Culture of Safety: Part 1

10 Actions to Create a Culture of Safety: Part I

Steve Shuman: The Head Start National Center on Health has developed this two-part presentation to introduce Head Start and Early Head Start staff to safety and injury prevention strategies and resources. We strongly encourage you to plan on viewing both parts. At any time, you can download the foundational document for today's recording 10 Actions to Create a Culture of Safety and all the supplemental materials for this presentation from the Early Childhood Learning and Knowledge Center or ECLKC. Look for the materials link underneath the link for this recording. My name is Steve Shuman. I've been a Head Start director and have been providing technical assistance and training on early childhood public health topics since 1987. My colleague Nancy Topping-Tailby and I are from the Head Start National Center on Health. The work we do includes helping programs implement effective injury prevention practices. Nancy is also a former Head Start and Early Head Start program director and a behavioral health clinician who has worked with Head Start staff and families for more than 20 years. We have both worked at the local, state, and national level. Building a culture of safety is part of a program's vision for serving children and families.

Children are safer when managers, staff, and families engage in continuous improvement activities to enhance their safety and injury prevention strategies. In programs that embrace the belief that children have the right to be safe, everyone works together to create a culture of safety. They provide an environment that encourages people to speak up about safety concerns, makes it safe to talk about mistakes and errors, and encourages learning from these events. Based on a comprehensive literature review and analysis of key data sources, the Head Start National Center on Health has identified ten actions that programs can use to create safe learning environments. We will be talking with you about the topic of safety and injury prevention and how to make your program an agent for change using the 10 actions as a guide. 10 Actions to Create a Culture of Safety are concrete steps for implementing change. Participants of these two health chats will increase their awareness of the importance of safety and injury prevention, improve their understanding of how everyone can contribute to a culture of safety, identify ten actions to improve safety in their program and community, and identify related resources for professional development. Nancy will now put injury into a context for Head Start and Early Head Start programs. Nancy Topping-

Tailby: It's important to understand that injuries are not accidents. Most injuries are predictable and can be avoided. You can look at these swings and know that there is a greater likelihood of a child sustaining a head injury by hitting his head on the hard seat. You can easily predict someone will slip and fall on the banana peel.

The National Center on Health developed this presentation to help you recognize early warning signs so you can reduce the number and the severity of injuries to children and adults in your program. Injuries are preventable, and Head Start staff are expected to prevent them. Safety features such as smoke detectors and childproof pill bottles, emergency procedures, and well maintained playgrounds will prevent injuries. Safety and injury prevention requirements are found throughout the Head Start

Program Performance Standards. Head Start staff demonstrate safe practices to prevent injuries to children and teach families to recognize and eliminate hazards.

Young children develop rapidly, exploring and experimenting to build new skills and learn what is safe. In order to promote optimal development, each Head Start program plans, implements, and evaluates actions that provide safe environments for children so they can become active and competent learners. According to the Centers for Disease Control and Prevention, or the CDC, injury and violence accounted for more deaths than infectious and non-communicable diseases combined among people ages 1 to 44. The leading causes of injury deaths differ by age group. For children younger than one year of age, two- thirds of injury deaths are due to suffocation.

Transportation, drowning, and fire are the leading causes of injury-related deaths among children ages one to four. Yet fatalities are just the tip of the iceberg. Most injuries do not result in death and are treated at home or at the Head Start center. More serious injuries may require a trip to emergency departments or even hospitalization. As with injury deaths, non-fatal injury rates vary by age group.

Looking at the pink slice of this pie chart, you can see that children age-eligible for Head Start and Early Head Start are among the most vulnerable. Here we see that falls are the number one cause of unintentional injuries. These injuries often result in a need for urgent care. Note that drowning is not listed here because this chart shows causes of unintentional injuries, and drowning frequently results in a child's death. This is also true for fires or burns, poisoning, motor vehicle incidents, and suffocation, which accounts in part for why these injuries appeared less prevalent in the previous chart. Now Steve will introduce the 10 Actions to Create a Culture of Safety.

Steve: 10 Actions to Create a Culture of Safety represent important safety and injury prevention strategies found in the national data on successful programs. The 10 actions are: Use Data to Make Decisions, Actively Supervise, Keep Environments Safe and Secure, Make Playgrounds Safe, Transport Children Safely, Report Child Abuse and Neglect, Be Aware of Changes that Impact Safety, Model Safe Behaviors, Teach Families about Safety, and Know your Children and Families. Managers and staff use Head Start management systems to integrate these ten actions into all program activities. Staff and families work together to create a culture of safety, and each person understands his or her role and responsibilities in preventing injuries. Each action in the written resource includes a description of what it is, why it matters, steps for implementation, and additional resources.

Nancy: The first action is Use Data to Make Decisions. Head Start and Early Head Start programs can use their injury and incident data to protect the children in their care. Reviewing this data can help staff identify and eliminate hazards before they lead to injuries. Programs use their record-keeping and reporting systems to look at the who, what, where, when, how, and why of injuries and incidents both in the short-term, through ongoing monitoring, and over time through the Annual Self-Assessment. This data informs decision-making and allows programs to constantly improve their safety and injury prevention strategies.

The National Center on Program Management and Fiscal Operations has introduced four data activities that your management team can use with any of your program data. For our purposes, we'll discuss how to apply these activities to safety and injury prevention data. First you prepare. Then you collect. Then you aggregate and analyze. And finally, you use and share. In prepare, managers and staff need to consider what data to collect, who will collect the data, who will enter the data into the program's record-keeping and reporting system, and who will check the data for accuracy. Staff also collect data about incidents and injuries using report forms. The most useful forms, those that tell a more complete story, gather information about the who, what, where, when, and how of injury. This report form comes from Caring for Our Children, 3rd Edition, and you can find it in your supplemental materials. In addition to injury and incident reports, other tools that programs may use to collect their injury and incident data include but are not limited to safety checklists. Staff use these preventive tools to find and record any identified hazards within the child's environment. Checklists are available for homes, centers, and playgrounds; and Facility maintenance logs: Staff and managers can use this information to track the status of repairs or replacement of equipment after a hazard has been reported. Individual forms provide only a data snapshot. But if you have a tool to collect the information and you aggregate and analyze the data, then you can determine trends. These trends can tell you where and when children are most likely to be injured.

Hazard mapping is both a collection tool and a way to analyze aggregated data. Staff and managers use hazard mapping to pinpoint the locations where injuries happen to help them identify the most hazardous places within their program. In this example, you can see the locations of the most frequent injuries in this classroom. Using this data as well as the data in the injury report forms, you can then develop an injury prevention plan. You can find hazard mapping instructions in your supplemental materials. Use the data from your ongoing monitoring activities and other sources of data that you have collected, aggregated, and analyzed to implement program improvements, inform staff, families, your Policy Council and governing body members, and your Health Services Advisory Committee of your progress. Review this data again during your Annual Self-Assessment.

The second action is Actively Supervise. The quality of adult supervision is tied to childhood injuries. This means having the right adult child ratios and adults who are fully engaged in paying attention to the children in their care. Studies indicate that young children are more likely to get hurt when they are not adequately supervised by adults and especially when they are out of arm's reach. Active Supervision offers an effective strategy for adults to look, listen, and engage to prevent childhood injuries. Staff never leave children unattended. Position themselves so that they can observe, count, and listen at all times. And anticipate children's behavior and redirect them when necessary Young children may be seriously injured if they are left unattended. Staff who are trained in and always practice Active Supervision can prevent this from happening. Active Supervision includes six basic strategies.

Programs that use active supervision set up the environment, position staff, scan and count, listen, anticipate children's behavior, and engage and redirect. In the following slides, we will discuss each strategy one by one. These strategies can transform what some may consider a passive skill of how to observe children and make it an active, intentional skill with specific steps for how to supervise children effectively. These skills build on each other to help keep children safe by making sure that you can observe everything that's happening and take action when needed. They are intended to be used together, as you will see in the following slides. Setting up the environment includes the layout of the room as well as the selection of equipment and materials. Early childhood environments are not static. They change as soon as adults and children enter the room and are constantly changing throughout the day. The layout of the room allows the staff to see and hear children at all times.

The toys, materials, and equipment are developmentally appropriate, and the furniture and toys are in good repair. Items are placed appropriately to allow room for floor-time play away from walkways. Consider the number of centers and activities that are open at any one time and make sure that they are set up so staff can observe multiple centers at once. In this picture, notice that the lighter-weight toys, like the plastic dinosaurs, are kept on the top shelf. It is best to keep heavy toys on the bottom shelves in case a child drops them. Staff position themselves so that they can see and hear all the children and can reach a child quickly if needed. Staff move closer to a child who needs more support; for example, a child who's learning to feed herself, is newly mobile, or is learning to use new equipment. This will include deciding where to locate staff so that they can see and hear, but most importantly, reach any child easily who may need assistance. Scan and count the children constantly so that you always know how many children there are in your group and where they are. During transitions, it is especially important to scan and count even more frequently as we know that there is a greater risk of children being left unattended during transitions. It can only take a moment when children are moving from one place to another for a child to wander off or fall behind. In addition to the visual cues in your environment, you also need to listen carefully when you are with children. Sometimes a specific noise or even silence can indicate that there is a problem and someone is in danger. Being alert means being able to determine what sounds are expected and part of children's play and which ones may signal an indication of trouble; for example, when a child is becoming frustrated. A bell on the classroom door can alert staff to a child who is prone to running out of the room.

When you know the children in your care, you can anticipate children's behaviors based on their developmental level, interest, issues they may bring from home, and the skills they are working to master. You provide choices to engage each child and are able to recognize the sometimes more subtle signs that children are feeling ill or stressed so you can provide additional support at any given time. Ultimately, there are times when children may need you to engage and redirect them. Staff quickly intervene when problems arise. Providing alternative choices can decrease children's challenging behaviors and help them to problem-solve. For example, helping a child who is struggling with turn- taking can help him learn how to share with his friends. You can find Active Supervision: A Referenced Fact Sheet from the Head Start National Center on Health in your supplemental materials.

Steve: The third action is Keep Environments Safe and Secure. This is when children's spaces are free of hazards. Hazards may involve elements like heat or cold that could lead to burns, heat stroke, or frostbite; objects like tools, appliances, and small toys that could cause cuts, pinches, bruises, and choking; chemicals such as bleach, cleaning items, medications, and art supplies that could lead to poisoning; bites and stings from animals and insects; structural impairments that could lead to falls or lacerations.

As early childhood professionals, we know that children learn by exploring and experimenting. Because they are unable to fully assess risk, they trust the adults in their environment are keeping them safe without inhibiting their play. This means that when caregivers remove hazards from a play area, a child has more opportunities to develop safely in all domains. In a culture of safety, staff identify risks and remove hazards before injuries occur while maintaining developmentally appropriate challenges, thus creating a safe and secure environment for optimal learning.

What does keeping an environment safe and secure look like and how do we make sure it happens? First, conduct a safety check before every use with a reliable checklist. Checklists should be detailed enough to include the easiest-to-miss hazards. Once the hazards have been identified, prioritize the ones that are most dangerous by eliminating them immediately. If a hazard cannot be eliminated without assistance, limit a child's access to any unsafe area until repairs are completed. Use your Head Start recordkeeping and reporting system and your facility's maintenance procedures to report, repair and maintain your facilities and equipment including removing hazards and repairing or replacing damaged and missing equipment.

Programs ensure a culture of safety when they obtain developmentally appropriate equipment designed to eliminate or reduce injuries – for example, safety gates, outlet covers, helmets for children riding wheeled toys, smoke alarms and carbon monoxide detectors, cabinet locks, and appropriate surfacing. Since a culture of safety is everyone's business, programs can educate staff about maintaining safe environments and developing and consistently implementing policies and procedures for maintenance of facilities, materials, and equipment.

The fourth action is Make Playgrounds Safe. Action number 4 uses the same ideas from the previous two actions, Active Supervision and Keep Environments Safe and Secure, but concentrates them outdoors. Regularly inspected, well maintained, actively supervised, and age and developmentally appropriate outdoor play spaces allow children to engage in active play, explore the outdoors, and develop healthy habits. Children can climb, run, and play safely in outdoor environments that meet federal, tribal, state, and local requirements as well as best practices. All children need opportunities to play in safe outdoor environments in order to develop a healthy active lifestyle. Between 1990 and 2000, 147 children ages 14 and younger died from playground-related injuries; 82 died from strangulation, and 31 from falls to the playground surface. Most of these deaths, 70 percent, occurred on home playgrounds. While children are usually safer in quality early childhood programs than they are at home, if a child is injured in out-of-home care, it usually occurs on the playground. Adults need to know their children and their abilities, the risks involved on certain pieces of equipment, and the safety measures needed to eliminate or reduce injuries.

These five steps foster a culture of safety outside: Install safe structures; Maintain impact-absorbing surfaces; Keep fall zones clear; Actively supervise, and; Inspect and repair A safe outdoor play space starts with selecting and correctly installing safe and age and developmentally appropriate structures. Be sure that the equipment meets Consumer Product Safety Commission, or CPSC, recommendations and American Society for Testing and Materials, or ASTM, standards and that whoever installs the structures follows the manufacturer's guidance. The play space design should not be a hazard. Carefully separate active play areas, such as swings and slides, from quieter activities, such as the sandbox, nature-based learning, and dramatic play. A playground surface is the material that lies under and around swings, slides, climbers, and other playground equipment.

The surface material under the equipment should be able to cushion a child's fall. Unsafe playground surfacing material is the leading cause of playground injury. Surfaces such as asphalt, cement, dirt, and grass are not acceptable surfaces. Children falling on these surfaces have an increased risk of serious injury. Unitary materials such as tiles, mats, or rubber surface, like the one pictured here, are engineered to be sufficiently shock-absorbing. Always check with the manufacturer to make sure the product you want truly meets your needs. Loose fill such as sand, gravel, shredded rubber, or engineered wood fiber, when installed correctly, will also safely cushion a child's fall. Keep in mind that programs have an opportunity to introduce and even encourage young toddlers to wear helmets once they are able to ride and not just sit on wheeled toys.

While there's no perfect surface material, there are several factors to consider when choosing the best one for your outdoor play areas. Budget – Calculate the short and long-term maintenance and replacement costs as well as the upfront price of the surface material. Utilization – Estimate the number and ages of the children using the space, the access others may have nights and weekends, and your ability to maintain the playground. Labor--Decide if your program has the staff necessary to maintain the product you select on a regular basis. Climate --Factor in temperature, wind conditions, and precipitation. They all impact the surface materials you choose. Accessibility – Remember that very few loose fill materials are accessible for wheelchair users without significant accommodations such as a special wheelchair. Engineered wood fibers are designed to provide better access.

Solid or unitary materials are best for people with mobility impairments. Loose fill materials will compress at least 25 percent over time due to use and weathering. This must be considered when planning and maintaining the playground. For example, if the playground will require nine inches of wood chips, then the initial fill level should be 12 inches to allow for compacting. For more information on loose fill materials, see the CPSC Handbook for Public Playground Safety. We have included the handbook in your supplemental materials. No surface material is considered safe if the combined height of the structure and the child standing on the highest platform is higher than 12 feet. Even the best surfacing can't prevent all injuries. Staff always need to practice Active Supervision. The area under and around equipment is known as a fall zone.

These areas must be free of structural hazards such as benches, barrels, fences, and other pieces of play equipment. They should also be free of moveable hazards like trikes, toys, rocks, and groups of children. Since children at play often move objects around, it is essential to keep fall zones clear, and this requires vigilance. A playground surface cannot protect a child who falls into a hard object instead of the surface. These strategies apply to indoor as well as outdoor activity. Be intentional. When setting up the environment, be sure to consider site lines, distances between activities, and potential areas of concern such as a gate or wall. Position staff to maximize the number of children they can see at any one time and focus on the areas of greatest danger. Staff should continually scan, count, and listen, keeping the welfare of all children their utmost responsibility. We know that children transitioning from one activity to another are at a greater risk for injury, and during outdoor play, children are often moving around constantly.

Outdoor play is one of the times when staff attention to children needs to be the greatest. Anticipate children's behavior on specific pieces of equipment and areas of the play space. If there are too many children on one structure or they are misusing it, engage and redirect them to another part of the playground. If for any reason a staff person must leave the playground, remaining staff should reposition themselves so that no child is left unsupervised. Outdoor play spaces are subject to a great deal of wear and tear from use, misuse, and weather conditions. Once your program has correctly installed safe age and developmentally appropriate equipment, it still requires regular inspections and maintenance. Just as in action 3, Keep Environments Safe and Secure, conduct a safety check before every use with a reliable checklist. This so-called sweep will identify hazards that may have appeared suddenly, such as broken glass, syringes, or feces.

A daily safety check will also alert staff to any pieces of equipment that may have broken or worn since last being used. Loose or missing parts and sharp edges are often associated with playground injuries. Once the hazards have been identified, eliminate them immediately. If a hazard cannot be eliminated right away, limit a child's access to any unsafe area or equipment until repairs are completed. Use your facility's maintenance procedures to report and repair the equipment promptly. Monthly and annual inspections can inform a program of equipment that may need to be eliminated and/or replaced. This concludes the first part of our two-part presentation. Again, we strongly encourage you to plan on viewing the second part soon. You can download the foundational document for this recording, "10 Actions to Create a Culture of Safety," and all the supplemental materials for this presentation from the ECLKC. Look for the materials link underneath the link for the recording. Use these supplemental materials as well as the many injury prevention resources on the National Center on Health ECLKC landing pages where you will find tip sheets, interactive tools, articles, and checklists. The Head Start National Center on Health is available to answer your questions by email or phone.

Thank you for listening.