Everybody who comes onto the program hates testing.
They’ve gone through a phenomenal amount of testing
before they’ve seen us, and they come here and here’s
yet another set of tests. So we thought that we would
make it easier by basically doing testing a little bit here
and there over a period of a full month. And they hated
that. They wanted to get it over with. We had to throw
out the first plan . . . now, the bulk of the testing is done
in a two week period. That was participant feedback
that drove that change.
Participants are also directly involved in directing
day to day activities: Participants “set their goals, their
tasks for the week, and then they bring us those tasks,
and Monday afternoon the staff meet and actually set
up the week’s schedule based on the participants’
tasks.”
At the staff level, staff are involved in decision making
concerning programming, ranging from mission
and values to deadlines and content: “Staff . . . are always
in on the ground floor of whatever’s evolving.”
For example, “one of the areas we needed to do some
real work on was what happens around behavioral incidents.
And so I developed a policy and procedure based
on the feedback from staff.”
As a direct result of participant feedback, “Over time
we’re gradually involving family members more and
more as well.”
At the board level, members include a combination
of professionals and people in the community with
stakes in the situation, ranging from frontline vocational
counselors to a graduate of the program.
In addition to community representation on the
board, “We’re now working on a survey to go to people
who have left the program, and the next on the list will
be developing a survey for payers and community
agencies.”
Its processes and strategies reflect health promotion
theories and beliefs. For example, a holistic approach
to health is taken. “We work with not just the physical
being but . . . the emotional being, to some degree the
spiritual being. It’s the whole person we’re working
with, not just one category, one area.”
Its processes and strategies reflect health promotion
relevant evidence. Evidence on which to base decisions
and plan programming has been drawn from a wide
range of sources: published literature, unpublished
material, staff and board members’ experiences and
understanding, feedback from participants, information
from other agencies and individuals inside and outside
the field, the internet, funders, participants’ community
workers, and results from regular evaluations of all program
components. Both objective and subjective evidence
are considered; for example, assessments of participants’
progress through standardized tools and
through direct input from participants themselves. Both
quantitative and qualitative evidence are considered:
The concrete results that we’re seeing already are that
the outcome measures that we use to look at power, the
degree to which a person feels that they have control
over their lives, are showing very, very favorable
changes. That’s a very numerical result. The feedback
that we get from participants [a qualitative result] is
that it is very difficult, taking responsibility for your
own life is very difficult, and there are moments in
which they would prefer that we take responsibility for
their lives, but in the end, as they progress through the
Kahan, Goodstadt / INTERACTIVE DOMAIN MODEL 45
Downloaded from program, they really appreciate it and realize how important
that is for them.
Its processes and strategies reflect a health promotion
understanding of the environment. Brownstone talks
about the critical importance of “climate,” or, in health
promotion terms, the necessity for a supportive
environment:
I think the climate is really critical. The setting up of an
atmosphere that says to the participants, “This is your
place, and this is your program, and this is your life,
and you need to take control and make use of the opportunities
you have in being here, and through that
opportunity build more opportunities for yourself and
your whole life.” And I think that’s a critical piece of
the puzzle, here, in terms of best practices. And whenever
I have a chance, I say, and I think that the staff say,
“The door is open, you have concerns about your program,
concerns about anything that’s going on here,
you let us know.”
For the staff, the climate is a very supportive board,
knowing that that’s there, that there isn’t a fight. In a lot
of agencies, there’s this kind of pressure between
board and staff, and that isn’t there. So that’s part of the
climate as well, climate of support.
The actual physical plant is also important. So often
people with disabilities, because of funding of programs,
end up in industrial areas. It’s very important to
me that we have a very nice central location that is as
bright as possible in terms of lighting and those kinds
of things, so that the feel of the agency when you walk
through the doors is welcoming and light and open.
Another factor important to climate is
hiring people who are very good at what they’re doing,
aren’t territorial, and aren’t afraid to try out new
things—[who] aren’t afraid to say, “that one didn’t
work, let’s see what I can try next. How can I do this
differently so it will work better?”
There are also attempts to address specific challenges
in the working environment. Lack of time is one
major issue, making it, for example, “very, very hard to
consistently carve out time to assess the outcomes, and
change the practice depending on those.” The agency
response to the time issue is that “We’re constantly trying
to figure out ways that we can deliver quality but
not burn ourselves out as staff. So we’re spending some
of this week looking at that.”
Another challenge concerns the need for funding,
which in some cases can constrain actions and undermine
values. Career Headways has made the following
attempt to reduce dependence on government funding:
For those [participants] who have access to third party
funders, we charge those third party funders, so that
we’re less reliant on government funding. And in the
end that means that we’re better off than other agencies
who are more dependent on government funding. If,
for instance, the majority of our funding came from the
areas of government that fund employment, we would
have to prove that most of our participants left here being
employed—(a) that’s not necessarily the goal of
our participants, and (b) many people with a significant
brain injury have difficulty becoming employed. So,
chances of the majority of our folks being employed is
pretty slight. If our funding is not tied to our participants
becoming employed, we can focus on what’s important
to them.
Also with respect to funding, Brownstone commented,
“I think it’s very important to stick to your values
and not allow funders to undermine that, or the
potential for making money in other ways, to undermine
that.” As a result of this position, although doing
evaluations for medical and/or legal purposes can be
quite lucrative, the agency has decided to focus on participants’
strengths instead: “And that means, instead of
spending time in courts, staff is spending time with participants.
But, easily, we could have been wooed by
money.”
Athird major challenge concerns the scarcity of relevant
measures resulting in the agency’s response of creating
them.
While there are many semi or standardized measures
that are being used with people with acquired brain injury,
almost none of them have proved their worth with
the population. So that’s a challenge right on its own.
The nice thing about that is that you feel like it gives
you the opportunity to try out some measures that
haven’t been tried out and see if they hold some of the
keys to the picture. It’s very difficult to find a measure
that can really satisfactorily show the kinds of changes
that people with acquired brain injury go through.
There can be some quite fine detail that can make the
difference between somebody who’s employable, for
instance, and not employable. And many measures just
look at, “are you able to work,” they don’t look at the
gradation of skills, and the changes in skills.
In addition to attempting to address challenges, the
agency recognizes potential facilitating factors and
works with them. For example,
the Career Headways board is made up of people from
many different walks of life, mostly within health care.
But all of them very strongly believe in the whole idea
of the program, and so work together in an incredibly
dynamic, supportive, exciting way. There are no hidden
agendas.
Brownstone’s conclusion concerning using a best
practices approach is that
I wouldn’t consider anything else. If we’re asking participants
to be the best that they can be, then as a whole
agency we have to require that of ourselves. We’re an
agency that’s about change and if we’re demanding
participants to go through extraordinary changes in
their lives then we certainly have to ourselves be willing
to go through changes as an agency.
Chief among the compelling reasons for adopting a
best practices approach to health promotion is the
increased likelihood that health promotion goals will be
achieved, such as optimal health for all, social justice,
and empowerment. A best practices approach is similar
to the “quality” movement (from which it draws some
of its motivation and processes) in promising benefits
that result from an increase in accountability to stakeholders,
attention to evidence in support of practice,
awareness of the internal environment, involvement of
staff at all levels in an organization, and continuous
improvement.
However, there are potential risks associated with
the quality movement, with its trend toward developing
guidelines, standards, and best practice norms; these
risks will vary in nature and degree, depending on the
approach chosen and the best practices cr