Best Practice & Avoiding Errors

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Presentation transcript:

Best Practice & Avoiding Errors Kemshall, H., Mackenzie, G., Wilkinson, B., (2011) Risk of Harm Guidance and Training Resource CD Rom, De Montfort University

Likelihood Impact Imminence Over estimating risk Under estimating risk Balanced Risk Judgements Kemshall, H., Mackenzie, G. & Wilkinson, B. (2011) Risk of Harm Guidance and Training Resources CD ROM. De Montfort University

Methodological Sources of Error Actuarial The group rather than the individual Re-conviction rather than re-offending Clinical Research done and made available Knowledge changing over time Confusion between cause and effect Lack of information about particular groups Lack of attention to resilience Kemshall, H., Mackenzie, G. & Wilkinson, B. (2011) Risk of Harm Guidance and Training Resources CD ROM. De Montfort University

What Goes Wrong in Planning might include Incomplete understanding of the behaviour - moving to solutions too soon. Assuming a risk factor is relevant to offending when it is not. Competing solutions that undermine each other's effectiveness. When something isn’t working doing more of the same, ‘turning up the volume’. Avoiding doing what needs to be done, using confusion about influences on offending to excuse inactivity. Kemshall, H., Mackenzie, G. & Wilkinson, B. (2011) Risk of Harm Guidance and Training Resources CD ROM. De Montfort University ie, G. & Wilkinson, B. (2011) Risk of Harm Guidance and Training Resources CD ROM. De Montfort University

The Iceberg Model External World Actions Feelings Thoughts Kemshall, H., Mackenzie, G. & Wilkinson, B. (2011) Risk of Harm Guidance and Training Resources CD ROM. De Montfort University ie, G. & Wilkinson, B. (2011) Risk of Harm Guidance and Training Resources CD ROM. De Montfort University

The Iceberg Model External World Actions Filters on our perceptions Feelings Thoughts Kemshall, H., Mackenzie, G. & Wilkinson, B. (2011) Risk of Harm Guidance and Training Resources CD ROM. De Montfort University ie, G. & Wilkinson, B. (2011) Risk of Harm Guidance and Training Resources CD ROM. De Montfort University

Sources of Bias and Error Value base Discrimination Invalid models Self belief of the assessor Unreal optimism Being afraid Perceptual bias Representative Confirmation Availability Kemshall, H., Mackenzie, G. & Wilkinson, B. (2011) Risk of Harm Guidance and Training Resources CD ROM. De Montfort University

Obstacles to Fair and Effective Risk Decision Making The busy screen Under or over critical appraisal of information The ‘decoy of dual pathology’ (Hollows) Our personal knowledge of the person Knowledge of the group to which the person belongs Kemshall, H., Mackenzie, G. & Wilkinson, B. (2011) Risk of Harm Guidance and Training Resources CD ROM. De Montfort University ie, G. & Wilkinson, B. (2011) Risk of Harm Guidance and Training Resources CD ROM. De Montfort University

Professional Reciprocal Enforcing Avoiding Kemshall, H., Mackenzie, G. & Wilkinson, B. (2011) Risk of Harm Guidance and Training Resources CD ROM. De Montfort University

Effects of Self Efficacy Beliefs Choices Effort Perseverance Resilience Thought patterns Kemshall, H., Mackenzie, G. & Wilkinson, B. (2011) Risk of Harm Guidance and Training Resources CD ROM. De Montfort University

Nurturing Skills and Efficacy Beliefs Managers who Focus on quality not just on targets Observe practice Provide clinical supervision Provide coaching opportunities Supported by Team discussions and practice seminars Peer coaching Kemshall, H., Mackenzie, G. & Wilkinson, B. (2011) Risk of Harm Guidance and Training Resources CD ROM. De Montfort University

Systemic Failures Individual Assessor The Systems & offender Processes Kemshall, H., Mackenzie, G. & Wilkinson, B. (2011) Risk of Harm Guidance and Training Resources CD ROM. De Montfort University

Some Questions ? Responsibilities ? Limits and boundaries ? Clear and realistic standards and priorities ? Appropriate supervision Kemshall, H., Mackenzie, G. & Wilkinson, B. (2011) Risk of Harm Guidance and Training Resources CD ROM. De Montfort University

Processes in Discussions No alternative Initial impressions Decisions first criteria second Impact overwhelming likelihood Strength of opinions Kemshall, H., Mackenzie, G. & Wilkinson, B. (2011) Risk of Harm Guidance and Training Resources CD ROM. De Montfort University

A Focus on Quality Have sufficient depth of knowledge and skills to keep a focus on the whole picture for each individual. Generate case formulations, or whole case hypotheses, to pull all of the information together and prepare a risk management plan tailored to the needs of the individual. Regularly review their assessments to change these formulations in the light of changing information. Kemshall, H., Mackenzie, G. & Wilkinson, B. (2011) Risk of Harm Guidance and Training Resources CD ROM. De Montfort University

Making Sure Your Voice is Heard Critically reflect on the quality of your own practice Constructively raise organisational blocks to good risk practice by Analysing clearly what you are concerned about. Trying to identify the ‘root cause’ of the problem. Evidencing your constructive criticism Kemshall, H., Mackenzie, G. & Wilkinson, B. (2011) Risk of Harm Guidance and Training Resources CD ROM. De Montfort University

Planning for Developing Practice Increasing knowledge and skill Critically reflecting on own decision making Understanding the perspectives of others Kemshall, H., Mackenzie, G. & Wilkinson, B. (2011) Risk of Harm Guidance and Training Resources CD ROM. De Montfort University

Key Messages Unnecessary mistakes in risk judgements can arise from Methodological error Human error Systemic error Both individuals and organisations have to take responsibility for minimising error Centrality of Public Protection Kemshall, H., Mackenzie, G. & Wilkinson, B. (2011) Risk of Harm Guidance and Training Resources CD ROM. De Montfort University