Being ‘preoccupied with failure’ can lead to protecting our kids

By Peter Finney Jr., Clarion Herald

As a Catholic pediatrician who specializes in treating children who have been sexually abused, Dr. Angelo Giardino is shaken every time he hears kids explain in their own words how they were violated by a trusted adult.

“That is something you never want to hear again,” said Giardino, the Philadelphia-born chair of the department of pediatrics of University of Utah Health in Salt Lake City.

Reflecting on the principles of the military and the nuclear power, airline and medical industries – where one inadvertent mistake can lead to a catastrophic failure – representatives of seven Catholic dioceses across the country met in New Orleans last week to continue their discussions on how the church can incorporate “high reliability organization” (HRO) practices into its commitment to eliminate sexual abuse.

Blazing a new trail

The pilot program, sponsored by the United States Conference of Catholic Bishops’ Office of Child and Youth Protection, hopes to develop a learning collaborative for all dioceses in the country.

“I believe adopting this high reliability organization set of principles will be transformational so that we can get ahead of this issue and not always be responding to the problem,” Giardino said. “This is what would get us ahead of it. That’s why it’s been so important to stick with this. This is the kind of organizational work that will prevent abuse.”

Learn from failure

The five principles are straightforward. The first starts with “a preoccupation with failure” – where a problem is dissected after the fact to see exactly what went wrong and how to put procedures in place to prevent it from happening again.

It is a foundational military principle that has worked its way into other industries where one mistake can have grave consequences, Giardino said.

“The preoccupation with failure is that you’re absolutely committed to preventing failure,” Giardino said. “You’re preoccupied with it, so when it happens you want to learn everything about it so that you can hard-wire things in your environment so that it never happens again. You’re absolutely preoccupied with learning from the failures because you know they’re going to happen.”

Guiding principles 

Other principles include:

  • Reluctance to simplify: “It means not overgeneralizing and not simplifying things, like, ‘Oh well, stuff happens. Well, what did you expect? You know, there’s always one bad apple,’” Giardino said.
  • Sensitivity to operations: “How do you make sure that you pay attention to what the people on the frontline are seeing and are concerned about and who know what’s happened?” Giardino said.
  • Commitment to resiliency: “You have to show up for work every day, and there’s a million other things you have to do, so how do you stay resilient?” Giardino said. “You can always deal with the failure, but you also have to deal with your other job.”
  • Deference to expertise: “That doesn’t mean deference to the expert or the leader,” Giardino said. “Sometimes the expertise is with the leader. Sometimes it’s with the person who sweeps the floor, because at the times they are sweeping the floor, they are seeing what’s happening. It’s always being willing to defer to the person who knows the most, so there’s a spirit of humility involved in that.”

Hospitals use system

Giardino says the system used by hospitals, adopted from the military, involves a brief operational briefing each morning.

“You say, ‘Was there anything that happened in the last 24 hours where someone was harmed? Do you anticipate any problem in the next 24 hours? What do we need to do to prevent or fix that?’” Giardino said. “It takes 15 minutes a day, and when that happens, you just start to sensitize everybody to what needs to get done.”

In a hospital setting, the problem might be that there was confusion in the operating room with a particular blood supply, Giardino said. That confusion can be shared with other hospitals to see if they experienced the same issue.

“Maybe they’ve never had that problem,” Giardino said. “But maybe they do have the problem, and they didn’t know they had a problem. But now they’re sensitized to it and now they prevent it, and it never has to happen again.

Military culture can help

Deacon Bernie Nojadera, executive director of the USCCB’s Office of Child and Youth Protection, said he learned the principles during his time in the Navy and the National Guard.

“It’s encultured, it’s part of your muscle memory,” Deacon Nojadera said. “There is always situational awareness and mindfulness. The idea is that responsibility is shared, not just on a few shoulders but on everyone’s. In the military, if you’re going to survive, you’ve got to make sure the person on your right and your left know what they are doing. That’s the only way you feel confident that you’re going to be OK, because someone’s got your back. Everyone carries that role out completely, competently and consistently.”

Giardino, who served for two terms on the bishops’ National Review Board, said many times it is the person on the “front lines” who picks up a “weak” signal that something just isn’t right.

“It’s just like someone telling you, ‘I’m noticing this, but I don’t know what it means,’” Giardino said. “But that ‘weak’ signal might be telling you that a strong signal is going to happen. So if you’re sensitive to the operation, that information is coming up to you as the coordinator or the director.”

Deacon Nojadera and Giardino envision the pilot dioceses – Kansas City-St. Joseph, Columbus, Gary, Manchester, New Orleans, Baton Rouge and the Romanian Eparchy of St. George in Canton – eventually training other dioceses in the HRO principles.

“We don’t have to reinvent the wheel,” Deacon Nojadera said. “We’re charting a new course (for the church). We’re the ones drawing the map.”

Dioceses can teach others

“It’s an ‘all teach, all learn’ collaborative,” Giardino said. “You don’t have to always have that problem in your own diocese to fix it, because that’s a very slow way of perfecting the church. As we work together, everybody who learns something shares it. You’re not doomed to create or experience that for yourself. From a hospital’s perspective, this format works. It’s been transformational.”

Regina Quinn, director of the safe environment office in the Diocese of Columbus, said diocesan officials reviewed its procedures last December when a priest accused of “excessive and questionable text and telephone communications with a minor” committed suicide by jumping to his death from the balcony of a Chicago hotel.

The priest, Father James Csaszar, had been placed on administrative leave while the charges were being investigated.

In the aftermath, the Columbus Diocese was proactive in going to the parishes where Father Csaszar had served, “not to glorify the priest but for the parish,” Quinn said.

“We offered social workers and did grief counseling,” she said. “We talked about what we had done correctly and how we could prevent this in the future.”

Alleged sexual predators are at a higher risk for suicide,  said Quinn, a former military lawyer, “because they always thought they were above the rules, and once they get called in by the police, once that mask is stripped away, they can’t handle it.”

That should prompt every diocese to try to assess more closely the accused’s mental state when charges are brought forward. 

After two days of meetings in New Orleans, the pilot group decided to focus next on using technology to share information on HROs; to create a “Train the Trainer” process, including a facilitator guide, to get additional dioceses trained; and to emphasize the theology involved with the HRO process.

Giardino’s first-hand experience treating child sex abuse victims has compelled him to get involved in stopping it.

“I don’t want to just be good at responding to previous cases of abuse and holding people accountable, which we have to do,” Giardino said. “What I’m really interested in is preventing it. My prayer is that 20 or 30 years from now, we’re going to say it’s likely that you would never be abused in the church because we have so many systems in place that it would be impossible.”

Peter Finney Jr. can be reached at pfinney@clarionherald.org.

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