From Aliza Tuttle, Project Manager, Implementation Lab for Human Services, Portland State University
For individuals, translating a new skill into practice can take years. At an organizational level, adopting new practices can be an endless, arduous, and overwhelming process with countless moving parts. Including the realities of staff turnover, shifting budget allocations, and leadership change, efforts to implement best practices like Trauma-informed Care can, and do, stall.
To help organizations track progress towards Trauma-Informed Care (TIC), provide a roadmap for next steps, and create feedback processes to help reach implementation goals, Trauma Informed Oregon partnered with the Human Services Implementation Lab (I-Lab) to create an implementation tool for TIC. The I-Lab gathers feedback from organizational leaders, staff, and individuals served, and reviews documents to provide a snapshot of implementation to the organization. This implementation tool can be used by the organization to determine if their TIC efforts are affecting the organization and service provision as desired or if they need to pivot. How do we do this and what is the point of tracking implementation at this level? I’ll use my gardening practice to illustrate.
In my first season gardening, I grew one tomato plant. The soil lacked the right nutrients, the plant had a major pest issue, and I was a distracted college student and couldn’t manage consistent watering. I harvested three tomatoes that season, but I totally caught the gardening bug. I needed to learn how to do this better! I read many gardening books that winter, expecting to see a major improvement with all of my new knowledge.
The next season, I grew tomatoes and basil and marigolds together—a pest control companion planting—but still forgot about consistent watering and soil nutrients. It was a scanty harvest, again. The following year I tested the soil, made adjustments, and added carrots to my garden. Season after season, I added more skills to my gardening practice. Last year, fifteen seasons after my three-tomato harvest, I grew so much food I was able to donate the extras! I felt a sense of awe as I enjoyed the food I grew while watching pollinators flit around in the garden. As I reflect on my gardening practice, I see it as an incremental, multi-faceted, and expensive hobby, yet one completely worth the outcomes.
To justify a pitch for continued funding for my hobby three years, six years, and 11 years into my practice, I needed to track the changes I had made. An implementation tool can help illustrate this change in practice, show incremental progress, and help provide a pathway to next steps.
Tracking Implementation Progress
Here is a graph showing that I practiced gardening over the past fifteen years, where 1 is not gardening and 5 is gardening.
While accurate, this chart doesn’t show the full picture! Gardening is multifaceted and complex, with interdependent elements and parts within those elements. I could also graph my pounds of food harvested, but that would be an equally flat line hovering around zero until year four or five. To set myself up to see a change in pounds of food harvested, I first learned about soil nutrients, companion planting, watering needs and schedules, space requirements, and how to fully enjoy the bounties of my harvest.
To show these changes over time, I divided my gardening practice into five elements, teased out specific parts within each element, and then tracked when I started implementing each part of each element. I graphed the average score of all parts within each element, where 1 is not implementing and five is fully implementing.
At year 14, we can see that I am implementing the elements of Enjoyment of Bounty and Companion Planting well, but I’m still struggling around Watering Needs. Now that I see that Watering Needs is the area that is holding me back the most, I have an argument to invest in a timer-run drip irrigation system!
This is the process of creating an implementation tool for evidence-based and best practices for organizations: The process to reliably rate myself on a scale of one through five for each element of gardening involved defining evidence to show progress and a definition of each rating.
An Implementation Assessment Scale for Trauma Informed Care
TIO and the I-Lab created a one-through-five scale for the Trauma-informed Care Implementation Tool based on the Stages of Change model. A rating of 1 means the organization has not yet demonstrated awareness for the need for this standard; a rating of 2 means the organization has demonstrated awareness but hasn’t yet started work; a rating of 3 means active work on that standard has begun; a rating of 4 means the standard is in place but not yet sustainably so nor monitored; and a rating of five means the standard is sustainably in place and monitoring for continuous quality improvement occurs regularly.
TIO worked closely with the I-Lab to develop definitions for standards within each of the five elements, and then specific, measurable aspects to rate each standard on the scale of one through five.
The I-Lab works with organizations to gather feedback from key leaders, staff, and individuals served, and reviews documentation to score standards of trauma-informed care within each standard. Then, we average the scores of the standards to come to a score for each of the five elements, provide a report that shows the feedback processes used to arrive at those scores, and discuss the scores with the organization.
Revealing Areas of Strength and Need Through Implementation Evaluation
These layers of feedback uncover potential areas of improvement. For example, leaders of an organization told us they require TIC training of all staff; however, when we surveyed the staff, we learned that very few had completed the trainings. This information around the training level of staff is valuable to the organization.
To fully implement elements and standards within those elements, a feedback process is to be in place. This feedback process is designed to help organizations learn from staff and individuals served, and adapt to changes that may not be noticed otherwise. For example, client demographics, staff training needs, and leadership support may shift over time. Regular feedback processes designed into each standard should help keep organizations current with their shifting circumstances and allow for small, incremental changes rather than sudden pivots.