Funder: Robert Wood Johnson Foundation

May 2018 | Profile



Big government entities like the San Francisco Department of Public Health (SFDPH) often have a bad rap for being large and slow to change. But despite its size, and offering physical and behavioral health services through a number of clinics, SFDPH has taken a progressive stance on the importance of creating a trauma-informed workplaces.

“We’ve seen small individual epiphanies confirming the value of a trauma-informed work environment — leadership must nurture these approaches if they are to become everyday practice.”

Ken Epstein, LCSW, PhD, Director, Child, Youth and Family System of Care

Ken Epstein, LCSW, PhD approached the department’s director, Barbara Garcia, about positioning the department to become trauma-informed back in 2012, long before many people had ever even heard of the concept. In response, Garcia commissioned a workgroup, led by Epstein, to bring together experts and leaders from across departments to discuss how to make the system more responsive to the needs of employees and clients with histories of trauma. They theorized that a shift toward a trauma-informed approach would decrease workplace stress, improve morale, and promote employee wellness, thereby improving services for city clients.

Epstein, a licensed clinical social worker who has worked with SFDPH since 2012, explains: “The symptoms individuals, families, and communities experience in response to trauma are the same within large public organizations and government.” As in the general population, departmental staff previously experienced withdrawal, decreased motivation, and lacked trust in the organization and their supervisors. Diverse and mission- driven employees felt disempowered, thus sapping their initiative and feeding into an “us versus them” mentality. For that reason, SFDPH’s Trauma Informed System (TIS) initiative is aimed at transforming the health department’s organizational culture into one that proactively empowers people, nurtures and respects their engagement, and is employee-led and self-sustaining.

Ingredients of Trauma-Informed Care

Based on expert insights, the Center for Health Care Strategies (CHCS) compiled these core organizational and clinical elements to guide practitioners in pursuing trauma-informed care. Many of these ingredients are incorporated into SFDPH’s approach, with select features described below.

SOURCE: C. Menschner and A. Maul. Key Ingredients for Successful Trauma-Informed Care Implementation. Center for Health Care Strategies, April 2016.

Select Features of SFDPH’s Trauma-Informed Approach

Based on ingredients of trauma-informed care outlined above, following are select aspects of SFDPH’s approach to addressing trauma.

Leading and Communicating about the Transformation Process

Gaining staff buy-in and encouraging interdisciplinary collaboration has been critical to the initiative’s success and long-term viability. Epstein notes that “engaging leadership is the holy grail of being able to sustain and promote a healing organization.”

Before starting, SFDPH allocated 45,000 staff hours to training so all employees could attend the foundational TIS training. To date, over 7,300 employees have been trained. This represented a significant investment by the department, and demonstrated to employees that SFDPH leadership was committed to giving the initiative the time and resources necessary to make an impact.

Creating a Safe Physical and Emotional Environment

SFDPH has sought to incorporate mindfulness practices into many workplace routines. For example, many employees incorporate three-to-five minute check-ins at the beginning of meetings. During these breaks, meeting participants perform breathing exercises or other types of mindfulness activities. In addition to improving staff wellness, SFDPH notes that the breaks help focus the group on the task at hand, and improve the quality and efficiency of meetings.

Additionally, and in line with the initiative’s core principles, champions and leaders have participated in a variety of trainings on “cultural humility.” The trainings have been so well-received that select departments have pursued additional training on the topic. SFDPH staff members also took part in a two-day mindfulness training conducted by the “Search Inside Yourself Leadership Institute”, an organization developed by former Google employees and dedicated to “train[ing] leaders and employees to better understand themselves and work well with others.” Certain staff have been trained to lead the trainings themselves, with the goal of eventually developing SFDPH’s own mindfulness curriculum.

Engaging Staff in Organizational Planning

Staff voices are integrated into SFDPH’s trauma-informed transformation whenever possible. During trainings, employees complete satisfaction surveys, the results of which help SFDPH prioritize which issues to address. It is clear the effort put into staff engagement has paid off — in surveys, employees indicate they believe the initiative is important, beneficial, and could be easily applied to their work. Their greatest concern is that the initiative might not be sustained.

Learning collaborative groups provide another opportunity for staff to participate in the TIS initiative. As part of the learning collaborative, each participating departmental team completes a TIS Self-Study assessment. Results from the assessment highlight strengths and needs, and provide a framework for developing Healing Organization Growth Plans. To support this process, each participating agency identifies a staff “champion” to lead and guide the change process. Champions from across agencies meet regularly during The Champions Learning Community (CLC). In addition to strategizing how to align TIS work with current priorities and initiatives, champions receive coaching on organizational change, project implementation, evaluation, and participatory decision-making. The current CLC cohort consists of eight leaders and 17 champions encompassing a range of physical and behavioral health service providers.

Next Steps for Trauma-Informed Care at SFDPH

SFDPH’s ultimate goal is to transition from a “trauma-organized” to a “healing” organization, one that is reflective rather than reactive, encourages growth and constructive conflict, and provides a safe and healthy environment for employees. Designed as a self-sustaining process, SFDPH has adopted a “train-the-trainer” model in which staff champions will lead new employees through the foundational TIS 101 and cultural equity classes. SFDPH’s leadership hope to build upon their work in the future by sharing new trauma-informed practices brought by champions to TIS meetings, and incorporating them into agency-wide daily practices.