtered to staff but it needs to be communicated just how the organization intends to use this learning. That is, does this learning mean there will be changes in the Social Workers own organization.

The key to ensuring lessons are learned and embedded are to ensure there is a strong stable line of communication throughout the organizations. This communication needs to incorporate key learning, what is going right in the home authority (if this is an external serious case review) and what might need to change within the organization to ensure it is not replicating the mistakes outlined in the review. This is setting the stage. Once you have done that, then managers needs to sit down and plan (or outsource) a change management program, a thorough one. Making sure that staff are involved and kept informed at every stage of the process. There is too much shrouded in secrecy. People operate much more openly in a structure that not only supports such thinking but operates within it.

[1] Organizational and personal change management, process, plans, change management and business development tips

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Posted by on July 16, 2014 in The Social World


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