trauma responsive systems implementation advisor · 2013. 12. 18. · addressing the impact of...

TReSIA: Section 4 TraumaResponsive Systems Implementation Advisor

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© 2012 www.epowerandassociates.com

About this Document Section Four . Extending the results of the assessment, this sect ion provides a template for designing your Transformation to a Trauma ‐Responsive System, and i t uses the appl icat ion of Trauma Informed Care as an example. I t ref lects general cl ient (customer, consumer, or service recipient) , cl inical (when appl icable) and organizational requirements.

Introduction Organizat ional change management (OCM) is a discipl ine that services many sectors

and industr ies. In the healthcare (both physical and behavioral) business, i t is often

thought to be the purview of large systems change in major inst itut ions.

We bel ieve that OCM is appl icable anywhere a system exists , especial ly when culture

change is the chal lenge. At a minimum i t helps the people who “own” the change

consider more broadly the potential impact on people, process and technology as

they consider the outcomes they desire against the general ly accepted requirements.

In the behavioral health f ield , OCM is appl icable even in the smal lest private agency,

even the one with only ten people from CEO to cleaning crew. This is because those

ten people interact with (when caseloads are at 80%) at least 140 people a week.

Those people have family and fr iends, and they are present in the community served

by the agency. They are part of the workforce, the social fabric, and the spir itual l i fe

of the community.

The breadth of the inf luence of the agency, the multiple contact points, and the

nature of the services and when the are needed means that small social service

agencies are as much at the effect of organizat ional change as is anyone else, and

may mean that they are more vulnerable to the impact of “things gone wrong” due to

their size.

Educational institutions, medical care providers, faith communities al l benefit from

a systems perspective on adjusting their frame of reference to incorporate an

understanding of trauma and how i t impacts their constituents. Chi ldren certainly

can’t learn i f they are dysregulated emotional ly, and teachers can’t teach i f their

l imbic system is activated. A tr ip to the doctor’s office may activate some people’s

l imbic systems depending on their history of trauma, their experience with their

provider at the same t ime the exposure takes a tol l on the provider. The f i rst place

many people turn to is their community of fa ith.

People are the foundation of your success . Without them as customers and cl ients,

your organizat ion would not need to exist . Their l ives inf luence your business. The

qual ity of their l ives, and of your culture, inf luences the people whom you would

have invest in your product or service. The mental/emotional load employees bring

with them, the impact on your benefits costs, t ime lost from work, confl ict

management, and human resources issues are part of your expenses.

Addressing the impact of overwhelming experiences and constructing a trauma ‐

responsive system has posit ive benefits for you. In addit ion to the direct benefits to

costs, think of the difference in how you are viewed when people in your market

sector experience a cr is is . They know you “get i t” about the impact of the

experience, and this is instant credibi l i ty. You become an employer of choice for

returning veterans, and your workforce is less vulnerable to the impact of events

such as tornadoes, tsunamis, and terrorism.

This OCM template focuses on changing the culture of your organizat ion, no matter

what sector you serve or work in, to accommodate the knowledge of the prevalence

of traumatic experiences and their impact on the people whom you manage, who

provide services, those who are your customers or cl ients, and you.

Organizational Change Management (OCM) Overview OCM is an ongoing effort that lasts from the conception of impending or needed

change to a point well beyond evidence of effect ive implementation and change. I t

involves planning, execution, monitoring, review and adjustment, just l ike any other

continuous improvement process. I t addresses people, process, environment,

technology, and structure as they relate to the part icular change in question. I t

engages discipl ines ranging from anthropology, sociology, psychology and education

to cognit ive sciences and chaos theory. Not unl ike project management i t involves

extensive planning, consistent communication, meetings, and reports. I t should

comprehend the pol it ical , technical , human resource, and pol it ical dimensions.

Specif ic tasks in most OCM models begin with defining the change, identify ing the

people who wil l play key roles in the process, assessing for supporters and

detractors, identify ing the areas impacted, and developing a coherent plan with clear

markers and criter ia for passage from one stage or element to the next.

How EPower & Associates Relates to These Ideas Our work encompasses learning, changing, and growth. As far back as the early

1980s, our concern focused on the human aspects of change ranging from the normal

and yet problematic reactions, the tendency to favor fa i lure over success because of

a normative set of benefits , to the role of self‐discipl ine in unlocking the nexus of

resistance. For years, we provided these interact ive and experiential trainings at a

now ‐extinct unit of ATT, GM, international aid agencies

We work in areas of analys is and adjustment of processes, developing and del iver ing

learning required for change, internal and external communication, and consult ing

for change. In the early years of our work in change management, we fol lowed Noel

Tichy’s work from the University of Michigan, applying i t to local sett ings in the

upstart automotive manufacturing company, Saturn. We have also studied Kotter,

Ackerman, and Lewin’s work, and have uti l ized the Prosci method of change

management.

During our t ime providing services through Intulogy, we became profic ient in

addit ional change management methodologies and appl ied i t in organizations

including publ ic power uti l i t ies facing massive aging out of employees, smal ler NPOs,

and health care companies where change management impacted succession planning.

In addit ion, our founder and CEO is a Six Sigma Black Belt .

Helpful Organizational Attributes With transformation, change occurs at al l levels from the level of pol icies and

procedures to marketing –as well as service del ivery.

Recognize that the fol lowing attr ibutes need to be present and actively fostered in

the process of the transformation to a trauma ‐responsive system:

Multidiscipl inary teams representing all stakeholders. Many funct ions and

discipl ines in your organizat ion may be involved in Trauma ‐Responsive

Systems, including IT, HR, Finance, Operations, direct services, and people who

are the organizat ion’s customers.

Will ingness to tolerate uncertainty . Uncertainty is a given during

transformation. People direct ing or affected by the transformation may not

always have the answers or know the next step. The discomfort of uncertainty

is a given during change. I t is the garden for creativity, and the provoker of

anxiety.

Realist ic expectations about how long culture change takes . I t takes years—

sometimes as many as ten—to develop lasting change in organizat ional

cultures.

Ongoing open communication about progress, needs, and challenges . People

need to know where they are in the journey: they need to celebrate the

successes and to be as informed as the organizat ional “grapevine” is about

what is going on.

The form ‐based pages that fol low al low you to create a narrative about stages or

issues in the transformation.

While al l the questions help you develop a sounder organizational transformation

plan, you may choose not (or not be able) to answer al l the questions in the

beginning, and you may choose to leave some unanswered for the duration of the

project. I t is good to revisit this narrative and update i t on a regular basis.

The “voice” in this form‐driven process is that of a change sponsor or in it iator who

may (sooner rather than later) share the results with the Transformation Teams, and

then engage the Team in helping to refine i t , develop and implement act ion plans,

and then evaluate the outcomes on an ongoing basis .

Please feel free to contact us at [email protected] for assistance in

working with these forms. We understand that i t is a chal lenge to consider the

adaptat ions across industr ies, and we wil l note when a sect ion or form is for a unique

sector.

Schedule of Activities (note—stages over lap)

Planning

Ear ly / Mid ‐project Stage

Planning accounts for as much as 50% of the total effort .

1. Select the change/transformation team and plan for their preparat ion.

Discuss ions of potent ial/needed changes with al l members of the team

2. Select values the transformat ion wil l demonstrate.

3. Draft your change/transformation statement.

4. Def ine the need. (3 and 4 may be reversed)

5. Descr ibe the potentia l organizat ional impact , based on the change/transformation statement.

Kickoff and f inal izat ion of plan

6. Kickoff informing organizat ion and community stakeholders of project , provid ing basic educat ion, f ine tune planning, what’s next

7. Apply kickoff learn ings to f ina l ize change plan

8. Develop strategies to address barr iers, and br idges

9. Create tra in ing plan inc luding preparatory and transfer of t ra in ing act iv it ies

10. Devise measurement strategy

11. Construct communicat ion plan to convey informat ion to stakeholders

Mid ‐Project / Late Stage

Late Stage / Closure

Implementat ion

12. In it iate communicat ion plan

12. In it iate tra in ing plan

13. Adjust pol ic ies and pract ices

14. Col lect data as planned

15. Adjust project plan to ref lect needed changes (based on metr ics and feedback)

Stabi l i zat ion

16. Assess communicat ion plan efforts

17. Assess integrat ion of pract ices against goals

18. Survey al l stakeholder groups for evidence of change and i t s impact

18. Del iver any addit ional tra in ing

19. Assure changes in pract ices have become standard operat ing procedures over t ime

20. Ensure plan of ongoing assessment and adjustment

21. Schedule mult i ‐year rev iews

22. Evaluate project for lessons learned

23. Archive documentat ion of project


For Agencies providing mental health or related services

I. Planning: Preparing for the transformation effort

1. Select and prepare your change/transformation management team.

This is the team that is responsible for ensuring that the voices of al l stakeholders

are included and that efforts have the greatest r isk of success.

While you may choose to have a total group of 10 ‐15 people, use working groups

of not less than f ive nor more than seven (the best and easiest s ize to work with).

Very small organizations may only have f ive people total—in any case, make sure

different groups and organization levels are represented.

Be aware of the distr ibution of perceived power. Too many from the “topmost”

level of assigned power and authority? This has a higher r isk of si lencing others.

Too many from the “lowest” or “least powerful” level may seem patroniz ing.

Next: Gather the people who are in it iat ing this change—this wil l usual ly be two

or three people. Use the Guided Form as you select your transformation team

and plan for their preparation. Remember that some tasks may be addressed in

the kickoff . The focus of these questions is on Team composit ion, Team

commitment required, and Team development. Use the numbers to the left of the

i tem to reference them.

Team Composition

1.1 Who needs to be invited to participate in the planning process?

Past and current service recipients

Name(s) , contact information:

Famil ies (of other service recipients)


Community‐at‐ large members?


Volunteers ( i f your organizat ion has them)?


Front l ine staff (direct care, case management)?


I f you have someone in mind, or have already selected team members l ist them.


Administrat ive‐clerical ( front desk, schedul ing, f inancial off ice)?


Professional (al l ied health, medical , cl inical , etc.)?


Management / Leadership?


Other:


1.2 Discuss and document responses to these questions about persons who receive services to focus on their inclusion and relationship with the organization.

We train people who receive services about the ten components of mental health recovery from SAMHSA. I f checked , how do you do this?

People who receive services are trained to request, design, develop, implement and evaluate new mental health recovery services. I f checked , describe the training:

People who provide services receive training about recovery from people in mental health recovery. . I f checked , what object ives does the training meet?

We have a counci l composed of people who receive services.

Our senior leadership, CEO, and/or Executive Director meet regular ly with people who are our customers to discuss their experience of our services and respond to them.

We have developed a Mental Health Recovery Plan for our agency with without the input and involvement of our customers.

Service recipients are in leadership roles in our agency. I f checked , how many and which roles?

How many

? Which leadership roles?

0 (role)

0 (role)


0 (role)

0 (role)

Team Commitment

1.3 What are the general expectations of Team Members?

1.4 What is the commitment that currently wil l be expected of the Team?

1.5 Does this commitment differ for people identif ied as current or former service recipients?

No.

Yes. How?

1.6 I f the commitment varies, describe i t by role or divis ion of labor based on your current plan.

Team Development

1.7 Which of the models l isted in NCTIC might be the best f i t , and based on what criter ia?

The model we currently think may be the best f i t for us i s :

Based on:

Sample Criteria:

Developed with the input of service recipients

Processes are col laborative instead of coercive

Provides electronic copies of supporting forms and materials

Materials provided are accessible and affordable

Engages social networking

Focuses on continued use of evidence

Bui lds on exist ing foundations

Values our experience

Provides new frame of reference

1.8 How often wil l Team meetings occur? For how long?

Frequency:

Duration: .


1.9 Is there a space that can be used for the f i rst several meetings (set up to increase part ic ipation and can, with planning, foster cross ‐functional engagement)?

Select from the dropdown: Yes

How wil l you create a meeting environment that avoids reinforcing power dynamics?

1.10 Who can you engage from another organization that is a faci l i tator for the in it ia l meetings?

(This is to make the team development transit ion through forming, storming, and norming easier)

We have engaged to help us faci l i tate the in it ia l meetings.

1.11 Education and training. These topics represent knowledge / ski l ls beneficial to implementation team members (and al l others impacted by this change). For implementation team members, mastery of these enables model ing for others expected to master them.

Incorporating knowledge of research and evidence regarding frequency and impact of trauma as factor in mental health issues.

Focusing on the core principles from the SAMHSA national consensus statement on mental health recovery (http://www.samhsa.gov/news/newsreleases/060215_consumer.htm).

Reconci l ing medical necessity and treatment requirements of different funding streams with the strength‐focused orientat ion of mental health recovery.

Understanding the mutual ly aff irming roles of al l part ies in the provis ion of services as well as the differences among the roles.

Conducting strength ‐based interviews

Creating individual ized mental health recovery care planning.

Implementing mental health recovery plans.

Uti l iz ing strengths in implementation of care plan.

Writ ing progress notes that focus on mental health recovery and strengths.

Using methods for engendering hope, optimism, and a focus on mental health recovery for people at every level of abi l i ty and motivation.

Translat ing conventional cl inical concepts such as boundaries, transference/counter ‐transference, resistance) into mental health recovery practices

Using a trauma ‐ informed perspective and trauma ‐specif ic methods to enhance mental health recovery.


Bui lding a cl inical relat ionship based on mutual ity and partnering.

Increasing healthy r isk‐taking by service providers and recipients.

Inspir ing people to assume or resume and thr ive in employment, education, normalized housing.

Promoting and responsibly support ing personal choice even when the provider and recipient disagree.

Locating community resources outside of the mental health system.

Support ing service recipients in using outside resources.

Modifying recovery practices to meet the specif ic needs of sub ‐groups.

Assist ing others in developing Advance Direct ives.

Speaking and reflect ing a focus on what happened in a person’s l i fe rather than what is “wrong” (diagnosis) with them.

Ski l l in accessing the materials and tools

1.12 From the previous sect ion, how wil l you convey the benefits of TIC to others?

Our communication and training plan to convey TIC to the community is to:

1. .

2. .

3. .

4. .

5. .

1.13 What tools wil l you use to develop general ly equal levels of knowledge among al l members about the process they are undertaking, and to create col laborative models of decis ion making and execution?

We (select from dropdown ) have organizat ion development/performance improvement staff .

We (select from dropdown ) have standardized decis ion making, problem solving, and meeting management tools in place that wil l be taught to team members.

I f you do not have either of these, specify the resources you wil l use to help you with these: .

1.14 Will you offer the RASIC model as a way to clar i fy roles and expectations on a task by task level?

Identify ing who : ‐ ‐ is Responsible ‐ ‐Approves ‐ ‐Supports ‐ ‐needs to be Informed, and


‐ ‐ is a Consultant

Select from the dropdown: Yes

How wil l you practice, reinforce and document RASIC?

1.15 Can general consensus decision making processes be appl ied (80% of the people involved need to be 80% comfortable)?

Yes, we wil l use a model that asks people to commit to act ion when 80% of the people involved are 80% comfortable.

I f no, we wil l make decis ions by .

1.16 How to ensure al l voices are heard equal ly (e.g. , via the Crawford Sl ip Brainstorming method, or via online anonymous poll ing to al low t ime for ref lect ion and thinking)?

We wil l seek everyone’s input through

1.17 Will you present general information about team formation to all team members to help them recognize what is happening and to reduce the r isk of tr iggering fear?

Yes, we wil l educate Team members about the stages of team formation.

We antic ipate resistance caused by

Hesitancy to chal lenge tradit ional value/power structure Personal investment in “the way things are” Personal bel iefs about the best methods or practices to use Lack of experience with new ski l ls Pol ic ies and practices that confl ict with TIC Concerns about resolv ing differences between systems of care that are reimbursable (such as Medicaid) and the TIC frame Concerns about qual ity of evidence for making the change or for techniques associated with TIC Other:

We wil l address resistance and fear among employees and customers by:

Multiple targeted communications: Training and practice:


T2TIC steering group resolves: Adoption recognit ion strategies : Encourage adoption in supervis ion:

Include measurements reflect ing concerns .

II. Select the values the transformation will demonstrate.

Fal lot and Harris ’ “Creating Cultures of Trauma‐ Informed Care” approach to

organizational trauma‐ informed care builds on f ive core values of safety,

trustworthiness, choice, collaboration, and empowerment. These are labeled

(1).

There are other values of equal importance in creating a trauma‐responsive

system—such as respect , seeking and sharing information , authentic

connection , and hope—which are tenets of the Risking Connection RICH®

model. These are operational values. These are labeled (2).

The Sanctuary model is built on values of nonviolence, emotional intell igence,

inquiry and social learning, shared governance, open communication, social

responsibil ity, growth and change . These are labeled (3).

Your organization may have stated values as part of i ts’ identity.

Next: The Transformation leadership team gathers and determines which values

the agency wil l adopt and demonstrate. Be sure to include people who have

received services who may have clearer perspectives about how things real ly

happen (a demonstrat ion of the operational values) . I f your organizat ion has

stated values, l ist and define those. Consider them as you select any addit ional

values.

2.1 Value 2.1 Value

Respect (2) Safety (1)

Trustworthiness (1) Empowerment (1)

Choice (3) Col laboration (1)

Shared Governance (3) Open communicat ion (3)


Information (2) Inquiry and Social Learning (3)

Connection (2) Emotional Intel l igence (3)

Growth and change (3) Hope (2)

Nonviolence (3) Social responsibi l i ty (3)

III. Draft your change/transformation statement. Your change/transformation statement addresses specif ics, structures and

strategy at the highest level . This short statement should tel l others what you

intend to accomplish, how, and why.

Here’s an example of a statement containing the specif ics, referencing structures

and strategy :

“Our outcome wil l be an organizat ion informed by and responsive to the

overwhelming events that our customers, stakeholders, and staff experience.

“We wil l achieve this through reviewing and adjust ing people, processes, and

programs, using learning activ it ies, modeling, coaching, and communication.

“We bel ieve this change is cr it ical because of the prevalence and cost of the

impact of overwhelming, traumatic experiences.”

Remember you may change and expand this over t ime. Sometimes your

explorat ion of the change generates information in response to which the team

that wrote the draft says “We need to adjust this .” Set this expectat ion among

yourselves.

You’ l l also expand on strategy in a later section.

Next: For greater buy ‐ in, have the implementation team craft the draft . Pay

part icular attention to the voices of the people who are tradit ional ly least

enfranchised. You may f ind i t helpful to review the needs analysis, or perhaps

change the order in which you complete 3 and 4 . Numbers to the left are for easy

reference in discussions.

Stem Completion


3.1 Our outcome wil l be; .

3.2 We wil l achieve this: .

3.3 We bel ieve we need to make this change because:

.


IV. Define the need. In this section, you’ l l both develop the case for change and define what is needed to accomplish the transformation defined in the statement you just created.. You’ l l describe your organizat ion ( information that may be helpful i f you are seeking funding), the

Next: This is a combination of subject ive and object ive information. Depending

on the size of your organizat ion and implementation team, this is a good t ime to

use smal l groups to complete the information. There are a number of ways this

information wil l be used later. As before, numbers to the left are for reference.

Driver/Perceived Benefits:

4.1 What’s in i t for your agency to make this change?

4.2 How wil l the community at large benefit?

4.3 What’s in i t for the people you serve?

4.4 How wil l employees benefit?

4.5 What drives you to make this change now?

Demographics:

4.6 How many people receive services from your organization?

1

4.7 How many does your organizat ion employ

1

4.8 Whom do you serve (general descript ion)?

How many by gender, age, race/ethnicity, income, most/least frequently given diagnoses ( i f the agency makes, uses, or f i les for funding based on them) etc.?

4.9 Gender: F: 0 M: 0 T: 0

4.10 Age: 0 ‐7: 0 7 ‐11: 0 12 ‐16: 0 11 ‐13 0 20 ‐40 0 40 ‐65 0 65+ 0

4.11 Race/Ethnicity by % of total # of people served: 0 % White 0 % Black/Afr ican American 0 % American Indian / Alaska Native


0 % Asian 0 % Other 0 % Hawai ian Native / Pacif ic Is lander

4.12 Income by % of total # of people served: 0 % Under $15K 0 % $15K ‐ $24,999 0 % $25K‐$34,999 0 % $35K‐$49,999 0 % $50K‐$74,999 0 % $75K‐$99,999 0 % $100,000 +

4.13 Five Most Frequent Diagnoses:

Date of data entry:

# 1

# 2

# 3

# 4

# 5

4.14 Five Least Frequent Diagnoses:

Date of data entry:

# 1

# 2

# 3

# 4

# 5

Please use the text entry box below to add any relevant information about the reasons you are making this change, especial ly as you ref lect on the information gathered and potential meaning:

(enter text here)

V. Describe the potential organizational impact In launching an effort of this size, i t ’s important to think about who wil l be impact

and how. This helps you prepare for potentia l chal lenges and define the scope of

the change, which is directly related to cost in terms of people, budget, and

schedule.

Next: This is a combination of subject ive and object ive information. Depending

on the size of your organizat ion and implementation team, this is a good t ime to

use smal l groups to complete the information. There are a number of ways this

information wil l be used later; r ight now i t is your best effort at identify ing where

you are along some specif ic scales. As before, numbers to the left are for

reference

Groups who might be impacted:

5.1 Who might be impacted (consider the organizat ion from the top down, by job role)?

( l ist groups by role)

5.2 Of these, who will be most and least impacted? How?

(enter select ions here)

5.3 Think about the people you serve. How do you think this project



might impact their experience of receiving services?

5.4 I f you feel there any groups or job categories that wil l not be impacted , l i st them and describe the reason you feel they wil l not be impacted.


Processes that are involved:

5.5 What processes in your organization involve the customer or cl ient? This is any interact ion between a person who receives services and a person employed by your organization.

Check al l that apply and add any needed.

Front desk Bi l l ing

Schedul ing Claims

Intake Transportat ion

Assessment Outreach

Advocacy Records

Service Planning Individual

Service contracting

Giving Feedback

Select ing services

Making Payment

Other

5.6 Staff , Setting. For each process selected or entered above, l ist the staff by role and name who are involved in that process and then describe the sett ing where the interact ion occurs.

1. Process ( from l ist) :

Role / staff involved:

Location / sett ing:


























10. Process (from l ist) :




























5.7 Process Mapping.

The abi l i ty to consider the experience of the other person is a foundation in relational process.

Your goal is to map the path of the customer through their experience as a customer, and then to map the experience of the staff people in the same experiences.

The “making vis ible” of how things occur and in what context is important in evaluating the environment, the outward signs of culture, and the awareness of the impact of trauma as a person engages your services.Of course, i f you have customers who part ic ipate in more than one activ ity in your organizat ion, this wil l take some t ime.

Map based on the activ it ies you checked. The customer experience from their point of view is the one to seek.

Method: Walk through : I f this is a walk through, prepare everyone who wil l be involved in this re‐enactment. Ask them to behave as ordinari ly as they can and treat the team as they normally would. They document as they go.

Method: Wall Mapping: Have a customer/cl ient and staff people involved in the process map i t out, using 2x2 or larger adhesive notes on a large wall (perhaps a hal lway or conference room wall) .

For example, in many places the f i rst few things a customer/cl ient does are: “I cal l for an appointment.” “I enter the bui lding.” “I s ign in at the front desk.” The last thing is often “I receive my appointment card” or “I leave the bui lding.”

Each action is written on one adhesive note. The notes are placed in sequence (a long wall is a great place to do this) .

Documenting processes this way helps you identify data about the customer experience and then as appropriate


consider changes to test. I t also lets you know where your organization may wish to focus i ts ’ efforts.

5.8 Review data about services provided, and identify the f ive most frequently and two least often provided services or activities .

This l ist is important when considered relative to the l i st of most and least frequent diagnoses—it may help provide ins ight or awareness about the relationship between these two sets of information as they relate to recovery.

Most Frequently Provided Services or Activit ies

#1:

#2:

#3:

#4:

#5:

Two least frequently provided services or activities:

#1:

#2:

6. Assess evidence of traumaresponsiveness Use this checkl ist to assess for evidence of trauma responsive practices. While

the l i st is by no means exhaustive, i t affords an opportunity to begin a general

comparison of current to changed state.

In each of the seven areas, use the dropdown to select the degree to which your

organization meets this criteria. Seven (7) is the maximum or strongest, and

zero (0) means you are unable to f ind evidence of this as you complete your

review. In meetings, use the numbers to refer to the i tem to help others f ind

where you are more quickly.

Next: This is a combination of subject ive and object ive information. This

continuum is useful to complete in the beginning, middle and at the late stage of

your transformation efforts as i t helps you review progress. Plott ing change over

t ime helps continue the focus on the transformation.

6.1 Faci l i t ies

(7=maximum)

7 6.1.1 Entrances / exits are marked with signs that are legible, clear, welcoming

7 6.1.2 Furniture is arranged in groups, clusters, or curves


instead (relat ional) of straight l ines ( institut ional) .

7 6.1.3 Differences in the décor in the wait ing area and the receptionist or front desk area are minimal (e.g. , the walls in both are equal ly decorated with warm and invit ing art) .

7 6.1.4 Intake or interview rooms are comfortable and invit ing, pleasant, calming colors.

7 6.1.5 Air circulates freely and there are no odor masking or scent releasing devices (people—esp with asthma—are often al lergic to perfumes and scents) .

7 6.1.6 Rooms and schedules are attentive to the needs of specif ic populat ions (e.g. , groups for domestic violence survivors are located far away from groups for perpetrators and preferably at a different t ime).

7 6.1.7 Employees/staff and customers/cl ients have adequate personal space and privacy.

7 6.1.8 Signs and posted information is written in posit ive language and uses others cases besides ALL CAPS.

7 6.1.9 “Send Assistance” buttons in place.

7 6.1.10 Persons providing service are trained on pol icies in place to reduce physical and emotional

7 6.1.11 Exits are readi ly accessible and unlocked.

6.2 Relational and Emotional Safety

7 6.2.1 People who greet service recipients are fr iendly, warm, and authentic, welcoming each person.

7 6.2.2 Staff who have any contact with persons receiv ing services have received training about the impact of trauma and are adjust ing their language and act ions.

7 6.2.3 Staff recognize and are responsive to s igns of discomfort from a trauma ‐ informed perspective.

7 6.2.4 Logs of events indicat ing a lack of safety have been reviewed for common precedents, contr ibutions of al l involved parties, and reframed from a trauma ‐ informed perspective.

7 6.2.5 Alternative responses to events in the safety log have been considered and implemented.

7 6.2.6 Staff and service recipient concerns for potentia l ly unsafe s ituations have been consciously considered.

7 6.2.7 Concerns regarding staff are welcomed and


considered from a trauma ‐ informed perspective.

7 6.2.8 People who receive services receive clear explanations of tasks, procedures and sequences and of the rat ionale for each.

7 6.2.9 Goals and object ives agreed on by the service provider and recipient are clear.

7 6.2.10 Co ‐signatures are required on care plans and progress notes.

7 6.2.11 Services provided focus on col laborat ion at every step of the way unless (1) threat of harm to self or others or (2) a situation invoking mandated report ing exists .

7 6.2.12 Staff members bring their emotional responses to people receiving services, concerns about care, doubts, and vulnerabi l i t ies to team meetings, staff ing, and supervis ion.

7 6.2.13 Service recipients are encouraged to develop a plan with a service provider to be implemented in the event of a personal cris is that describes known causes of cris is , helpful responses, and contacts who may be helpful .

6.3 Frame of the work

7 6.3.1 People who receive services have options about which services to receive or use.

7 6.3.2 Persons providing services have autonomy and choices about how they meet specif ic work requirements.

7 6.3.3 Persons providing services have input into schedules, kinds of caseloads and cl ients with whom they work, off ice décor, and other areas of their work such as schedules.

7 6.3.4 Options of t ime of day, day of week, and as possible, locations are offered to the service recipient.

7 6.3.5 Service recipients can select the way in which they prefer to be contacted, and their preferences for t ime of day, and day of week.

7 6.3.6 An observer l istening for choices would hear questions l ike “Tel l me, what you l ike to be cal led?” and “How would you l ike me to contact you, or would you prefer to contact me?” or “Which t ime of day would you prefer?”

7 6.3.7 People who receive services are del iberately offered choices (many, and small ) in every contact from


greeting through good ‐bye.

7 6.3.8 The exercise of part icular choices does not result in negative consequences.

7 6.3.9 In the beginning of the relat ionship, operating boundaries are defined and discussed, and any boundaries of concern to the person receiving services are discussed and defined.

7 6.3.10 Informed consent and individual responsibi l ity in performing tasks is taken ser iously for both service provider and recipient.

7 6.3.11 People who receive services may designate who can attend meetings with them or on their behalf .

7 6.3.12 The priorit ies of the person receiving service are given equal weight in the service del ivery planning and care process.

7 6.3.13 There are no services to which access is contingent on receiv ing other services (no requirement to “prove” themselves to access other services) .

7 6.3.14 Information about the processes, r isks and benefit s for proposed interventions are clearly defined and discussed at a level at which the service recipient can comprehend.

7 6.3.15 Information about the r ights and responsibi l it ies of the person receiv ing services is provided in ways the service recipient can comprehend.

6.4 Services 7 6.4.1 Screening includes assessment for such events as the Adverse Chi ldhood Experiences (ACEs).

7 6.4.2 Select ion of assessment tools has considered the core data set used by the organizat ion and contr ibutions to larger data pools.

7 6.4.3 Timing of assessment for adverse experiences in chi ldhood (ACEs) or traumatic events considers the stress i t may cause.

7 6.4.4 Trauma ‐specif ic services that focus on a specif ic diagnosis or symptom and that are backed by evidence are avai lable to service recipients.

7 6.4.5 Service recipients and providers have talked about what i t means to ask about traumatic experiences and how to consider them in the recovery process.

7 6.4.6 Screening avoids unnecessary repetit ion, and paces the gathering of information across multiple points in the


process.

7 6.4.7 Standardizat ion of assessment across sites is balanced with each s ite’s needs.

7 6.4.8 As information is gathered regarding the presence of trauma in a service recipient’s l i fe, conversations between recipient and provider include open conversation about how to best use this information (for example, specif ic services such as trauma‐specif ic treatment, areas of specif ic impact and remedies for those, strengths, etc.)

7 6.4.9 Service and progress notes focus on the present, on strengths, and on the development of ski l ls .

7 6.4.10 Electronic Health Record appl ication ref lect trauma ‐ informed care (notes, strengths ‐base assessment, co ‐signature capacity).

7 6.4.11 Clinical supervis ion is focused through the trauma ‐informed lens and also helps the service provider focus on the management of vicarious trauma.

7 6.4.12 The language used with service recipients is the language and wording used by the community outside of care (that is , “psychiatr izat ion” of service recipients is minimized).

7 6.4.13 Services exist to help long‐term service recipients learn how to relate to and interact with the people in their larger world.

7 6.4.14 Service providers are cert i f ied in the provis ion of specif ic trauma ‐ focused Evidence Based Practices and offer those as methods support ing recovery.

7 6.4.15 Information regarding specif ic EBPs and their usage, benefits , and processes is avai lable to all staff and service recipients.

7 6.4.16 Service recipients are act ive members of the committee that reviews EBPS for addit ion to services.

6.5 Human Resources

7 6.5.1 Polic ies and materials reflect ing them such as employee orientat ion, benefits .

7 6.5.2 The recruitment and select ion process includes engaging appl icants around their training in trauma ‐informed care, trauma ‐specif ic interventions, and their frame of reference around trauma and i ts impact.

7 6.5.3 Value is placed on employee engagement in trauma ‐


informed program design, development, implementation and evaluation.

7 6.5.4 Multiple methods for seeking the input of employees are in place and action is taken on i tems of concern.

7 6.5.5 Day to day processes focus on shared power, col laborative processes, the present, and strengths for employees and service recipients.

7 6.5 6 The focus of the words used, the act ions taken, and the att itudes of service providers is on “what happened” over “what’s wrong.”

7 6.5.7 Job structure includes mechanisms that bui ld on staff ski l ls and abil i t ies, support the use of posit ive frames of reference towards service recipients, and accountabi l i ty and responsibi l i ty is shared.

7 6.5.8 Employees across al l levels avoid the “blame and shame game” while addressing confl icts directly.

7 6.5.9 The HR r isk and reward process includes reinforcing desired behavior in a trauma ‐responsive systems, such as del iberate attention to issues of vicar ious trauma and self‐care.

7 6.5.10 Support for training and development in knowledge and ski l ls related to becoming trauma ‐informed exists in the form of schedul ing, funding, and the release of l ine staff to learn and develop.

7 6.5.11 Service system planning involves service recipients with acknowledged histories of trauma who support service planning, implementation and evaluation.

7 6.5.12 Pol ic ies, manuals, forms, and al l printed materials ref lect our focus on trauma ‐ informed care.

7 6.5.13 Use of respectful language that refers to problematic behaviors rather than diagnoses is reinforced.

7 6.5.14 Service providers receive specif ic training in establishing and maintaining col laboration.

7 6.5.15 Coaching and personnel development focus on the strengths of staff rather than their defic its .

7 6.5.16 Service recipients are referred to by name rather than diagnosis, and rather than diagnosis being used as a shorthand, characterist ics and behavior are described.


6.6 Marketing 7 6.6.1 All of our col lateral material reflects our incorporation of trauma ‐ informed care and our creation of a trauma ‐responsive culture.

7 6.6.2 Regular community events that include the voice of people in mental health recovery who have histories of trauma help educate the community about our work.

7 6.6.3 When we form cooperative agreements with other organizations, we make clear our commitment to trauma ‐informed care and ensure a degree of al ignment among al l parties on the basics in TIC.

6.7 Quality 7 6.7.1 Metrics that help us measure the effect of our trauma ‐ informed care in day to day are integrated into our qual ity efforts

7 6.7.2 Document and chart reviews include checking for language that reflects the service recipient’s strengths, specif ic goals they set, accomplishments, and improvements.

7 6.7.3 In each of the tasks related to qual ity, the maintenance of any accreditat ion, and reviews of process, we use a trauma ‐responsive lens

7 6.7.4 Metrics that assess the outcomes of efforts in mental health recovery are tracked and adjusted as our ski l l in del ivery matures.

7 6.7.5 Metrics for usage and outcomes for evidence ‐based practices are reviewed and shared.

7 6.7.6 Analys is of diagnoses of the cl ient base is done on a regular basis to consider the degree distr ibutions against knowledge of the relat ionship between history of trauma and diagnoses.

6.8 Dates By now, you have a lot of information about where your organization is and where i t would l ike to be. How long do you think this effort wil l take? While you may only have funding for a portion of the t ime, what wil l you do to sustain the effort after that?

Set start and end dates that al low t ime to f inal ize the plan, obtain resources needed, del iver training, evaluate efforts, and implement transfer of knowledge activ it ies.


Recognize these may shift a l i tt le as you f inal ize plans.

Start date: (date) End date: (date)

6.9 Milestones Throughout this project, there wil l be specif ic dates that are milestones. The typical milestones marked include the ones below, which have areas for dates adjacent to them. I f your organization has a change management or project management office, they may use these to craft a plan in an appl ication l ike Microsoft Project.

Of course, i f these do not work for you, use the form f ie lds at the bottom of this cel l to create your own milestones.

2011 January 01 Formal start

2011 January 01 Team selected, trained on change management

2011 January 01 Kickoff (educate al l stakeholders, set expectations)

2011 January 01 Content from Kickoff integrated into plan

2011 January 01 Init iate communicat ion plan (broadcast email , newsletter art ic les, press releases, scheduled communications—requires set of assets to deploy)

2011 January 01 Init iate TIC training schedule for selected staff ( f i rst one includes potential trainers i f train the trainer or T3 planned)

2011 January 01 Environmental walk ‐through complete (with recommendations and observation)

2011 January 01 Second TIC training

2011 January 01 Pol icy review complete (with recommendations for change and plan of act ion for implementation

2011 January 01 Process review complete (processes adjusted to incorporate changes)

2011 January 01

2011 January 01

2011 January 01

2011 January 01


2011 January 01

2011 January 01

2011 January 01

2011 January 01

2011 January 01

2011 January 01

Remember: milestones are project ions of achievable dates that can be adjusted. They exist to help manage resources including t ime, talent, and dol lars.

VI. Kickoff / Finalization of plan With at least some of the information completed in steps I ‐V, plan the kickoff

which is the formal beginning of the effort .

This event:

Brings everyone who wil l be involved and affected together

Provides consistent information about the change, the reasons for the

change, and the goals of the change

Dispels myths and rumors that may have developed in the run up to the

kickoff

Provides information for each set of stakeholders

Gives attendees a vis ion of what the end result wil l be and why i t is

important

Provides an arena for work teams to gather feedback on what is presented

in preparation for init ia l adjustment of the change plan, and f inal izat ion of

the overal l plan for the purpose of implementation.

VII. Apply Kickoff Learnings to finalize plan In your Kickoff, or i f you had informal events instead, you probably received a

lot of information and feedback. You may have shared schedules and plans

only to get pushback from others.


This is the t ime to look at your plan and at the activ it ies you have on schedule

and see i f things sti l l make sense. This f inal ization is the t ime when you can

adjust before launching into another phase of the work.

VIII. Develop strategies to address barriers and bridges

Typical barriers:

Excess or inadequate communication, or communication that is

information only without a cal l to action or engagement.

Underest imating resistance in the form of deeply ingrained habits

Inabi l i ty to “walk a mile” in the shoes of survivors of trauma

Lett ing the momentum s l ip, or stopping the project too soon.

In general , strategies for these barriers focus on:

Intentional del ivery of information, engaging organizat ional evangel ists

to continue to talk about TIC

Recogniz ing how deeply ingrained and unconscious bel iefs may become

Continuing to model TIC strongly

Adopting and using language from the new frame

Identify ing the core bel iefs of the new framework and constructing a

method for re ‐considering service recipients in the l ight of this new

framework.

Usual bridges :

People who have been wait ing for these ideas for a long t ime.

Timing that coincides with publ ic ized efforts relat ive to effect ive

responses to issues such as PTSD, chi ld abuse, domestic violence, etc.

Announced expansion, remodel ing, other signif icant events that lend to

new things.

Incessant commitment by a key few bel ievers in the power of being

trauma ‐responsive.

Strategies:

Identify natural al l iances between individuals and new bel iefs.

Find success stor ies and publ ic ize them.

Form relat ionships with service recipients who are employed, enjoying

healthy relat ionships, and whose l ives have meaning to help.

Set up automated searches for keywords and for community news.

There are many others, and in your pre ‐kickoff work, they have probably

become more apparent. As you work to define them, ensure that the language


presents neutral information, or “just the facts.” The more factual and neutral

your observat ion, the “cleaner” your strategies wil l be.

IX. Create training plan including preparatory and transfer of learning activities

The training plan answers these questions:

Who needs to learn what?

Remember that TIC is not something you do to others. This means all

staff , from faci l i t ies to the boardroom, and even Board members, need

Training. Make sure your selection of programs has multiple levels of

training that work for different population without a loss of f idel ity.

For what reason?

In any number of environments, being sent to training feels l ike

punishment or is a standard response anytime change is needed.

Training is the correct response when there is new knowledge, ski l ls ,

and when there are new att itudes to learn (and training only addresses

these issues). I t needs to be delivered in ways that are engaging and

foster learning instead of “death by PowerPoint.” Your provider should

evaluate the training using a standard form, sending you a copy of the

evaluations. I t is helpful i f your provider is a professional ly identif ied

adult learning special ist as the curr iculum should contain the topical

content.

What support wil l learners need to set and fulf i l l appropriate

expectations? One classic loss of investment in training occurs when

learners attend a class, return to work. . and that’s i t . The manual goes

on the bookshelf .

To incorporate information and learnings, students need to manipulate

and use the information once they return to work. I f the program has

forms that guide learners in adopting the frame, implementing usage of

those after training in a group sett ing is helpful .

How much capacity do supervisors have to meet with each learner

before training to set expectations and after to f inal ize action plans?

I f the only communication with a learner is an email that they are to

attend classes, the chances of adoption are greatly lessened.


Bui lding on the Kickoff the supervisor or manager needs to talk with the

learner about the training, i ts importance, and to ask the learner how

he or she might actively use i t once back at work.

After the training a fol low ‐on meeting occurs where the learner

commits to a plan and metrics of their choosing and with their

supervisor detai ls accountabil i ty for their learning.

As you consider training programs, what criter ia wil l you use to select

yours? Considerations include cost, length, f lexibi l i ty in schedul ing,

amount of addit ional change required, changes the training mandates,

inclusion of people with l ived experience in i ts ’ development, degree to

which the training or model al igns with organizat ional values selected

earl ier .

The way others describe the training, the way in which the training is

characterized, all give indicat ion of the degree of al ignment of your

organizational intention and the model.

How much t ime does the training take? Any model that front l ine staff ,

leadership, and community trainings on the same model that al l fol low

the same “cognit ive map” and that has some variabi l i ty in the length

and pattern of del ivery is more l ikely to be successful .

The al ignment among vers ions models the ideal of f lexibi l i ty and choice

we hope the people we serve can develop. Modeling is very powerful in

both demonstrat ing the desired behavior as well as talk ing about i t ,

which indicates to others that i t is important.

What are the implications for staff ing? Finding t ime for training is

diff icult . I f the training day is too long, people quit learning. When

their “f i l led up” they shut down—and can’t learn. Providers that can be

f lexible with how and when they del iver the training are helpful .

What are transfer of training activit ies? These activ it ies begin before

the training and also occur after i t for the t ime required for learners to

adopt and demonstrate the new frame. They are pre ‐ and post‐

meetings with one’s supervisor, creating and implementing a plan of

act ion for continued use of the material , at the individual and team

level .

How wil l you evaluate the training? Kirkpatr ick’s Four Level evaluation

of learning is a classical evaluation tool for the effect ivenesss of the

learning and adoption, which involves preparation and fol lowup after

the training.


The Level One in this model is often cal led a “smile sheet” as i t records

only the learners’ immediate react ions.

Level Two is the assessment of what was learned. In some cases, a pre ‐

test assesses for knowledge to be learned and a post ‐test immediately

after the training assesses for learning.

Levels Three and Four assess retention over t ime, which is inf luenced by

fol low ‐up activ it ies and return on investment. There are many sources

of information about Kirkpatr ick’s Evaluation model as well as

alternatives avai lable on the internet.

X. Devise measurement strategy When you created your change / transformation statement, the idea of

measurement began to emerge in your plan.

Each port ion of that statement specif ies things that can be measured: any

“outcome” has vis ible signs of some sort , and contains many data points that

can be counted.

How the outcome wil l be achieved often tel ls you how you’re going to create

this desirable state, which contains data points that can be measured. The

act ion to take is to define the results of your successful implementation in

terms of the difference implementing TIC wil l make in your community wide

stabi l i ty in famil ies and neighborhoods in your community.

XI. Construct communication plan to convey information to stakeholders.

The communicat ion plan is often the least attended to i tem, and i t can be one

of the most effect ive tools.

Depending on the size of your agency, and communication instruments in

place, adding information about your change effort may be easy through the

employee newsletter, e ‐mail groups, inserts in checks, texts, group voicemai ls .

I f your organizat ion does not have this level of technology, i t becomes

everything from a water ‐cooler standup meeting to bul let in boards and t ime

spent sharing coffee.

Your communication plan addresses these questions:


What types of art ic les in our newsletter get the most comments?

How many of these can we write in advance and save as assets to use?

What is our capacity to create group emails and send brain teasers on a

sl ightly erratic not quite monthly basis? What would i t take to set this

in motion now?

Are there “change evangel ists” who would be wil l ing to ask people who

have received the training for their response to the brain teaser?

How does your organization’s technology support mass messaging on an

intermittent but scheduled basis?

When does your plan get created, when is i t launched, and what are

points at which something gets sent?

Contents of the communicat ion may be short vignettes of a posit ive story

ref lect ing some key learning from your training, such as vignettes asking key

questions based on the training, or ideas for self‐care.

Remember that there wil l be requirements for sett ing up and managing email l ists

and i f you choose, social media regarding your transformation efforts and

reinforcing them.

XII. Initiate communication plan Once you have developed enough assets to deploy your plan over the course of

the next year, deploy i t . Often this wil l be targeted communications—the

same core runs through each asset or communication to be distr ibuted even i f

the job roles are very different.

Offering a consistent, constant message about the change and the intent of i ts

meaning is important.

XIII. Adjust policies and practices With the results of the organizational assessment in TReSIA’s previous section in hand along

with the contents you have added to this template, the effort to adjust policies and procedures

is easier. Of course, someone has to identify the area that needs adjusting, propose the

adjustments and start the change,

There may be legal implications involved in changing as well.


XIV. Collect data as planned. All along the way, the project has encouraged changes in behavior and

thinking. Planning included looking at these changes, and assessing actions to

take to inf luence them to occur.

Changes result in changed behavior, thoughts and actions. Organizat ions that

become trauma ‐responsive seem to report better outcomes; systems see

dramatic drops in specif ic diagnoses, and people feel better.

XV. Adjust process W. Edwards Deming, the American statistician from World War II whose job it as to help the

Japanese recover from Hiroshima and Nagasaki, taught the Plan‐Do‐Check‐Act (PDCA) cycle of

continuous improvement.

The PDCA cycle is part of your change and transformation effort. One challenge will be how to

sustain the effort working via distributed networking.

A chief task of the Change / Transformation team is to support the ongoing success of the

process through adjustment based on the PDCA cycle.

trauma responsive systems implementation advisor · 2013. 12. 18. · addressing the impact of...

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