Safety science helps child protection agencies move from an organizational culture focused on blame to one of open dialogue and accountability, with staff input and feedback viewed as critical to solving an organization’s underlying systemic issues. Safety culture is not created by writing new rules and policies, but by changing the way people engage in the work.

One way to strengthen an organization’s safety culture is by implementing effective mindful organizing practices — the patterns of interactions between staff — to create resilience at a team level that is anchored by an understanding of both the context of the work and the capabilities of all members of the team.¹ Ultimately, mindful organizing enables a team to rapidly and effectively identify and respond to unexpected events.

Studies show that investing resources and time in supporting and engaging the workforce to reduce turnover positively impacts outcomes for children and families. Mindful organizing also supports better decision-making and care delivery, which lead to better child safety and improved family well-being.

Adaptation and evidence²

Mindful organizing has its origins in high-reliability systems such as aviation and nuclear power, where the workforce is required to navigate dynamic, complex, and time-pressured situations consistently and without error. Being highly reliable in these environments requires individuals and teams to “mindfully organize” to effectively detect and correct errors, as well as find ways to adapt when unexpected events occur.³

Mindful organizing behaviors help the team build resilience and provide enhanced services to children and families. A team that utilizes mindful organizing builds habits and opportunities to plan ahead and reflect back, which may include discussing potential sources of system failure, questioning assumptions and perceived wisdom about the work, discussing ways to learn from errors and near misses, and drawing on and deferring to each other’s expertise when needed.

Positive affirmation is a key principle in mindful organizing that decreases burnout and improves performance, as are the six enduring habits of mindful organizing:

1. Make candor and respect a precondition to teamwork.
2. Spend time identifying what could go wrong.
3. Talk about mistakes and ways to learn from them.
4. Test change in everyday work activities.
5. Develop an understanding of “who knows what” and communicate clearly.
6. Appreciate colleagues and their unique skills.

Evidence shows that higher levels of mindful organizing practices result in improved safety and quality outcomes in a range of health care contexts.⁴ Additionally, child protection teams in both Arizona and Tennessee have successfully adapted mindful organizing practices in their efforts to create a safety culture. While there is a shortage of research evaluating outcomes in child welfare, four years of safety culture data from organizational assessments in Tennessee have shown consistent improvement in psychological safety and improved staff retention. In addition, teams that practice a higher level of mindful organizing have been found to have a higher percentage of children exiting care and fewer children re-entering care, although more evidence is needed to understand the connections between these outcomes and mindful organizing behaviors.⁵

Strategies and tactics

Mindful organizing requires the intentional building of habits by individuals and teams. Huddles and debriefs are two strategies that provide opportunities for the team to be mindful both before and after a situation occurs. For example, a team may huddle prior to a Child Family Team Meeting (CFTM), to talk for 15 minutes (or less) about the possible risks and how the plan may develop. The huddle is not a time for the team to make decisions without the family, but is a chance to share opinions and ideas that team members may have concerns about sharing while the family is in the room. In Tennessee, these huddles have prevented custodial interventions by providing team members an opportunity to brainstorm creative ideas about where to find resources for the family that may not have been voiced during the meeting.²

Team debriefs are also planned after every CFTM (not just when something goes wrong) and after every bench order that places children from an open case into custody. These debriefs provide intentional opportunities to learn, reflect, and pass that learning on to others in order to strengthen future efforts in the organization.

Situation-Background-Assessment-Recommendation (SBAR), another tool used in mindful organizing, helps process safety-critical information and communicate information more clearly. Often, attorneys only want to hear from supervisors because they believe that caseworkers provide too much information, or offer details that are not organized in a useful way. Teams have found that this structured tool assists caseworkers and supervisors in more effectively sharing information with other stakeholders by helping them be more succinct, professional, and detail-oriented in their communications.

Implementation considerations

Leadership is crucial to enabling the conditions for a psychologically safe organization that promotes trust, accountability, and continuous learning. Mindful organizing requires that leaders demonstrate how they think about and learn from mistakes or unintended consequences. Agencies can take steps to structure events where leaders model trust, respect, openness, learning, and social connectedness; and implement processes that emphasize improved decision-making rather than punishment and blame. Leaders also can enhance the use of mindful organizing behaviors by hiring staff based on their interpersonal skills as well as their technical capabilities, and develop robust training plans to help strengthen staff’s interpersonal skills and build a shared language across the organization. In particular, hiring and training efforts that emphasize the skills of prosocial motivation and emotional ambivalence have been found to contribute to success in mindful organizing.⁶ Individuals with prosocial motivation are more focused on the needs of others than their own and are willing to put the purpose and interests of the organization before their own interests. Individuals with emotional ambivalence, defined as simultaneously experiencing contradictory feelings, are more receptive to alternative perspectives and are creative, flexible thinkers.

There are several other important considerations to implementing mindful organizing:

• Ensure establishment of agency-wide psychological safety. Team members who feel psychologically safe respect one another and can take risks. In Tennessee, mindful organizing was part of the implementation of safety culture. Teams met over the course of a year to talk candidly about their concerns and ideas, and to identify the practices that fostered greater efficiency. Through these discussions, teams developed a healthy appreciation of what could go awry, and talked openly together in planning for those situations.
• Identify early adopters. Teams should strategically identify and seek out individuals with an improvement mindset who are interested in trying new strategies.
• Use culture coaches to support development of new habits. Implementation is not just about teams finding ways to fit behaviors into existing approaches; they need to create new habits in order to see results. Culture coaches can be deployed to support these new habits. In 2018, Tennessee started using volunteer culture coaches trained in psychological safety to support local office teams in their development of mindful organizing habits.
• Allow time for face-to-face discussions. These discussions provide opportunities to practice the six enduring habits of mindful organization. While training can serve to inform caseworkers about mindful organizing, dedicated time for discussion to advance practical application is key.
• Customize for teams’ unique context. Teams must develop their own ways of implementing the habits. It is important for teams to take the tools, try them out, and adapt them to fit their specific needs. For example, huddles and debriefs should be held at times that make sense to the team, rather than at times dictated by management. 

Additional resources

• Collaborative Safety, LLC offers a range of resources that support human services agencies to embrace a safety science approach to learning and improvement
• Lead.Team.First is a learning community website
• TeamFirst Toolkit: Strategies and Tactics to Support Safe, Reliable, and Effective Child Welfare Teams
• Safe Systems Improvement Tool is used in critical incident reviews and as a part of larger efforts to support safety, improvement, and resilience in child protection agency 

1 Kudesia, R.S., Lang, T. & Reb, J. (2020). How institutions enhance mindfulness: Interactions between external regulators and front-line operators around safety rules. Safety Science, 122, https://doi.org/10.1016/j.ssci.2019.104511.
2 Interviews with Tiffany Goodpasture and Michael Cull at Casey Family Programs’ Safety Convening in May 2018.
3 Vogus, T.J., Rothman, N.B., Sutcliffe, K. M., & Weick, K.E. (2014). The affective foundations of high-reliability organizing. Journal of Organizational Behavior, 35, 592–596.
4 Vogus, T.J. (2011). Mindful Organizing: Establishing and Extending the Foundations of Highly Reliable Performance in Cameron, K.S. & Spreitzer, G.M. eds. The Oxford Handbook of Positive Organizational Scholarship (664-676). New York, NY: Oxford University Press.
5 Interview with Tiffany Goodpasture at Casey Family Programs’ Safety Convening in May 2018.
6 Vogus, T.J., Rothman, N.B., Sutcliffe, K. M., & Weick, K.E. (2014). The affective foundations of high-reliability organizing. Journal of Organizational Behavior, 35, 592–596.