For the past two years, one set of pipes has really captured my attention. If you follow the Public Great blog, you know that our guiding beliefs are that “the work of government is noble; the people of government are amazing; and the systems (or the pipes) of government are a mess.” Nowhere is all of this more evident than the pipes we work in to keep children safe.

According to the American Humane Association, approximately 12 in every 1,000 children are victims of abuse or neglect. Is there a nobler calling than to protect those who cannot protect themselves? As a nation, I would hope we can all agree that investigating child abuse allegations and helping the 900,000 kids living in these circumstances is something we should be doing with our tax dollars. This is the work of government at its core. We can argue about how we do it and the effectiveness, but as an outcome, keeping children safe is a noble pursuit.

Have you met some of the people who have dedicated their professional lives to this cause? I went on a ride along with some of them in the late ‘90s, and by the third home we visited, I was a mess. I was in no way prepared to see the living conditions and deal with the parents face to face. I couldn’t do that every day. I’m not wired that way. My host had been doing it for seven years and went on to do it another four or so before taking a desk job in the agency. He loved what he did, and he’s not alone.

In the two years since I’ve been concentrating on these pipes, I’ve met scores of workers who won’t let bad pay, horrible working conditions and outrageous caseloads deter them from their calling to protect kids. These are truly amazing people.

So we have a noble outcome helping to be achieved by amazing people, but the process from the hotline call until the case gets closed is an absolute mess. I lost track of the articles I’ve read where a child was hurt or killed who was “in the system.” These become high-profile fatalities that lead to blue ribbon commissions and special investigations that lead to suspicions and suspensions that lead to policy changes and promises — until the next high-profile fatality and the cycle begins again. Backlogged cases, follow-ups that never get followed up on and caseloads that overflow from the cubicle to the hallway all contribute to the gunked up, kinked up, twisted up pipe that traps these amazing people inside and robs us of our capacity to do more for these kids.

So, what have I learned about this noble, amazing mess? CYA — what we like to call “cover your assets” safeguards we build into the work — is killing children. Well, to be very clear, the only thing physically hurting these children is the person abusing them. But the root cause of most of the problems in this area is the CYA of the past that we’re still dealing with and the fact that we continue to contribute to it.

CYA almost always starts out with the best intentions — no one wants to gunk up the pipe. When something goes wrong (and in this pipeline, usually that means tragically wrong) we instinctively want to put in place some new rule, procedure or policy to assure that it never happens again. What we hope is that whatever was missed will be caught, whatever was dropped will be held onto, and whatever was forgotten will be remembered. Often our only recourse is to discipline whoever was involved and then establish some new way to do the work to help others avoid the same situation.

The alternative — telling people a mistake was made and chalking it up to “life happens” — is the fastest way to seeing a series of articles in the local paper about the ineptitude of child protective services (CPS) that end with one about the director “stepping down to spend more time with family.” But, the truth is: Sometimes, “life happens” would be the best answer and would do the least amount of damage.

The problem with CYA is it almost always kinks the pipes, adds more work or builds in the redundancy that eventually slows down the work. Our attempts to build quality assurance actually damage the overall process and that typically means quality suffers in the long run.

Here’s a hypothetical example: A call comes in from a daycare center about 3-year-old Billy who’s been coming in wearing soiled clothing, looking malnourished and weak. The daycare employee hopes someone at CPS can check in on Billy and assure his well-being. CPS sends out an investigator to the daycare to talk to Billy, then visits Billy’s home to interview his mom. Billy’s dad, however, never shows up to the interviews and doesn’t return phone calls. The investigator notes that, while life is hard for the family, there’s no immediate indication of criminal neglect or abuse, so the report goes into a pile that needs to be completed but can’t be until the dad is interviewed. It’s in the pile, but as far as we can assess, Billy is safe.

Unfortunately, a month later, Billy is left unattended and drowns in a neighbor’s pool after wandering through an open gate and falling in. The reporter covering the story finds out that Billy’s family was investigated by CPS for neglect 30 days earlier. A call to the agency for comment shows that the case is still listed as open and now has been for some time. An unsupervised 3-year-old and a pool gate without a lock seems like neglect to both the public and the agency, so they question the investigator’s assessment. The media conclude that a more complete investigation would have led to a more informed decision and maybe even a life-saving removal of Billy from his parents. Four articles later, the governor is calling for child welfare reforms across the state.

Now comes the CYA. There’s a mixture of reactions to the boy’s tragic death, which include speculation and pressure to do something, and “Billy’s Law” passes with bipartisan support. Now all CPS house visits must include a visual confirmation of pools within a reasonable distance, assurance of proper fencing sizes, and confirmation that childproof locks are present and functional. Maybe it doesn’t seem like much, but Billy’s Law increased the time to complete an investigation and potentially added more people to interview.

This might be an extreme example, but ask anyone who works in child protection and they can trace almost every policy change to an incident, each of which — like Billy’s Law — added just a little extra to the time it takes to do their jobs.

How much time? I worked with a team that had more than 20 hours of labor needed to finish a single case. On good weeks, they got three new cases; bad weeks could bring seven or more. That’s 60 to 140 hours of work per worker, per week. You don’t have to be a math major to know that it cannot physically be done in a 40-hour workweek. If you’re lucky, when Fridays come around, you’re just 20 more hours behind than last week. This is why we read about horrendous caseloads.

CYA adds time; added time leads to backlog; backlog leads to higher caseloads; higher caseloads make it impossible to keep up with everything; and failure to keep up forces investigators to do the minimum to assure a child’s immediate safety.

Still, of all the teams I’ve worked with in this area of government, and all the “aha” moments we’ve had, none of us have come up with a foolproof way to stop the foolishness of CYA. We know it’s going to happen the next time there’s a high-profile incident. What we have been able to do is go back over the past 20 years of CYA that we’ve incorporated into our work and begin to straighten the pipe and clean it up.

While we may not be able to make our pipes CYA-proof, we can reduce the need for CYA by removing the obstacles that these amazing investigators face so that they can more easily and efficiently do their jobs and, ultimately, help the families they work with. The more time they can spend on the true work and not the gunk, the more safe kids we have. More safe kids leads to less incidents, and less incidents is the only way to reduce CYA.

CYA doesn’t really kill kids, but it does prevent employees from doing everything they can to keep them safe. By fixing the pipes of child protection, we can increase our capacity to do good. The next few articles you’ll find on Public Great are going to be dedicated to child protection and how we fix this noble, amazing mess.

*Originally published as CYA is Killing Kids (Public Great @, June 25, 2013)

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