The 'Paper Pipe' and the 'Practical Pipe'

Part 2 of the tale of the overworked social worker.
by | February 14, 2012

Let's pick up where we left off in last week's Part 1 post, with our tale of Robin, the beleagured social services worker:

The pile of cases on Robin's desk is now larger than it has ever been before. Knowing each day that the hole she's in continues getting deeper has introduced new stress into an already stressful job. She takes work home at night and on the weekends, but there is only so much time she can dedicate in her off-hours. And without her work computer, there is only so much she can do.

There are deadlines for everything. Accountability measures set by a time management consultant mandate how long she has to do her work. (They would be the root cause of the stress if they were not so unrealistic as to be comical.) The real source of the kink in Robin's neck is knowing that she's having to take shortcuts just to keep her head above water.

The investigation and interviews with the families are critical to the assessment, and Robin can sleep at night knowing she has put eyes on every family in every case file. It's everything else that is not "in alignment with policy" that has her contemplating acupuncture. It's not having the time to follow up with a step-sibling who lived in the home over the summer but moved back with his mom. And it's not that, after 4 failed attempts, she needs to again follow up that the parent called the community services they promised they would. And it's not that Robin knows she'll be up late putting all her notes into the system.

So many policies and practice guides that outline every step she is supposed to follow. Robin's been trained on each, and then retrained and reminded after each high-profile incident exposes a step that was not followed. The stress is knowing that if something were to happen to one of her families, not every policy was followed to the letter. Despite her intentions, there just is no time to do everything the central office wants done. So she does what she can to put eyes on the families and assess the safety and risks as best she can.

There are two very different pipes in this story (and throughout government).

One pipe is the "paper pipe." It includes the policies, practice manuals and regulations that clearly explain how the pipes should work. The paper pipe is full of well-researched methodology, it's ingrained into new employees ad nauseum, and it can be quoted by most folks at the central office. Question the "paper pipe" and expect a story. Every policy is tied to a child's name, a missed opportunity to intervene, a circumstance where we coulda, shoulda, woulda.

The other pipe is the "practical pipe," or the real-world pipe. It's the way the process actually works in the field. It sidesteps time-consuming processes that rarely yield assistance to the case, and it prioritizes based on the backlog of cases and the time at hand. This process is not defined anywhere, but question it and every worker and supervisor can justify each step, each work-around.

The feeling is that if workers could just do the paper process, we'd be OK. However, in almost every news article we read, the paper process was not adhered to, and the consequences were dire. How can amazing people — people who care so much — fail to follow the well-planned steps in the paper process? Why are they so bad at their jobs? Why do factors 1 and 3 contradict each other so? Because of 2.

When the pipes are this full, we lose the capacity to keep up with the volume. We have no choice but to work under tremendous pressure and try to find any way we can to move the water through the pipes. What do amazing people do? They do their best to make sure kids are safe.

Of the 22 hours of work needed to be done to complete a case, more than a third of the time is spent documenting the investigation. The computer-based documentation template is designed to assure workers have done the paper pipe and really thought about every indicator of risk and safety. Then documented it. There is a popular saying among management: "If it isn't documented, it never happened."

With up to five new cases to do each week, documentation was slipping. Most workers were putting the priority on getting to the family, interviewing the child and guardians, and completing an investigation. If the child was as safe as we could assess, the documentation was ready to be completed, but before we could get to it, there was a new case, and a new family to go out and see. Soon we have 10, 20, 60 cases that need to be entered into the system, but the water continues to flow in, and we continue to head out.

This volume meant that of the 22 hours of work, half was being done within days of the initial call, but it was going to be 220 days before the case was finally fully documented and closed.

How does 22 hours become 220 days? Imagine you get three reports on Monday. Tuesday you see Family 1: A head-lice report from a school nurse started the investigation, but the child is well cared-for and mom and dad appear to be good parents. Family 2 has a child showing bruises on his face and arms. He says they are from rough -ousing with his older brother, but there have been prior reports from this family. The paper pipe says facial bruises mean a mandatory trip to a doctor for assessment, but mom cannot commit to getting the child in to the hospital and dad cannot be found. Family 3 you meet portions of at the hospital that night. The child has broken bones and he will not be returning to the home tonight. It's up to you to find placement and work with law enforcement.

Documentation: Family 3 has to be done now: Chances are you're going to be in court in a day or two to defend taking a child from their parents. You also need to check on any other children in the home and interview every adult who has lived with the family or could have interacted with the child. You still need to get back in touch with Family 2 to see if the child has seen a doctor, or you need to go out and temporarily take custody and assure the visit occurs. Family 1, the call from a school nurse that found head lice? That's gonna have to wait until these others are done.

Imagine that's a slow week. It's no wonder documentation is a low priority. But without it, we have no record of being there and of what we saw. Imagine Family 1 actually has a backlog of allegations of neglect, but each of those cases is still open, so the latest worker never saw the case notes.

It's not the workers. They are trying to get to the families as fast as possible, and they really want to keep these kids safe. But the pipes are making it harder.

The answer? Hire more people.

Fat chance, in this economy. But believe it or not, finding money would actually be the easy part. The bigger issue? There aren't any people to hire.

For years, people with the qualifications and aptitude for this work have been hard to find. This isn't a job where any warm body will do. Under the immense pressures of social work, many employees quickly tire of the seemingly endless stream of hurt and neglected children. I was done after one day of ride-alongs. I couldn't last a week, let alone a career.

People are not the answer: The real answer must be in the pipes. In the paper pipes, the practical pipes, and the way work gets done. The best workers are carrying over a dozen open cases. Their pile is smaller than others, but even if you could clone the absolute best people, you're still behind. If you don't change the work, you can't change the results.

The team in this case worked to eliminate more than six hours of actual worktime by re-doing the way documentation is handled. Paper-process advocates argued the documentation is when critical thinking occurred. I hope not, since it wasn't done for months after the actual investigation.

The team also changed the roles of the supervisors and workers and modified the computer system to allow work to flow more naturally. These changes together, on paper, should bring closure times from the 220 days closer to 40. It will be a long time before they see that though. The mountains of backlogged reports are still there, and the process is just in a piloting phase in several areas around the state. However, there is finally a light at the end of the tunnel.

Will it make kids safer? I hope so. I hope it frees up workers to spend more time with families and more time following up on cases. That's what they want to do, what they got into this field to do. We just need to get them working in pipes that are designed for the volume of work that flows through them and relieve a little bit of the pressure.

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