1 A Primary Prevention tool Module created by Huckshorn, 2004 Leadership Toward Organizational Change A Core Strategy © Creating Violence Free and Coercion

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A Primary Prevention toolA Primary Prevention toolModule created by Huckshorn, 2004Module created by Huckshorn, 2004

Leadership Toward Leadership Toward Organizational ChangeOrganizational Change

A Core Strategy A Core Strategy ©©

Creating Violence Free and Coercion Free Service Environments for the Reduction of Seclusion and

Restraint

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OutlineOutline

The Fundamental Role of LeadershipThe Fundamental Role of Leadership

Leadership PrinciplesLeadership Principles– VisionVision– ValuesValues– Human TechnologyHuman Technology– DataData– Staff PerformanceStaff Performance– Plan DevelopmentPlan Development

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Successfully Reducing S/R UseSuccessfully Reducing S/R Use

Changes the way we do businessChanges the way we do business

Changes the way we view our customersChanges the way we view our customers

Changes the way we see our own rolesChanges the way we see our own roles

Requires and results in a culture change Requires and results in a culture change that occurs over timethat occurs over time

Requires effective, committed Requires effective, committed leadership…leadership…

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How Does this Practice Change How Does this Practice Change Occur?Occur?

Leadership – “Carrying the mantle”Leadership – “Carrying the mantle”

Leadership – Planning the strategyLeadership – Planning the strategy

Leadership – Taking actionLeadership – Taking action

Leadership – Following throughLeadership – Following through

Leadership Leadership – Mentoring and– Mentoring and

developing new leadersdeveloping new leaders

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The Role of LeadershipThe Role of Leadership

The The most importantmost important component in successful component in successful reduction projects.reduction projects.

Only Leadership has the authority to make the Only Leadership has the authority to make the changes that are necessary for success: changes that are necessary for success: – Make S/R reduction a high priorityMake S/R reduction a high priority– Assure for Reduction Plan DevelopmentAssure for Reduction Plan Development– Reduce/eliminate organizational barriers, Reduce/eliminate organizational barriers,

including changing policy and proceduresincluding changing policy and procedures– Provide or re-allocate the necessary resourcesProvide or re-allocate the necessary resources– Hold people accountable for their actionsHold people accountable for their actions

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The Power of LeadershipThe Power of Leadership

The power of Leadership in creating change The power of Leadership in creating change is mostly within our is mostly within our controlcontrol

Used ineffectively, or not at all, it becomes Used ineffectively, or not at all, it becomes the the major barriermajor barrier in any effective in any effective organizational changeorganizational change

Leadership can be considered the most Leadership can be considered the most important and fundamental resource in any important and fundamental resource in any project seeking culture change project seeking culture change ((AnthonyAnthony, 2004), 2004)

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Fundamental Principles of LeadersFundamental Principles of LeadersCreating the VisionCreating the Vision

1)1) The essence of Leadership is the The essence of Leadership is the ability to motivate one’s staff to ability to motivate one’s staff to action around a shared visionaction around a shared vision e.g… e.g…

Reducing the use of seclusion and Reducing the use of seclusion and restraintrestraint

Creating non-violent and non-coercive Creating non-violent and non-coercive treatment culturestreatment culturesImplementing a trauma-informed system Implementing a trauma-informed system of care. of care. ((AnthonyAnthony, 2004; , 2004; HuckshornHuckshorn, 2004), 2004)

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A shared organizational vision is like a A shared organizational vision is like a magnet - it attracts to it people with magnet - it attracts to it people with special characteristics. special characteristics.

Organizational Vision or Policy Statements Organizational Vision or Policy Statements can be pieces of paper can be pieces of paper or or they can they can energize and mobilizeenergize and mobilize the organization in the organization in common cause common cause

((AnthonyAnthony, 2004), 2004)

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Vision/policy statements can provide a Vision/policy statements can provide a sense of purpose and meaning to staff, sense of purpose and meaning to staff, service recipients, families and the service recipients, families and the communitycommunity

Must appeal to reason Must appeal to reason andand emotions to emotions to be effective be effective

((AnthonyAnthony, 2004), 2004)

Must be shared with staff…Must be shared with staff…

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Leadership Sets Clear Goals Leadership Sets Clear Goals Based on A Vision or Policy goalBased on A Vision or Policy goal

To reduce the use of seclusion and restraint To reduce the use of seclusion and restraint by defining and articulating a vision, by defining and articulating a vision, philosophy, philosophy, action planaction plan and then holding and then holding people accountablepeople accountable

To create a system of care that is fully To create a system of care that is fully informed and directed by the principles of informed and directed by the principles of trauma informed care that has as one trauma informed care that has as one outcome the reduced use of S/Routcome the reduced use of S/R

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Leaders Articulate Agency Policy Leaders Articulate Agency Policy on S/R Use Based on Clear Goalson S/R Use Based on Clear Goals

Clear and unambiguousClear and unambiguous

Restricts use only for “safety in response to Restricts use only for “safety in response to imminent danger”imminent danger”

Includes statement of agency’s expressed Includes statement of agency’s expressed goal to reduce/eliminate and whygoal to reduce/eliminate and why

Links reduction with agency philosophy of Links reduction with agency philosophy of care and expressed valuescare and expressed values

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Fundamental Principles of LeadersFundamental Principles of LeadersLiving Organizational ValuesLiving Organizational Values

2)2) Leaders create an organizational Leaders create an organizational culture that identifies and tries to live culture that identifies and tries to live by key values by key values Values are the “organizational Velcro” that Values are the “organizational Velcro” that binds vision to operationsbinds vision to operationsLeaders must be clear about the values Leaders must be clear about the values that underlie reducing violence and that underlie reducing violence and coercion coercion Then they can start to team build… Then they can start to team build… ((AnthonyAnthony, 2004; , 2004; HuckshornHuckshorn, 2004), 2004)

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Leaders must get clarity and consensus on Leaders must get clarity and consensus on the values that underlie a different culture of the values that underlie a different culture of care and service…care and service…

For recovery/resiliency based settings…”From For recovery/resiliency based settings…”From one that is rule-based, institutional, one that is rule-based, institutional, impersonal and at times coercive to one that impersonal and at times coercive to one that is based on person-centered care, that is is based on person-centered care, that is respectful, never shame-based and that respectful, never shame-based and that strives to avoid homogenous approaches and strives to avoid homogenous approaches and generalities” generalities”

((AnthonyAnthony, 2004; , 2004; HuckshornHuckshorn, 2004), 2004)

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Policy, procedures, treatment activities, Policy, procedures, treatment activities, language and rules need to be held up to language and rules need to be held up to this “values threshold” and measured this “values threshold” and measured against it against it

When this happens, practices change…When this happens, practices change…Agencies become “informed” about Agencies become “informed” about becoming congruent (what we say is what becoming congruent (what we say is what we do) we do)


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Leaders provide Values ClarificationLeaders provide Values Clarification

Takes thought, work, and time in meetingsTakes thought, work, and time in meetingsRequires planning from multiple stakeholdersRequires planning from multiple stakeholdersMany facilities still use consequence-based Many facilities still use consequence-based philosophies, not strength-basedphilosophies, not strength-basedOften staff mistake the signs and symptoms of Often staff mistake the signs and symptoms of illness or learned coping strategies for willful illness or learned coping strategies for willful acting outacting outReview your treatment values and objectively Review your treatment values and objectively critique whether current practices are workingcritique whether current practices are working

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For Example…For Example…

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Crosswalk Values with Practices: Crosswalk Values with Practices: Some ExamplesSome Examples

ValueValue: Person Centered Care: Person Centered Care

PracticePractice: “Everyone goes to bed at 10:00 : “Everyone goes to bed at 10:00 PM and lights out”PM and lights out”

ChangeChange: A range for bedtime that identifies : A range for bedtime that identifies and adapts to individual’s difficulty with and adapts to individual’s difficulty with night-time, bedrooms, and different night-time, bedrooms, and different

bio-rhythms bio-rhythms

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ValueValue: Consumer (adult, child/family) inclusion in : Consumer (adult, child/family) inclusion in treatment planning and caretreatment planning and care

PracticePractice: Consumers are “invited” to team meeting (but : Consumers are “invited” to team meeting (but no one really cares if they do attend), and fill out no one really cares if they do attend), and fill out satisfaction survey at dischargesatisfaction survey at discharge

ChangeChange: Inclusion of consumers in committees, : Inclusion of consumers in committees, procedural reviews, Governing Body, unit rule reviews, procedural reviews, Governing Body, unit rule reviews, employment opportunities, new employee orientation employment opportunities, new employee orientation ANDAND real work to educate patients in their place and real work to educate patients in their place and power in treatment planningpower in treatment planning

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ValueValue: Facility is trauma-informed : Facility is trauma-informed

PracticePractice: Trauma not formally assessed or : Trauma not formally assessed or included in treatment/crisis plans. included in treatment/crisis plans. Environment gives “mixed messages”: Rules Environment gives “mixed messages”: Rules posted, no welcome signs, institutional posted, no welcome signs, institutional décor/color, metal detectors, searches, S/R décor/color, metal detectors, searches, S/R rooms, does not feel warm… rooms, does not feel warm…

ChangeChange: Soften environment & reflect trauma : Soften environment & reflect trauma awareness in treatment & facility operationsawareness in treatment & facility operations

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ValueValue: Avoidance of triggers/shaming: Avoidance of triggers/shaming

PracticePractice: Public and verbal redirections and : Public and verbal redirections and “deletion of points or privileges” for what “deletion of points or privileges” for what staff deem undesirable behaviorstaff deem undesirable behavior

ChangeChange: Respectful, private discussion of level : Respectful, private discussion of level status/privileges and practices that status/privileges and practices that immediately reward for pro-social behavior immediately reward for pro-social behavior but avoid punitive subtractionsbut avoid punitive subtractions

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ValueValue: S/R only used for “imminent danger”: S/R only used for “imminent danger”

PracticePractice: “Any kind of property destruction, : “Any kind of property destruction, threats, physical acting out results in S/R use”threats, physical acting out results in S/R use”

ChangeChange: People who engage in “one time only” : People who engage in “one time only” hitting, break furniture, kick a staff person, hitting, break furniture, kick a staff person, throw something, lie down in middle of floor, or throw something, lie down in middle of floor, or otherwise act out and calm down are not S/R; otherwise act out and calm down are not S/R; this behavior is addressed in treatment team this behavior is addressed in treatment team planning WITH the individualplanning WITH the individual

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A note about languageA note about language

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See how we speak…See how we speak…

De-humanizing Labeling and Language De-humanizing Labeling and Language

– Target populations, line staff, “in the trenches”, Target populations, line staff, “in the trenches”, “take downs”, “aggression control”“take downs”, “aggression control”

– Units, wards, lock downs, surveillance, strip Units, wards, lock downs, surveillance, strip searches, curfews, consequences, “handling”searches, curfews, consequences, “handling”

– Schizophrenics, THE mentally ill, borderlines; non-Schizophrenics, THE mentally ill, borderlines; non-compliant, manipulative, attention- seeking, compliant, manipulative, attention- seeking, needy, juvees, needy, juvees,

– Case managers, Case workers, “cases”Case managers, Case workers, “cases”

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RealityReality

Please do not ever believe that language is Please do not ever believe that language is unimportantunimportant

How would you like to be referred to as a How would you like to be referred to as a “case” or to be “handled or controlled”?“case” or to be “handled or controlled”?

Of course the people we serve have needs Of course the people we serve have needs (needy), require attention (attention-seeking), (needy), require attention (attention-seeking), and have learned that to get attention they and have learned that to get attention they need to beg (attention-seeking)need to beg (attention-seeking)

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Person First LanguagePerson First LanguageChosen language to use for Recovery-Oriented Chosen language to use for Recovery-Oriented systems of caresystems of care

A major change/shift from usual languageA major change/shift from usual language

Is culturally competent, respectful and person-Is culturally competent, respectful and person-centeredcentered

Based on linguistic philosophy e.g. “How we Based on linguistic philosophy e.g. “How we speak about something is indicative of how we speak about something is indicative of how we value and treat it” value and treat it”

(IAPSRS, (IAPSRS, 20032003))

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Person First LanguagePerson First LanguagePromotes the use of words like Promotes the use of words like individual, individual, consumer, given names, service userconsumer, given names, service user in in place of patient, client, inmate, resident or place of patient, client, inmate, resident or using a diagnosis when referring to persons using a diagnosis when referring to persons served in the mental health systemserved in the mental health system

Never uses phrases like “the mentally ill” or Never uses phrases like “the mentally ill” or “the retarded” or “a borderline personality “the retarded” or “a borderline personality disorder”disorder”

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Person First LanguagePerson First Language

Says that people are “people first” and that the Says that people are “people first” and that the routinized, consistent use of “one word” to routinized, consistent use of “one word” to describe groups of diverse individuals is describe groups of diverse individuals is dehumanizing, demeaning, ignores individuality, dehumanizing, demeaning, ignores individuality, encourages a herd mentality and encourages a herd mentality and institutionalizes institutionalizes *Using one word, like “patient, client, or *Using one word, like “patient, client, or resident” is for staff convenience. Does not resident” is for staff convenience. Does not honor individuality. Use kids’ names!honor individuality. Use kids’ names!Encourages individualized/respectful descriptors Encourages individualized/respectful descriptors that do not label that do not label

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Fundamental Principles of LeadersFundamental Principles of LeadersUsing Human TechnologyUsing Human Technology

3)3) Leaders create processes that develop & Leaders create processes that develop & empower their staffempower their staff

Workforce development is imperativeWorkforce development is imperative

Staff become empowered to negotiate and Staff become empowered to negotiate and empower customers; provide choices that are empower customers; provide choices that are win:win win:win

Leaders allocate resources that assist in this Leaders allocate resources that assist in this process process


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Fundamental Principles of LeadersFundamental Principles of LeadersUUssing Human Technologying Human Technology

Avoidance of trauma and re-traumatization Avoidance of trauma and re-traumatization becomes valued over rules, property damage becomes valued over rules, property damage and negotiation timeand negotiation time

Staff become change agents, without fear of Staff become change agents, without fear of repercussionsrepercussionsA safe culture of CQI is embedded; one that A safe culture of CQI is embedded; one that understands that mistakes will be made but understands that mistakes will be made but learning will occurlearning will occur (Anthony, (Anthony, 20042004; Huckshorn, ; Huckshorn, 20042004))

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Leaders find champions and create teamsLeaders find champions and create teams

Leaders put in place practices that Leaders put in place practices that provide staff with “prevention tools” and provide staff with “prevention tools” and skills to useskills to use

Adult, children, staff and families views Adult, children, staff and families views are sought in all decisions are sought in all decisions


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Especially important:Especially important:

The oversight of coercive events are The oversight of coercive events are elevated and consistently “witnessed” by elevated and consistently “witnessed” by staff who can objectively evaluate and staff who can objectively evaluate and make changesmake changes

((HuckshornHuckshorn, 2004), 2004)

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Executive leadership creates opportunities Executive leadership creates opportunities to hear staff concerns on a routine basisto hear staff concerns on a routine basis– Informal “no management” Rap sessions with Informal “no management” Rap sessions with

direct care staffdirect care staff– Lunch with CEO, COO, Med Director Lunch with CEO, COO, Med Director – Total staff “Town Center” meetingsTotal staff “Town Center” meetings– Suggestion boxes Suggestion boxes – Feedback provided after meetingsFeedback provided after meetings

((HuckshornHuckshorn, 2004), 2004)

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Fundamental Principles of LeadersFundamental Principles of LeadersUsing Data to Inform PracticeUsing Data to Inform Practice

(Six (Six Core Strategies Core Strategies ©)©)

4)4) Leaders use information to drive changeLeaders use information to drive change

Gather historical data by event/hours (6 Gather historical data by event/hours (6 months to 1 year) to use as baselinemonths to 1 year) to use as baseline

Set goals as 100% reduction (as you would for Set goals as 100% reduction (as you would for adverse med errors or suicide attempts adverse med errors or suicide attempts

Mandatory: Gather and track multiple variables Mandatory: Gather and track multiple variables (S/R events & hrs; injuries, Stat meds)(S/R events & hrs; injuries, Stat meds)

Post reports on units monthlyPost reports on units monthly

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(Six Core Strategies (Six Core Strategies ©)©)

Use Data To Identify & Analyze Events:Use Data To Identify & Analyze Events:– Unit/Day/Shift/Time of dayUnit/Day/Shift/Time of day– Age/Gender/RaceAge/Gender/Race– Date of admission/DiagnosisDate of admission/Diagnosis– Attending PhysicianAttending Physician– Pattern of staff involved in eventsPattern of staff involved in events– Number of GrievancesNumber of Grievances– Precipitating EventsPrecipitating Events– Safety issues justifying seclusion/restraintSafety issues justifying seclusion/restraint

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(Six Core Strategies (Six Core Strategies ©)©)Use Data To:Use Data To:― Monitor ProgressMonitor Progress― Discover new best practicesDiscover new best practices― Identify emerging staff S/R championsIdentify emerging staff S/R champions― Target certain units/staff for trainingTarget certain units/staff for training― Create healthy competition (PA, MA)Create healthy competition (PA, MA)― Assure that everyone knows what is Assure that everyone knows what is

going on going on

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Fundamental Principles of LeadersFundamental Principles of LeadersValuing Exemplary PerformanceValuing Exemplary Performance

5)5) Leaders build their organization Leaders build their organization around exemplary performersaround exemplary performersBest practices are recognized and Best practices are recognized and rewardedrewardedEfforts are made to encourage reports of Efforts are made to encourage reports of “near misses” and what worked“near misses” and what workedKnowledge is transferred and sustained Knowledge is transferred and sustained in policy, procedures, and practicesin policy, procedures, and practices

((AnthonyAnthony, 2004; , 2004; HuckshornHuckshorn, , 2004)2004)

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Fundamental Principles of Leaders Fundamental Principles of Leaders Develop a SR Reduction PlanDevelop a SR Reduction Plan

6)6) Leaders develop plan and approach Leaders develop plan and approach

Safety needs to start with a Prevention Safety needs to start with a Prevention UmbrellaUmbrella

Performance Improvement Principles (CQI)Performance Improvement Principles (CQI)

Create Facility/Unit Accountable TeamCreate Facility/Unit Accountable Team

Inclusive of person servedInclusive of person served

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Leadership Responsibilities: Leadership Responsibilities: Summary of Key PointsSummary of Key Points

S/R Reduction is PRIMARILY a leadership S/R Reduction is PRIMARILY a leadership responsibility, not your staff’s responsibility, not your staff’s Create the Vision Create the Vision Clarify ValuesClarify ValuesUse Human Technology to change practiceUse Human Technology to change practiceUse Data to InformUse Data to InformValue Top PerformersValue Top PerformersDevelop an Organized Plan Develop an Organized Plan

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Leadership Specifics in Reducing the Leadership Specifics in Reducing the Use of Seclusion/RestraintUse of Seclusion/Restraint

These fundamental principles help set the stageThese fundamental principles help set the stage

Actions are characterized by the required Actions are characterized by the required denominator… denominator…

Leadership Effectiveness and Leadership Effectiveness and Responsibility to ACTResponsibility to ACT

““Do not follow where the path may lead, Do not follow where the path may lead, go instead where there is no path and leave a go instead where there is no path and leave a

trail…” trail…” R.W. EmersonR.W. Emerson

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Contact InformationContact InformationBeth CaldwellBeth CaldwellCaldwell Management AssociatesCaldwell Management Associates413-644-9319413-644-9319bethcaldwell@[email protected]

Kevin Huckshorn / Sarah CallahanKevin Huckshorn / Sarah CallahanNational Technical Assistance Center (NTAC)National Technical Assistance Center (NTAC)NASMHPDNASMHPD703-739-9333, ext 140 & 141703-739-9333, ext 140 & [email protected]@nasmhpd.org or or

[email protected]@nasmhpd.org

Documents

1 A Primary Prevention tool Module created by Huckshorn, 2004 Leadership Toward Organizational Change A Core Strategy © Creating Violence Free and Coercion