Runtime: 2018 - 2019
Client: Inspectie Gezondheidszorg en Jeugd (Dutch Health and Youth Care Inspectorate)
Co-operation with NIVEL, Utrecht.
The Dutch Health and Youth Care Inspectorate (IGJ) and the Security and Justice Inspectorate jointly carry out national supervision within the framework of the Youth Act. When the inspectorates investigate sentinel events (calamities and violent incidents), they do this to prevent recurrence within the specific institution. Inspectors increasingly find the lessons learned from these individual investigations to be relevant for other institutions as well. To this end, the inspectorates make their investigative reports public and write summary reports and reports about the underlying causes of various incidents.
In this research we focus on the need for the IGJ and others to contribute to the quality of youth care with its monitoring of incidents, and we focus on their aim to stimulate a culture of learning. Currently, there is insufficient insight into the extent to which youth care institutions learn from the ways in which incidents are being supervised by the inspectorate. In addition, there is insufficient insight into which factors influence the learning ability/abilities of youth care institutions, and what approach might fit best with practice. What is needed to learn from things that went wrong? In this research we particularly explore how one might learn from incidents occurring at institutions and organizations other than your own. How do professionals and organizations in the field of youth care learn from the incidents occurring in other organizations? Insights into these content and structures of these practices of learning is necessary to be able to determine exactly if, how and why the inspectorates can promote such ‘sector-wide’ lessons: what do the (im) possibilities of sector-wide learning mean for the role and method of the supervision of youth care facilities in the Netherlands?
Practically we will examine the policy theory behind the monitoring of incidents; what is the method of the inspectorates and how are people expected to learn from this? In addition, the aim is to address the underlying, more fundamental question about the significance of learning from incidents. We aim to reflect on the role that incident can play in a system that learns and on how the inspectorates might be able to play a role in this.
Results are expected to be published by the end of May 2019
Team
ESHPM: dr. Kor Grit, dr. Bert de Graaff, Judith Venderbos, BA
NIVEL: Prof. dr. Roland Friele, dr. Mattanja Triemstra