TRINITY TREATMENT CENTER

Quality Factors in a Psychiatric Unit

by

Linda Foss and Carol Ainsworth

 TRINITY TREATMENT CENTER:

Quality Factors in a Psychiatric Unit

by

Linda Foss and Carol Ainsworth

7 August 1992

OVERVIEW

Prior to the implementation of "quality improvement" concepts at Austin State Hospital (ASH), a
specialty unit for the treatment of adults with both mental retardation and mental illness gained
a reputation for being an unusually effective program. That unit, Trinity Treatment Center
(TTC). received recognition from both within the hospital and from outside sources. To identify
the factors which contributed to the success of the program, the authors conducted a survey of
persons who worked at TTC during the 1980's. Factors which detracted from the program's
effectiveness were also explored. This paper presents the results of the survey and discusses the
relevance of these findings to the process of continuous quality improvement (CQI).

INTRODUCTION
Almost none of the persons who worked at Trinity Treatment Center in the 1980's chose to
specialize in working with adults with both mental retardation and mental illness, persons who
were considered some of the most difficult to treat among an already challenging state hospital
population. When TTC opened in 1980, it attracted staff members who had some expertise in a
variety of mental health fields such as social work, psychiatry, rehabllitation, psychology,
mental retardation, behavior therapy, but none in the specialty area of mental illness and mental
retardation. The staff included persons who were interested in the development of a new
treatment program, people who had no prior clinical training or experience, and people who had
not the faintest idea of what they were getting into.

Patients admitted to TIC not only showed the symptoms of the psychoses, depreSSions, character
disorders, and other mental illnesses one would expect to find at a state hospital, they also had
the limitations in resources that are associated with mental retardation and other developmental
disorders. Most had limited language skills. Few had ever lived independently.

When TTC opened in 1980, the first persons admitted were individuals who had lived on other
treatment units of the hospital for many years with no apparent hope for discharge. At the time
of admission to TTC, some of these persons seemed unable to relate to others. Some were
seriously self-injurious, physically marked by self-inflicted scars. Some refused to
collaborate at the most basic levels, refusing to eat meals or to wear clothing. Many were highly

dangerous, using scratching, kicking, biting, weapons, body wastes to get what they wanted, or to
maintain a degree of control and power within the highly controlling environment of a state
hospital. Some remained in the hospital only because there had been no other place for them to
live. During the 1980's, the staff of TTC treated and discharged most of these individuals, some
who had lived at the state hospital for as many as 30 years.

Many people who worked at TTC during the 1980's recognized that they were a part of a
peculiarly successful and satisfying experience. The unit's goals for patients were met in a more
spectacular way than anyone would have predicted. Also, despite poor pay for many workers,
often inadequate numbers of staff, inadequate treatment resources, and the difficulties,
indignities, and dangers inherent in working with this population, many staff members reported
that being a part of TTC was a highly satisfying and rewarding experience. Years after having
moved on to other work, a large number of former workers continue to have contact with current
TTC workers and with each other.

It is relevant to note that from 1980 to 1988, there was a normal attrition of staff due to better
job offers, personality clashes, location changes, burn-out. However, staff turnover was
relatively low. In 1988, a major administrative restructuring of the unit by hospital
administration resulted in significant changes in operation, management style, and treatment
focus, leading to a subsequent exodus of staff.

The authors of this report met each other and worked together at nco They wanted to identify the
factors that contributed to the success and satisfaction they experienced at TTC. What made TTC
so special? To find out, they sought people with whom they had worked for their opinions. At the
same time, Austin State Hospital began to pursue ways to. implement quality improvement
processes. The authors thought it would be of value to compare whatever findings emerged from
this study with those processes.

METHOD
This study was conducted in two stages. For the first stage, a questionnaire was devised that
asked only two, open-ended questions: "What made TTC an effective treatment center?" "What
detracted from TTC's effectiveness?" Fifty-eight questionnaires (See Appendix 1) were sent out
to persons who had worked at TTC at some time during the 1980's. Twenty-eight of the
fifty-eight were sent to persons no longer employed by the hospital and the remaining thirty
were sent to persons still employed at Austin State Hospital. Forty-four percent (N=2S) of the
questionnaires were completed and returned. Of the twenty-five responses, nine were from
mental health workers, one was from clerical staff, two were from administrative staff, five

were from teachers (rehab techs), three were from social workers, three were from psychology
staff, and two were from nurses. Ten were from former employees and fifteen from persons still
employed by the hospital. Thus, information was obtained from a representative (though
less-than-scientific) sample and a broad range of disciplines.

For the second stage of the study, the authors reviewed every comment obtained in stage one, then
grouped those comments into similar categories. Some of the same ideas were offered by several
individuals. These were combined into single items. None of the comments were completely
dropped. The items were then formatted to be used with a Likert scale, to be rated on how
essential it was to TTC's success or how much it detracted from success. For example, "Patient
treatment was based on team observations and team 'talking out loud' diagnostic work" was
followed by a four-point scale ranging from one for "essential" to four for "not important" with
an additional option, "don't know," which was not scored. Fifty-eight items regarding TTC's
success and fifty items concerning factors that made TTC less effective were constructed.

The surveyors noted that no one had mentioned the characteristics of the patients themselves as
contributing to failure, so an extra item was created, noting that it had been added after the fact.
Individuals were also asked to circle the five factors they felt were most important in each of the
two categories. The survey had 109 items with additional space for comments (see Appendix 2).

Sixty-two survey forms were sent out, thirty to former hospital employees and thirty-two to
current hospital employees. Thirty-nine percent (N=24) of the forms were returned. For part
two, no information was obtained regarding the respondents themselves.

FINDINGS
In Appendix 2, mean Likert scores and standard deviations are noted for each item. Almost every
comment generated in stage one was met with some degree of agreement in stage two, i.e., there
was a large degree of consensus, particularly regarding what made TTC a successful operation.
Items that were ranked as most essential to TTC's success are as follows, in order from most
important. Asterisks indicate items that were most often circled as being one of the five most
essential factors.

*Programs were geared to fit the individual patient, treatment was figured out on a
patient by patient basis.

*Teamwork, interdisciplinary collaboration, involvement of all staff in team process,

most staff were "team players," "everyone was involved in making decisions," there was
a belief that we all have a role to play.

*"Cross-shift'" [TTC's afternoon shift change meeting]

 Consistency among staff in treatment of patients, especially MHW [mental health

worker] and rehab [rehabilitation] staff.

The whole team (including and especially MHWs) was involved and present where
important treatment decisions were made (including medication changes).

Staff showed a willingness to be innovative, creative (even coming up with "crazy"

ideas). There was support, trust, and nurturance for these new ideas, for flexibility.

Belief in and practical use of positive reinforcement, reward, praise in treating the
patient.

Staff had a "can do" attitude, a belief that even the most "impossible" patients could get
betters, no matter what their history.

Input given from all levels, good two-way communication, sharing and dissemination of
information (minutes, detailed TTR (treatment team review) notes, answers to
behavior therapy program questions, "cookbook" treatment plans, memos on procedures
and policy changes, cross-shift, modeling by experienced staff, etc.)

MHW's and techs who wanted to do much more than baby-sit, who wanted to be involved
in active treatment.

Patient treatment was based on team observations and team "talking out loud" diagnostic
work.

Shared vision. The patient's welfare was a common goal. Staff tried to put aside
personal differences, role differences toward that common goal. There was a sense of
unity and comaraderie.

"Good," "dedicated," "skilled," "talented," "gifted" staff.

South Program staff [providing treatment for dangerous behaviors] were well trained.

Almost every item in part one was endorsed by respondents (refer to Appendix 2).

Factors that made TTC less efffective are identified below, in order of those most significant. The
items endorsed as the five most critical by respondents are marked with an asterisk.

*Empowerment of nursing staff to administrative leadership leading to loss of behavior

therapy as central treatment modality.

Poor morale.

Diminished valuing of teamwork from new unit administration.

*Destruction of or lack of support for two-way communication methods (cross-shift,

staff notes).

*Dissolution of team by new staff, lack of participation in team work by new

administrative staff.

Changes in supervisory techniques from supportive model to punitive model.

Administrative changes toward medical supervision and approaches leading to a mass

exodus of staff in a short period of time.

4
 Hospital reorganization diminishing potent leadership on unit.

Tendency to take path of least resistance instead of best path for treatment.

Administrative staff changes toward persons with more autocratic style of leadership.

Loss of administrative staff who understood and endorsed unit mission.

*Emphasis on medical issues over behavioral programing issues.

TTC always needed ten fewer patients or five more staff. TTC was understaffed
considering the intensity of the needs of the patients.

Enforcement of hospital guidelines toward multidisciplinary medical model rather than

interdisciplinary treatment program.

Hospital "pulling staff" to [work on] other units.

As strong leaders resigned, new ones were less able, less interested in unit mission.

DISCUSSION
The staff of TTC endorsed several general factors as critical to the success of their organization.

VISION, COMMON GOAL

Putting aside personal differences and role differences toward a common goal, the patient's
welfare, was identified as an essential factor. Staff suggested that treatment and programs were
geared toward that goal rather than toward staff comfort or toward satisfying departmental
bureaucracy. Administrative staff endorsed the vision daily through cross-shift meetings,
ongoing involvement at treatment team meetings, and standing up for the individual over the
status quo with bureaucrats outside of the unit. Tied to and communicated with the vision were a
"can do" attitude and "we've all got something to learn" message that made the most difficult goals
seem reachable.

TEAM WORK AND PARTICIPATION

Numerous ideas endorsed by the staff related to team work. All staff members were involved in
the treatment process and in decisions regarding that treatment. Working as teams had the
additional benefit of informally educating and reinforcing in all team members the unit goals, the
rationale for treatment procedures, and the proper implementation of procedures. There was a
relationship between administrative/clinical staff and direct care staff that was reinforced daily
by administrative involvement with the patients (e.g. serving as case managers, helping in
emergencies) and by direct care involvement in traditionally administrative/professional
activities (e.g. revision of policies. involvement in treatment team meetings). For example, the
unit director and administrator also functioned as advocates and case managers for one or more

Cross-shift and a special process called "staff notes" (involving writing detailed and
congratulatory compliments to fellow staff and their supervisors simultaneously) were
procedures used to support staff in their efforts toward treating the patients. The creative,
flexible, and ultimately successful environment of TTC would likely not have flourished in a
more blame oriented, autocratic system.

AUTCNOMY
Autonomy was a significant factor for the treatment teams, for the patients, and for bolstering
the satisfaction and effectiveness of individual staff members. Administrative staff demonstrated
trust in their clinical teams: teams were given considerable autonomy and decision-making
power. Clinical staff had the expectation that all patients, regardless of degree of impairment,
could act and be treated as adults. Administrators, on the whole, treated all workers as
colleagues rather than as subordinates.

EVALUATION At\ID PRIORITIZATION

Thorough and ongoing evaluation, of patient needs, conditions and progress, and of the needs and
progress of staff, were characteristic of TTC's approach. Use of staff and patient report, in
conjunction with data, were used in evaluation and treatment, at cross-shift and Treatment Team
Reviews. Team process was used to obtain material for the evaluation, to come up with a
formulation and a plan, and to implement the plan. Communication and data were. necessary, but
not sufficient, tools in that process. The team process of formulating, of understanding what the
patient was experiencing and then of trying treatment approaches driven by that formulation,
was the key factor.

The administrative team worked in much the same way inmainJaining unit function and vision.
Endorsing the unit vision meant prioritizing the patient's needs, many times over the demands of
the bureaucracy. Participants in the survey suggested that programs designed to fit the needs of
each individual were an essential element.

TREATMENT APPROACHES
TTC's provision of a strong, high-consistency, high reward environment for the patients was
sometimes negatively perceived from outside the unit as controlling. The staff in this survey
disagreed, endorsing those approaches. One comment stated that the programs were
"empowering. The patients ... discovered very quickly that their access to rewards was no longer
governed by staff whim but by entitlement that they could control by their own behavior."

It is important to note here that use of behavioral and other unit data was an integral part of TTC.

8
However, it was treated as one source of information, along with staff observations, patient
input, historical information on the patients, clinical hypotheses of professional staff. It was
never used to the exclusion of other sources of information.

COfVIARJ\DERIE
Shared fears related to the risks of the job and shared pride in helping people to reach for their
potential forged a comraderie among staff that enhanced morale and effectiveness. Although this
factor is listed last, it may have contributed most to team function and to staff stretching their
skills and energies to the limits.

LESS THAN CRITICAL

The following were apparently viewed as important but not critical factors: salaries, inadequate
resources, inadequate support from outside the unit. Either these were less than relevant, or
they fostered unity by increasing the challenge of an already daunting task. The qualities that
made TTC patients difficult to work with apparently were perceived as part of the challenge and
success rather than part of the failure.

DETRJ\CTING FACTORS
Management changes imposed on TTC from hospital administration, leading to the diminishing of
the strengths described above, was perceived as the most powerful force detracting from success.
The trust management staff had for their employees within the unit was not evident from outside
the unit. When hospital staff decided to effect a more autocratic, "medical model" style of
management across the hospital without consultation with the units, TTC may have suffered most.
All clinical and administrative staff were soon supervised outside the unit, leaders who
supported the unit vision and whose management style encouraged autonomy and creativity were
taken off the unit. Treatment focus was no longer unified.

DEMING'S CONTINUOUS QUAUTY IMPROVEMENT

W. Edward Deming's fourteen-point guideline to attain universal commitment, commonality of
goals, and relinquishment of formal and informal controls on employee creativity was affirmed
independently by TTC staff. Vision, fostering an environment where workers feel free to express
their ideas and concerns, the destruction of barriers among different departments while
fostering interdisciplinary team work, management responsive to worker needs, and data
gathering all were identified by Deming as conditions important to effective and successful
industry. According to this survey, they are the same factors valued by TTC workers and
identified as relevant to the unit's success in treating patients with serious mental and emotional

disturbance, prior to formal education about Deming's concepts for quality improvement. This
survey independently supports much of Deming's theory.

OTHER COMPARISQ\JS
The authors conducted a limited review of relevant issues (Le., as work on the project
progressed, participants sent the surveyors pertinent articles.) Smithsonian published an
article concerning the critical balance of management on an aircraft carrier crew. Several
former staff of TTC felt the article to be descriptive of the spirit of relationships on the unit.
The following passage from the article could have been written about TTC:

... Officers work hard to maintain ... a quality rarely encountered in the civilian
world--completely unselfish devotion to the task at hand. A feeling for the team,
the ship, the Navy, a feeling so intense that when someone else slips up, you feel
as depressed as if it were {our own failure. "This is the sort of thing that usually
happens only in a family."

The characteristics of the carrier crew described as critical to their success and their survival
included sharing of duties in emergencies according to what was needed. A junior serviceman
might find himself in a leadership role, while a senior officer might perform menial duties
toward alleviating the emergency. In trying to contain a violent and dangerous episode with a
patient, a mental health worker could be found orchestrating decisions, with the unit director or
supervising nurse in support roles, opening doors, directing other patients away from the
dangerous area, picking up overturned furniture. "This is plain common sense, ...that in periods
of peak emergency, strict chain-of-command systems work best. Common sense happens to be
'dead wrong.,,2 Routine recognition of team and individual effort was also a characteristic of the
crew in common with TTC.

An article on the success of Walmart stores suggested the importance of managers' involvement
and interaction among employees and customers. Sam Walton's hands-on management, daily
making surprise visits to his stores around the country, talking to employees and customers,
was considered to be a critical factor in his enormous success. Management was taught to treat
employees as adults, making the most of their ideas and contributions. Administrative and
clinical staff at TTC were asked to drop by once or twice a day to visit the relatively isolated
program area for patients exhibiting dangerous behavior. Because of the visits, the staff there
felt more supported and less isolated in their difficult job. The clinical and administrative staff
were more aware throughout the day of the problems or progress in the program. Ineffective
therapies were less likely to be maintained and more effective ideas were likely to be generated
between direct care workers and administrative/clinical staff during the visits.

10

IMPLICATIONS FOR SIMILAR ORGANIZATIONS

The authors have been asked how does an organization change from an autocratic, ineffective
structure to one more fluid and enabling as described in this paper? Creating such a system has
been described as difficult, if not impossible, when a less functional system is already
entrenched. The authors have been reminded that TTC started as a new unit with new staff where
destructive patterns had not already become hardened from years of tradition.

The following approaches might be useful in such a situation:

Identify the end product desired, not the reports and papers and numbers, but the
reason for the organization's existence.

Encourage managers to become more available where the end product is being

produced. In a psychiatric unit, this means the unit director, the administrator, the

charge nurse, the supervisor, the psychologist, the social worker, and the doctor

going to the dayroom, the bedrooms, the classrooms, the campouts, the sleeping areas

on a routine, day-to-day basis. Encourage managers to spend time "on the floor"

with patients and workers, listening, observing, and helping where needed without

"telling" initially. Once the staff realizes that managers have the same understanding

of operations that they do, they will be better able to listen to recommendations and

contribute their ideas and talents. The better the managers understand what's going

on, the better their recommendations will be. Managers will learn first hand the

strengths and weaknesses. (Top-line adminstrators, in teaching managers to do this,

of course, must routinely model these behaviors themselves.)

Front line employees must make themselves ask questions, generate and give voice to

their ideas. Managers and peers must acknowledge and reward this effort by

listening, recognition, and praise. Employees who take part in their organization,

who dream for their organization, will assume responsibility for the end product.

All employees must get to know their "patients" as people. They must learn as much

as they can about them, about their history, their clinical condition, their desires,

before presuming to make treatment decisions that will affect their lives.

An organization can start small with change. Permit sections or units to volunteer to

be first for new approaches. Let improved productivity and morale in the trial

sections provide the stimulus for other sections to request the changes.

11
Understand that it will seem like more work for managers to spend time "on the
floor" or for mental health workers to ask questions and talk about ideas. In the long
run, this process is surprisingly more efficient and productive than remaining in
traditional, compartmentalized roles. Patients benefit from such an approach.

12

 FOOTNOTES

1. Management for Quality and Introduction to Statistical Process Control. The University of
Texas at Austin Division of Continuing Education, Industrial Education Department,
1990.

2. John Pfeiffer, "The Secret of Life at the Limits: Cogs become big wheels," Smithsonian,
July 1989, pp. 38-48.

3. John Huey, "America's Most Successful Merchant," Fortune, September 1991, pp. 46-59.

13

 SUGGESTED READING

Adams, Edward. "The Quality Revolution: A Challenge to Safety Professionals," American

Society of Safety Engineers, August 1991, pp. 22-28.

DePree, Max. Leadership Is an Art, Doubleday

Dumaine, Brian. "What the Leaders of Tomorrow See," Fortune Magazine, July 3, 1989, pp.

48ff.

Frey, William R. "Here Comes 'Total Quality Improvement'," Occupational Therapy Forum,

September 27, 1991, pp. 8 & 9.

Glasser, William. The Quality School, Harper Perennial, 1990

Gold, I.M. ET AL. "Developing a Unit for Mentally Retarded-Mentally III Patients on the

Grounds of a State Hospital," Hospital and Community Psychiatry, August 1989, Vol 40, #8,

pp. 836-840.

Hisrich, Robert D. " Entrepreneurship/Intrapreneurship," American Psychologist, February

1990, pp. 209-222.

Huey, John. "America's Most Successful Merchant," Fortune, September 1991, pp. 46-59.

Juran, LM., Frank M. Gryna, Jr., and R.S. Bingham, Jf. Quality Control Handbook, McGraw­

Hill, Inc., Third Edition, 1979. Chapter 12 Principles of Quality Service by D. Keith Denton

Koska, Mary T. " Adopting Deming's Quality Improvement Ideas: A Case Study," Hospitals,

July 5, 1990, pp. 58-64.

Management for Quality and Introduction to Statistical Process Control, The University of Texas

at Austin Division of Continuing Education, Industrial Education Department, 1990.

March, Artemis. "A Note on Quality: The Views of Deming, Juran, & Crosby," Harvard

Business School, #9-689-011, 1986, revised Feb. 1990.

Peters, Tom. Thriving on Chaos, John Wiley & Sons, New York, New York, 1986.

Pfeiffer, John. "The Secret of Life at the Limits: Cogs become big wheels," Smithsonian, July

1989, pp. 38-48.

Pickens, T. Boone. "Pickens on Leadership," Hyatt Magazine, Fall/Winter

Roberts, James S. "CQI Revisited - Clinical Applications," The Quality Letter for Healthcare

Leaders, May 1990, pp. 2-12.

Roster, Sandra L. "Total Quality Improvement," Journal of Quality Assurance,

September/October 1990, pp. 18-21.

Scholtes, Peter R. The Team Handbook. Jointer Associates Inc., 1988.

Sherman, V. Clayton. IITotal Management, Not Total Quality Management," Journal o/Quality

Assurance, September/October 1990, pp. 26-29.

Semler, Ricardo. 11Managing Without Managers, n Harvard Business Review,

September/October 1989, pp. 76-84

 Appendix 1

Dear Friend,

Working at TTC was a very special experience for us. Sometimes it was
just awful. Sometimes it was wonderful.

We accomplished some impressive goals. At our best times, people from

many different backgrounds, different levels of education, different
personalities, different feelings and opinions worked together as a
team for the common goal of the welfare of the patient. We were able
to discharge patients who had lived in hospitals for decades, patients
that no one wanted, that others had given up on. We kept a very
complex, effective program going with so many of our staff trying to
keep it consistent, to make it work. We invented new strategies and
treatments for folks who were not helped by the old approaches. At
best, we were able to turn a very complicated array of therapies
(education, medicine, behavioral) into a cohesive treatment plan. We
were never a perfect unit, but we were impressively effective,
especially when you consider how limited our resources were and how
little training most of us had for this kind of work.

We're ~rying to find out what made it work. When we were good, why
were we good? We want to pull it all together and write it up because
we do not want to lose what we learned. So, we're am asking you to
sit down and write what you think were some of the major factors in
making TTC effective when TTC was at her best.

We know that you are very busy people and that you have little time
for outside projects. We also know that you are good at your work and
will want to contribute to ?omething that may provide some ideas for
others in the future. Will you please take a little time to jot down
your thoughts and send them to us? Enclosed is a form and return
envelope for your convenience.* We will pull them all together as
best can and share them with you at a later date. Thank you so much l

TTC-exers,

Linda Foss & Carol Ainsworth

* If you don't feel like writing, give Linda a call a

NAME (Optional) _____________________________ _

DATES WORKED AT

SHIFT(s) ____________________________________ _

POSITION(s) _________________________________ _

What made TTC an effective treatment center?

What detracted from TTC's effectiveness?

 Appendix 2

TIC SURVEY
17 September 1990

All of the ideas below came from you and your former coworkers at Trinity Treatment Center.
We would like for you to rate how important each of these factors was to the success of nc.
Please circle a "1" for "essential," meaning without this, TTC would not have been successful.
Score·a "2" for very important, a "3" for somewhat important, a "4" for not important, and a
"OK" for don't know.

Then when you have completed the questionnaire, go back and please circle the five ideas you feel
were the most important, in your opinion. As always, there's plenty of room for comments, and
we'd surely like to read them.

I. Fadors Contributing to Success of TTC

Staff Attitudes
Mean SD
1. 70 .82 1) Staff shared responsibility without too much concern about "turf." There was a
willingness to do "someone else's job/' blur the distinctions among job
responsibilities. (For example, there were MHWs in the classroom,
administrative staff on the wards, rehab techs doing clinical work, nurses doing
behavior contracts.)
1.48 .59 2) Staff showed a willingness to be innovative, creative (even coming up with
"crazy" ideas). There was support, trust, and nurturance for these new ideas, for
flexibility .
1. 50 . 67 3) Staff had a "can do" attitude, a belief that even the most "impossible" patients
could get better, no matter what their history.
2.05 .65 4) Pride, maybe conceit, about the quality of our work. We held ourselves in high
esteem.
1. 55 .51 5) Shared vision. The patient's welfare was a common goal. Staff tried to put aside
personal differences, role differences toward that common goal. There was a
sense of unity and comradery.
1. 78 . 67 6) Belief in and use of positive feedback and positive reinforcement for staff
(support, Employee of the Month, staff notes, cross-shift) .
1.83 . 65 7) Failures were not punished. Instead, staff tried to devise new strategies to
compensate for failures. They moved forward .
1. 87 . 69 8) The patients improved visibly as a result of our efforts, giving us a sense of
confidence and accomplishment, a belief that our~fforts had value.
1. 64 . 73 9) There was enthusiasm and optimism from persons in key positions.
1. 91 . 75 10) Staff belief that this kind of work was special, had some higher value (meaning
helping those with the least ability to help themselves).
2.26 .75 11) All staff "owned" TIC, feIt responSible for success or lack of success.
1. 65 .71 12) Shared responsibility in physically dangerous tasks like takedowns, restraints.
1.48 .59 13) Belief in and practical use of positive reinforcement, reward, praise in treating
the patients.
1. 74 . 81 14) Administrfltive staff believed in and acted on their beliefs to share power and
decision making. Input and involvement were encouraged from aiL

Staff Qualities

1.73 .83 1) Unit directors gave fre<.:dom, autonomy, trust to teams.

1.96 .65 2) Skills and openness of physician, "brilliant diagnostic work" by physician.
2.09 .73 3) The MHWs were led to believe that their jobs were just as important, maybe
more so, as the highest paid employee there.
1. 86 .83 4) MHWs were program aides rather than nursing aids.
1. 68 .48 5) Rehab staff turned unit theory into practice on a day-ta-day, hour-ta-hour basis.
1. 91 .67 6) Leadership and skills of clinical and administrative staff, "strong" people in key
positions.
Mean SD
1. 65 .71 7) Mutual respect, trust among diSciplines.
2.05 .58 8) Administrative team modeled teamwork and cooperation to direct care teams.
1. 91 .81 9) Administrators appreciated people with different skills, ages, personalities,
backgrounds, genders, cultures and tried to make the mosl of their individual
offerings.
1. 61 .72 10) Unit and individual behavior therapy programs were supported by staff in all
disciplines
1.52 .51 11) MHWs and techs who wanted to do much more than baby-sit, who wanted to be
involved in active treatment.
1. 74 .54 12) Old staff with experience modeled approaches, team work for new, less
experienced staff.
2.00 .54 13) Administrative staff were willing to listen and easy to talk to.
2.50 1.05 14) Separate nursing and MHW supervisory structures.
2.16 .69 15) Physician, unit director ran interference for us in administration.
2.19 1.05 16) TIC was a new exciting adventure. All staff were "inexperienced" at its startup.
1.55 .67 17) "Good", dedicated", skilled", "talented", "gifted" staff.
U

2.50 .86 18) The staff included a diversity of personalities, beliefs, and characters
("comedians, anarchists, Republicans, drug runners, bureaucratic trolls") who
contributed to the unit's success.

Unit Structure

2.05 .59 1) Central Office and hospital administration gave autonomy, independence to TIC
(because they saw our population as being "different"). "We were allowed to be
freewheelingl"
2.05 .76 2) The design of the old building, with all its flaws, contributed to success.
Administrative offices opened out into patient areas leading to greater
administrative staff involvement and a better informed administrative staff.
2.7 .87 3) The unique qualities of persons with mental retardation and psychiatric
problems.
2.32 .84 4) Relatively small size of unit (when census was 35).
1. 75 .64 5) South Program was effective for dangerous behavior, and allowed for more
safe, effective programming for all patients.
1. 55 . 51 6) South Program staff were well trained .
1. 64 .58 7) Staff shared the opinion that Behavior Therapy, with Proactive meds as an
adjunctive to that therapy, was the best approach.
1.81 1.05 8) Melodie Clemons (who compulsively designed the program, helped forge a
cohesive staff, and contributed the unit with a special mission attitude).
2.22 . 60 9) Low staff turnover.
2.09 .61 10) Low staff turnover in administrative staff.
1.87 .76 11) The level system and token economy were pervasively therapeutic.
2.00 .62 12) We tried to prioritize what was most important given limited resources,
sometimes choosing goals different from those given us by hospital
ad ministration.
1.83 .78 13) Behavior therapy was primary treatment used.
1.65 .65 14) The "structure" on the unit contributed to patient improvement the level
system, token economy, classes, and consistent daily routine provided
"structure."
2.00 .73 15) TIC was free to hire according to its own perceived ne<c.'Cis, unit hiring instead of
hospital hiring
1.44 .51 16) "Cross-shiftl"
2.57 .81 17) We knew who the boss on the unit was.
2.09 .79 i8) Enough st9-ff to try a few things.
2.05 .81 19) Enough money to get a few things.
1ean SD Team Work

l.44 .59 1) Consistency among staff in treatment of patients, especially MHW and rehab
staff.
L50 .51 2) Input given from aU levels, good two-way communication. sharing and
dissemination of information (minutes, detailed TIR notes, answers to Behavior
Therapy Program questions, "cookbook" treatment plans, memos on procedures
and policy changes, cross-shift, modeling by experienced staff, etc.).
1.91 .68 3) ''MASH effect," frequent emergencies and crises led to necessary team building,
teams became "tight" despite dislikes, personality differences.
1. 26 .45 4) Programs were geared to fit the individual patient, treatment was figured out on
a patient by patient basis.
1. 55 .67 5) Patient treatment was based on team observations and team "talking out loud"
diagnostic work.
1.46 .67 6) The whole team (including and especially MHWs) was involved and present
where important treatment decisions were made (including medication changes).
1. 39 .58 7) Teamwork, interdisciplinary collaboration, involvement of all staff in team
process, most stalf were "team players," "everyone was involved in making
decisions," there was a belief that we all have a role to play.
1.83 .58 8) Encourage as much independence as each patient could handle, discouragement
of dependency role.
1. 91 . 61 9) Administrative team modeled teamwork and cooperation to direct care teams.
1. 70 .56 10) TTRs were used to train as to the hows and whys of strategies.

Remember, circle five (5) ideas that you feel were the most important in contributing to TIC's success.

Each of the following statements were offered by you or one of your former coworkers. How
much of a role did each of these factors play in making ncless effective 7
Circle" 1" for critical meaning this factor played a major role in nT's failure, "2" for very
important, "3" for somewhat important, "4" for not important, "DK" for don't know.

Again, when you are done, go back and circle the five most important factors in our failure.

II. Factors That Made TIC Less Effective

Staff Attitudes

1. 53 .64 1) Changes in supervisory techniques from supportive model to punitive model.

3.25 1.07 2) n'c is no longer a new, uncharted challenge.
1. 50 .79 3) Destruction of or lack of support for two-way communication methods (cross­
shift, staff notes).
2.33 .97 4) Staff became more rigid, less innovative as we b<..><:ame "experts"
1. 79 .71 5) As strong leaders resigned, new ones were less able, less interested in unit
mission.
2.42 .96 6) interpersonal differences among staff.
2.22 1.11 7) Staff concerned more about paycheck than unit and patient goals
1.8 .77 8) "Battle fatigue," "Burn-out," "rust trying to stay alive rather than trying to make
improveITl€nts," "overworkc-'d staff."
2.00 .88 9) High staff turnover.
1.44 .62 10) Poor morale.
2.14 .96 11) Inadequate salaries given the job responsibilities and expectations.
2.00 1.00 12) Not enough staff appreciation.
1.82 .88 13) Loss of common goal.
 [
ean SD Unit Structure
[
,75 .85 1) Requirements for too much and sometimes repetitive documentation, "too much
paperwork/' "too much time and resources put into paperwork requirements
that had little direct relationship to patient care." [
.39 .98 2) The new building's design led to segregation of professional/administrative staff
from wards.
.11 .94 3) Inadequate funds to properly implement programs, to buy new materials, to
properly supply core aspects of treatment like token store.
[
.42 1.07 4) Too many patients in too small a place (when census was 55), crowding.
.28 .58 5) Empowerment of nursing staff to administrative leadership leading to loss of
behavior therapy as central treatment modality. [
.18 1.02 6) Changes mandated from outside impinging on program quality (such as 3­
cigarette rule, change from PORS to ITPS, staff scheduling, staff selection).
. 95 1.03
.67
7) lack of hospital support. [
.65 8) Loss of administrative staff who understood and endorsed unit mission.
. 22 .89 9} As unit aged, fencing off of territory by disciplines.
.11
.93
1.08
1.1
to)
Il}
As unit aged, newness of mission wore off. .
TIC didn't fit in with the other units, with the hospital administration's vision of
[
other units.
.56 .86 12) Administrative changes toward medical supervision and approaches leading to
mass exodus of staff in a short period of time. ['
.63 . 76 13) Hospital reorganization diminishing potent leadership on unit..
.72 .96 14) TIC always needed ten fewer patients or five more staff. TIC was understaffed

.00 . 00 15)
considering the intensity of the needs of the patients..
TIC had too many staff, "we were better when we had half the staff'.

.80 1.06 16) Medical model of supervision, medicalization of MHW staff supervision.

.90 .97 17) Because our patients were the "worst of the worst", Central Office and hospital

administration saw TIC as a stopping point rather than a transitional treatment

[
center. There was no place to go when a patient improved, a lack of placements.

.. 77
:.06
.56
.77
18)
19}
There were too many folks ready for discharge and stuck on the unit.
Hospital "pulling staff' to other units.
Forces from outside toward more standard, bureaucratic approach.

_.65 .88 20) Emphasis on medical issues over behavioral programming issues.

~ .11 .74 21) Difficulty translating TIC approaches into the community settings.

Team Work
l
l. 74 .65 1) Enforcement of hospital guidelines toward multidisciplinary medical model
rather than interdisciplinary treatment program
C
1.50

1.63
.61

.76
2)

3)
Dissolution of team by new staff, lack of participation in team work by new
ad ministrative staff.
Tendency to take path of least resistance instead of best path for treatment.
,­
"
1.8 .83 4) Loss of common goal, loss of unit vision.
2.14
2.47
1. 47
1.11
1.01
.62
5)
6)
7)
Supervisory emphasis on staff problems rather than patient goals
Not enough emphasis, resources to develop community skills of patients.
Diminished v-aJuing of teamwork from new unit ad ministration.
r
1.84 .77 8) Dictating jobs by discipline and degree rather than by individual qualifications. i
Mean SO Staff Qualities

1.83 .86 1) Conflict of interest between medical and other staff, medical staff had medically
oriented goals, other staff had program oriented goals.
1.84 .83 2) Dictating jobs by discipline and degree rather than by individual qualifications.
1.85 .81 3) Inconsistent skill among direct care staff.
2.19 .93 4) Overwhelming expectations for direct care jobs.
2.11 .99 5) Supervisory emphasis on staff problems rather than patient goals.
1.65 .70 6) Administrative staff changes toward persons with more autocratic style of
leadership.

No one mentioned qualities of tlte patients themselves as a contributing factor toward failure,
which is of interest. We thought we'd add an item, though, to get your impressions.

2.82 1.00 * This special population of individuals has characteristics making them unusually
difficult to work with: impaired communications, difficulties relating to others, needs for
intensive monitoring and care, dangerous behaviors, toileting and hygiene challenges,
and sometimes incredibly disturbing behavior patterns.

Remember, please circle the five{ 5) ideas that you feel were the important in
contributing to TIC's success ( Section I), and circle the five (S) ideas you feel
most critical in contributing to n'C's failures (Section II),

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