Systems Thinking in Maltreatment Investigations: Evaluating the Use of an AcciMap Approach to Assist Licensing Investigators

Sammanfattning: To help protect the health, safety and well-being of vulnerable adults and children receiving care within licensed facilities and prevent future incidents of maltreatment, state human services licensing departments investigate allegations of maltreatment occurring within these facilities. Despite these efforts, maltreatment continues to occur and is increasing within licensed facilitates across the United States. A systems approach to incident analysis is one of the dominant concepts within accident analysis research today, especially in complex socio-technical systems, and has been shown to improve learning from critical incidents, and support systemic changes that better prevents future incidents. However, no studies have been conducted within the domain of licensing investigations within human services departments that examine what a systemic approach can bring to this safety critical industry. This study sets out to address this gap in the literature by seeing how an AcciMap, as a tool for systems thinking, can both support investigators of maltreatment in facilities in achieving systemic learning and identify systemic influences that, if changed, could better prevent future incidents. To achieve this, two AcciMap sessions were facilitated with licensing investigators from a large state agency. Qualitative analysis of the maps and focus group information showed that the AcciMap did contribute to systems thinking for the investigators and provided them with a systemic approach to incident analysis when applied to maltreatment related investigations within licensed care facilities. Specifically, the investigators indicated the use of the AcciMaps helped them move away from blame, see the big picture behind the incident that emerged from interactions across multiple levels of the system, understand and communicate about multiple perspectives, including those on the frontline, and supported them in conducting key components of their investigative work. Finally, the use of a systems safety approach highlighted critical learnings (or systemic features) often missed through traditional linear models of investigation used within this field. These types of learnings may lend themselves to support improvements to the system that would better prevent future maltreatment, as has been shown in other industries.