Supporting a Safe Culture that Surfaces Problems: Transforming Child Welfare into High-Reliability Organizations

Heather H. Kestian
Deputy Director for Strategic Solutions and Agency Transformation, Indiana Department of Child Services

While working in child welfare over the course of the past 11 years, I have seen a number of excellent employees leave child welfare as a result of tragedy: a child fatality, a near-fatality, or serious injuries to a child welfare teammate. The initial response after such tragedy may be a call for someone to lose their job—someone must have done something wrong.

As a manager in field operations, I recall one night where I sat on the phone and discussed the decisions of the previous day with an employee who had asked whether we had made the right decision. I remember hearing my phone ring, turning over to look at the clock, and noticing that it was early in the morning hours.

“Department of Child Services. This is Heather.”

“I need to know we made the right decision. Did we get it right?” The voice on the other end needed reassurance. I remember hoping I had chosen the right words of support. This is a question that is repeated across the country, countless times a day, that affects thousands of children, families, and employees: Did we make the right decision to leave a child at home? Did we make the right decision to remove a child from their family and their familiar surroundings? Did we properly assess safety? Did we understand the risks? Did we sufficiently mitigate the risks and provide reasonable efforts to prevent removal? Is there anything else we could have done?

I began my career in child welfare as a local office attorney for the Indiana Department of Child Services. It was in this role that I learned how to litigate and present sufficient evidence to support the agency’s decisions. It also was in this role I learned how to translate legal elements into a meaningful conversation with social workers so that when we arrived at court, we understood our shared objective with similar language and a common understanding. Sometimes, our positions were quite different, and the way in which we saw a set of facts and circumstances varied. Comparing the facts of a situation to what is permissible and reasonable according to the law sometimes left both sides wondering which position was better at ensuring child safety and risk mitigation. I learned—after all of those conversations—that creating a safe environment in which to share our different perspectives and have challenging conversations allowed us to develop a reasonable, prudent course of action together.

Shortly thereafter, I spent time as an administrative law judge (ALJ) for the Indiana Department of Child Services, reviewing, among other things, the decision of the agency to substantiate child abuse and neglect. Here, I learned to listen more, talk less, and weigh differing perspectives. This role gifted me the ability to be able to see what happened through a variety of lenses. In reviewing what the agency had decided, themes began to appear that begged the question: “What can we learn from this situation?”

While working in field operations, I experienced the tragic loss of a child who had been involved in the child welfare system. The feeling of that loss is indescribable. The fear that accompanied the loss—as a secondary response to the tragedy—consumed staff members. We asked a lot of questions: Whose fault is this? Did we make the right decision? Who was involved in the decisions? What could we have done differently?

It wasn’t until I began to understand continuous quality improvement that I learned that I had not been asking the right questions or in the right manner. People will not be honest about the issues within the system until we support a culture where it is safe for them to do so. Adopting and embracing safety science will help child welfare organizations move from a fear-based culture to a safety culture focused on open dialogue and authentic engagement of those who are closest to and most knowledgeable about the work.


Heather H. Kestian has been a licensed attorney in good standing with the Indiana Supreme Court since October 2008. She joined the Indiana Department of Child Services (DCS) in 2008 as a local office attorney where she represented the agency in Child in Need of Services (CHINS), Termination of Parental Rights (TPR) proceedings, and in appellate matters. She has served as an Administrative Law Judge for DCS, a Local Office Director for DCS, and the Collaborative Care Field Director. She currently serves as the Deputy Director for Strategic Solutions and Agency Transformation (SSAT). In this role, she works with quality service assurance, continuous quality improvement using Lean and Six Sigma principles, research and evaluation efforts, as well as safe system implementation. She graduated cum laude from the University of Toledo College of Law in May 2008. During the first semester of law school, she attended a CASA training program and was sworn in as a CASA volunteer.