Introduction
The pursuit of learning is the characteristic that distinguishes high-quality service delivery systems. Organizations with a well-developed culture of excellence find ways to successfully identify improvement opportunities, implement strategies for change, evaluate change over time, and hardwire what they learn.
Teams are a crucial network of professionals in providing high-quality care. Safe, effective, reliable teams engage in six habits: spending time identifying what could go wrong; talking about mistakes and ways to learn from them; testing change in everyday work activities; developing an understanding of "who knows what" and communicating clearly; appreciating colleagues and their unique skills; and making candor and respect a precondition to teamwork.
Overview
The SSIT is an effective assessment tool for use in event analysis, such as the debriefing of serious or critical events. Rather than holding singular individuals responsible for a critical incident, the SSIT assumes the best intentions of all involved and dives supportively into how multilayered system factors misaligned and contributed to harm.
The SSIT is designed to help agencies learn and improve from incidents with the aim of high-quality care delivery broadly. Its ratings are generally intended for use in aggregate — threading learnings together across reviews to advocate for strategic and effective system improvements.
History & Background
The SSIT was first developed for use in Tennessee's Department of Children's Services' (TN DCS) critical incident reviews. Since 2015, it has been used to support the analysis of deaths and near deaths, reports to TN DCS' Confidential Safety Reporting System, and critical incidents not involving death or near death.
In 2019, Casey Family Programs led a team of twelve child-welfare jurisdictions to form the National Partnership for Child Safety (NPCS). By 2025, NPCS had grown to 39 public child welfare jurisdictions. Since 2019, the SSIT has been increasingly adapted for use across community and residential behavioral health settings for youth and adults.
SSIT Basic Structure
The SSIT is organized into four nested domains: a family working with a professional, who works within a team, who all work within an environment. The domains provide structure but are not mutually exclusive — they guide the reviewer into assessing all system levels.
Rating Items
Family Domain Ratings
| Rating | Observation | Retrospective Action Level |
|---|---|---|
| 0 | No evidence | No action was needed |
| 1 | History | Watchful waiting/prevention was indicated |
| 2 | Need interfered with functioning | Action/intervention was needed |
| 3 | Need was dangerous or disabling | Immediate action/intensive action was needed |
System Domain Ratings
| Rating | Observation | Appropriate Action Level |
|---|---|---|
| 0 | No evidence | No action needed |
| 1 | Latent factor | Watchful waiting/prevention |
| 2 | Influence to IO without proximity to outcome | QI action may be needed. Track IOs over time and compare with other quality data. |
| 3 | Influence to IO with proximity to outcome | QI action to protect against recurrence. May include case-level or system-wide education, ad hoc QI team, or system-level improvement projects. |
Improvement Opportunities
Improvement Opportunities (IOs) are actions or inactions in the case under review that are either relevant to the outcome or an important industry standard. The most important IOs are family-centered and describe what the family needed versus what they received from the helping system.
In order to rate an item in the System Domains as a 2 or 3, the item must be contributing to an identified IO. The SSIT is best used by someone well-versed in their system and current industry standards, who acknowledges the high-risk and complex sociotechnical nature of human service work.
Rating the System Domains: Proximity
Proximity differentiates between ratings of 2 and 3 in the three system domains. If an IO was close in time or distance and with relationship to the critical incident, a rating of Proximal (3) is appropriate.
Proximal (3) vs. Non-Proximal (2)
Example: If an infant dies in an unsafe sleep environment and the agency did not provide infant sleep education, tailored problem-solving and resources, SSIT items related to that IO are rated proximal (3).
If engagement with older siblings did not occur or collaterals were not contacted — also IOs, but not necessarily proximal. Those contributing factors would be rated 2.
System Domain Decision Scoring Tree
How to Score a System Domain Item
Family Domain
This section focuses on factors present in the family at the time of the critical incident. It documents the family, caregiver, and child/youth's needs — even if unknown to the agency prior to the incident. Unmet family needs identified here are potential Improvement Opportunities to explore during the review.
| Rating | Category | Action Level |
|---|---|---|
| 0 | No evidence | No need for action at time of critical incident |
| 1 | History | Need for "watchful waiting" at time of critical incident |
| 2 | Action needed | Action was needed at time of critical incident |
| 3 | Dangerous/disabling | Immediate and/or intensive action was needed |
Family Conflict
FamilyHow much fighting and arguing occurred between family members. Family or domestic violence refers to physically aggressive acts in which one or more family members might get hurt.
- Did members of the family get along well?
- Did arguments escalate to physical altercations?
Caregiver Developmental
FamilyDevelopmental disabilities including autism and intellectual disabilities. Includes experiences with inattention and hyperactivity (e.g., ADHD, ADD).
- Had the caregiver been identified with any developmental or intellectual disabilities?
Caregiver Mental Health
FamilyMental health needs only (not substance use). A formal mental health diagnosis is not required to rate this item.
- Did the caregiver have any mental health needs?
- Were the caregiver's mental health needs interfering with their functioning?
Caregiver Substance Use
FamilyProblems with alcohol, marijuana, illegal drugs and/or prescription drugs. A formal diagnosis is not required to rate this item.
- Did caregivers have any substance use problems?
Cultural Stress
FamilyExperience being treated as an "other" or not included/accepted in one's local community. Can diminish experiences of belonging, freedom, safety, and self-worth.
- Did the family experience community and connection?
- Did they have cultural experiences honored by or similar to those near them?
- Did they feel safe in their community?
Caregiver Economic Stability
FamilyThe caregivers' ability to consistently have met daily needs: affordable and safe housing, childcare, adequate income, healthy food, and reliable transportation. Temporary or at-risk government/non-governmental assistance warrants a rating of 2 or 3.
- Did the caregiver ever struggle financially?
- How economically stable was the family's life at/near the time of the critical incident?
Caregiver Parenting Behaviors
FamilyThe caregiving behaviors of primary caregivers. Rates whether the caregiver gave developmentally-appropriate care and followed the care-based recommendations of professionals (e.g., physicians).
- Did caregivers provide developmentally appropriate supervision, connection and protection?
- Did caregivers follow through on recommendations of professionals?
Child/Youth Medical/Physical
FamilyThe child/youth's medical/physical health. Most transient, treatable conditions = '1'. Most chronic conditions (e.g., diabetes, severe asthma, HIV) = '2'. Rating '3' reserved for life-threatening conditions. Formal diagnosis not required.
- How was the child/youth's health?
- Did the child/youth have any chronic conditions or physical limitations?
Child/Youth Developmental/Intellectual
FamilyThe child/youth's development compared to standard developmental milestones, and presence of developmental or intellectual disabilities. Includes IDD and Autism Spectrum Disorders, and challenges related to attention and hyperactivity (ADHD, ADD).
- Did the child/youth's growth and development seem age appropriate?
- Had the child/youth been screened for any developmental problems?
Child/Youth Mental Health
FamilyThe child/youth's mental health (not substance use). A formal mental health diagnosis is not required to score this item.
- Did the child/youth have any mental health needs?
- Were the child/youth's mental health needs interfering with their functioning?
Child/Youth Substance Use
FamilyProblems with alcohol, marijuana, illegal drugs and/or prescription drugs. A formal diagnosis is not required to rate this item.
- What was the child/youth's experience with substance use?
Professional Domain
This section focuses on factors primarily present within professionals. Largely intrapersonal in focus, this domain centers on the experience, knowledge, perceptions, and skills of professionals assigned to the family's care. Neither this domain nor any domain is created to assign individual blame — it offers an organized way to deconstruct perspectives before, during, and after decision-making.
Cognitive Bias
ProfessionalMental shortcuts that lead to errors in thinking, evaluation, remembering, or other cognitive processes (e.g., confirmation bias, cognitive fixation, focusing effect, transference).
- What were your thoughts when you received the referral/case?
- At the time of an IO, what were you expecting to see happen next?
Stress
ProfessionalPsychological strain or tension resulting from adverse or demanding circumstances. Professionals express or exhibit difficulty managing the strains of casework and/or other life circumstances (e.g., divorce).
- What were the pressures you faced, professionally and personally?
- How did that impact casework or specifically an IO?
- How do you know when you are stressed?
Fatigue
ProfessionalExtreme tiredness as a result of casework and/or other life circumstances (e.g., single parent, personal illness).
- What pressures contributed to fatigue, professionally and personally?
- How did that impact casework or specifically an IO?
- How much sleep had you received in the days preceding the IO?
Knowledge Base
ProfessionalAn absence of knowledge or difficulty activating knowledge (i.e., putting knowledge into practice).
- Was there anything you learned from this case that you previously had not known?
- Were there things you felt unequipped to assess or support?
Documentation
ProfessionalAbsent or ineffective official, internal records. Note: Only score a 2 or 3 if Documentation contributed to an IO — not if Documentation was the IO itself.
- If someone only read the notes, would they know what was going on?
- How did documentation challenges contribute to an IO?
Information Integration
ProfessionalDifficulties in obtaining externally-sourced information (e.g., medical records, criminal records, statements from key members, formal assessments). Note: Only rate 2 or 3 if this contributed to an IO. If knowledge gaps contributed to misunderstanding external records, rate under Knowledge Base instead.
- What records were requested, and were they received?
- How did challenges related to obtaining information contribute to an IO?
Team Domain
This section focuses on factors primarily present within teams. The pressures, communication, and climate of the team are considered here, with specific attention to the supervisor's unique role. This domain is not exclusive to internal teams — collaboration with relevant community partners is also assessed.
Teamwork/Coordination
TeamIneffective collaboration between two or more internal and/or external entities. Does not encompass the client's willingness or cooperation — only the team of helping professionals. Ineffective teamwork between a supervisor and supervisee is captured under Supervisory Support.
- Who was identified as "the team" working with this family?
- How did communications across the group occur?
- Were there challenges with teamwork or coordination that contributed to an IO?
Supervisory Support
TeamSupervisor provides ineffective support, communication, teamwork, and/or is unavailable.
- What support was received from supervisors during this case?
- What is supervision generally like on this team?
- What was the supervisor's leadership style?
Supervisory Knowledge Transfer
TeamCase direction from supervisor was inconsistent with best practice.
- What case direction was received from supervisors during this case?
- Was case direction aligned with best practice?
- What case direction occurred specific to an IO?
Production Pressure
TeamDemands on professionals to increase efficiency. Distinct from Demand-Resource Mismatch (DRM) — Production Pressure describes pressures within casework (e.g., overdues, extensive court involvement, child removals in other assigned cases). The presence of DRM may impact Production Pressures.
- What did your workload look like, and the workloads of your teammates?
- Did workload pressures contribute to an IO?
- What was happening in other cases during the time of this incident?
Environment Domain
This section focuses on factors present in the team's environment. This domain fosters an appreciative inquiry of the team's internal and external access to resources, policies, services, training, and technologies needed to support safe and reliable care delivery. Items refer to the public and private "helping macrosystem."
Demand-Resource Mismatch
EnvironmentA lack of internal resources or programs (e.g., inadequate staffing, limited access to drug testing supplies, insufficient funding for services) to carry out safe work practices. The absence of equipment/technology and external resources are scored in separate items.
- What was the staffing pattern at the time of this case?
- How long has it been that way?
- What problems did it cause in this case?
- What gets in the way of having adequate staffing?
Practice Drift
EnvironmentA widely-accepted, often gradient departure from work-as-prescribed. Usually occurs as a result of experienced success and as a means of managing production pressures. Uniquely describes an environmental (system-wide, county-wide, office-wide) departure from work-as-prescribed, and may involve a single or multiple child-serving agencies.
- Were workarounds present at the time of the case?
- Did these workarounds potentially affect the family in a positive or negative way?
- Was the workaround widely-used in the county or across the state?
Equipment/Technology/Tools
EnvironmentAn absence or deficiency in the equipment and technology used to carry out work practices. Tools refers to structured assessments and any related decision-making support.
- What equipment would have been helpful in this case?
- Were there difficulties in acquiring or using certain equipment or technology?
- Did assessment results make sense?
Policies/Rules/Statutes
EnvironmentThe absence, poor clarity, or ineffectiveness of an internal written practice or procedure. Conflicting policies would also be rated here, as well as other written rules, statutes, and procedures detailing work-as-prescribed.
- What policies, protocols, or forms affected this case?
- How did they impact decisions?
- What would have been more helpful?
Training
EnvironmentThe absence, poor clarity, or ineffectiveness of internal formal instruction. May include a variety of learning modalities: web-based, classroom, independent study, formal mentoring or coaching, etc.
- What trainings affected decision-making in this case?
- Were needed trainings helpful and available?
- What trainings would have been useful?
Public Service Array
EnvironmentThe unavailability or ineffectiveness of a particular public service. These services include county and state partners (e.g., public health, education/school, human services, court, law enforcement).
- What public services are available in the area?
- How accessible are those services?
- How effective do services appear to be?
Private Service Array
EnvironmentThe unavailability or ineffectiveness of a particular private, external and/or community-based service.
- What private services are available in the area?
- How accessible are those services?
- How effective do services appear to be?
Interactive Rating Sheet
Complete one rating sheet per case review. The SSIT is completed once and finalized at the closing of every review. SSITs are aggregated and analyzed on at least a quarterly basis to review findings and discuss trends. Narrative is required for all ratings of 2 or 3.
SSIT Rating Sheet
Quality Improvement Advocacy
SSIT action levels are not prescriptive. They are a steady and reliable guide for targeting system reform in the areas most likely to prevent a future critical incident. Items scoring "3" translate into a priority for action because the item influenced an IO proximal to a critical incident.
Organizational Recurrence Rating
| Rating | Description |
|---|---|
| 0 | Minimal or no likelihood of recurrence; problem appears a rare outlier. |
| 1 | History of recurrence that appears to have been successfully addressed through organizational improvement(s). |
| 2 | Likelihood of future recurrence. Though some organizational constructs exist to address the problem, it is unproven or disproven whether these will successfully reduce recurrence. |
| 3 | Minimal or no organizational constructs currently exist to address the problem. |
QI Advocacy Matrix
Use this matrix to identify and advocate for IOs that should be prioritized, considering both proximity (from SSIT) and recurrence likelihood.
Advocating for System Change
Those tasked with reviewing critical incidents rarely have formal authority to move systems to change. Their success lies in their ability to effectively use data to tell a story and influence communities with formal authority. These traits — accurate story-sharing and influence — are the hallmarks of an effective advocate.
QI advocacy requires dedicated, experienced individuals armed with information. The SSIT allows a system to standardize important information about its functioning and to support QI advocacy.
Acknowledgements
A large number of individuals have collaborated in the development of the SSIT, especially Dr. John Lyons — leader of Total Collaborative Outcomes Management. The first versions of this tool were made in collaboration with Tennessee Department of Children's Services. The critical incident review program leaders within National Partnership for Child Safety were instrumental to making this tool practical, teachable, and well-defined.
The SSIT is an open domain tool. The copyright is held by the Center for the Helping Professions to ensure it remains free to use. Training and certification are expected for appropriate use.
Contact Information
Tiffany Lindsey, EdD, LPC/MHSP · Chief Operating Officer
Copyright © Center for the Helping Professions · Cull, Lindsey & Epstein · 2025