APPENDIX C: SHARED DECISION MAKING

SHARED DECISION MAKING

Shared decision making will be systematically employed by DCFS for key decisions. Shared decision making takes different forms as it is implemented throughout the Division. Shared decision making means identifying those decisions that need to be shared with supervisors, area managers, regional administrators, and headquarters. Shared decision making means a commitment to team decision making whenever possible; such teaming to include peers, members of other units, foster parents, DSHS staff from other divisions and community professionals involved in our cases. Shared decision making means participation and partnership on cross program treatment teams (wrap-around teams). Shared decision making means sharing tough decisions with the community through the use of consultation teams.

The Shared Decision Making Committee was convened at the request of Rosie Oreskovich, Assistant Secretary, for Children's Administration. The committee represented all Regions, Headquarters, and Community representatives. Members were: Nancy Zahn, Dee Wilson, Carol Bailey, Ruthie Morris, Arlene Miletich, Shirley Moore, Ed Cote, Dr. Jill Cole, Charlene Ramirez, Lee Doran, Carol Clarke, and Peggy West.

Our committee has structured our report in three key areas:

• Shared Decision Making Within the Division

This proposal for sharing decision making with supervisors, managers, and headquarters attempts to establish a minimum baseline expectation statewide. Currently decisions that are expected to be "shared up" are at the discretion of individual Regional Administrators and Area Managers. We found extreme variations in expectations between regions and within regions by Area Managers. It is no wonder line staff are confused and desperately ask "just who is to make what decisions"!

The first portion of our report proposes a common baseline of accountability for key decisions that will be the same statewide. We are in some instances formally creating new policy expectations (in some instances these areas are informal "common sense" expectations, in some instances these are areas that are "getting us in trouble", and in some instances these are areas where three of six regions require "sharing up" and the others do not.) And there are some areas where we have set a decision point at a level lower than some regions currently require.

We identified those areas where Tribes need to be informed and given the opportunity to review and/or approve the decision. We attempted to entwine the areas of the Tribal/State agreement throughout the report as opposed to doing a separate document to reflect ICW Tribal issues.

This proposal is submitted for review and comment by the Greater DCFS Management Team at the April Retreat. We recognize that different folks visualize differently and that there are different ways to format these charts; this format is the way that worked for our committee. We also recognize the need to refine group decision areas (such as grouping licensing, CPS, CWS, etc.).

One of the questions asked of us was whether or not there should be a common expectation for information sharing/monthly reports. We reviewed several currently in use and found wide variation. Common themes were data regarding workload, compliance issues, constituent complaints/difficult cases, personnel and office issues, community activities/issues, good news, and "other". We believe we have captured these areas in establishing common expectations for information sharing. We see our role to establish the expectation for information sharing; the regions need to determine the format (verbal, written, report, etc.).

• Shared Decision Making Teams

Shared decision making means systematically employing teams for key decision making. Team decision making will provide opportunities for critical thinking and creative problem solving; share responsibility for decisions; share liability; and provide opportunities for ensuring quality assurance.

Our committee proposes several key decisions that should be team decisions. In some instances, the Division already employs a team decision making format; that needs to continue. We are proposing new requirements for team decision making. We recognize this has a substantial workload impact and will require the initial up front work of establishing the team composition and structure, the decision making protocols, and the team building necessary for the establishment and maintenance of successful teams.

We suggest the following teams be established in each region: Prognostic staffing, permanency planning, CPS/Licensing, CPS/Abuse Neglect, Administrative Review, Adoption Review, DDD/DCFS Teams per Regional agreements, and community cross program teams (wrap-around). The first five teams are new expectations; it is this committee's belief that the last four teams currently exist in most areas.

We recognize the issues highlighted by Health and Safety concerns require immediate action to establish teaming in CPS/Licensing and identify that as the first priority. This committee believes that most long term benefit to children and families will come from implementing prognostic staffing teams. We recommend this team be the priority team to implement. Next in priority, we would recommend permanency planning team staffings, CPS/Abuse Neglect teams.

Each Region needs to clarify with Tribes and ICWAC the nature of tribal/ICWAC participation in DCFS teams.

Cross-program teams (wrap-around) exist in all areas of the state. These teams are external teams for which DCFS staff are key participants. These teams are generally developed under the auspices of Children's Mental Health statutes and are generally managed by RSN's, and/or education. Teams include decision making for admission to mental health facilities and programs and also individual treatment teams. Our committee identifies the need for Regions to develop guidelines clarifying these teams' authority to make case planning decisions and authorize funds. Problem resolution mechanisms also need to be in place for these teams. Regions need to clarify with Tribes and ICWAC the nature of tribal/ICWAC participation in these community teams (as it relates to Indian children in DCFS caseloads).

• Shared Decision Making with Community Consultation Teams

DCFS currently has statutory and policy mandates for several community consultation teams. With the exception of Child Fatality Review teams, this committee does not recommend establishing any additional community consultation teams. We do however identify the need to clarify the teams. We believe staff need to understand the statutory mandates in terms of expected staffings and team membership. We also believe these teams can be strengthened and are identifying recommended areas of staffing/consultations.

It is also essential the Division recognize these teams require nurturing and maintenance. This generally means a DCFS staff assigned to facilitate the team, arrange coffee and light refreshments, recruit new team members, etc. This workload must be legitimized and built into workload study standards if we expect these consultation teams to thrive.

Our committee was also asked to recommend a format for problem resolution when there is conflict with community professionals serving a child/family. Our first recommendation is the utilization of existing consultation teams, such as CPT's. Recognizing that this will not always be successful, we identified as a "sharing up" decision, conflict with community professionals. At every level, we would recommend that the supervisor, area manager, Regional Administrator convene a staffing to include all professionals involved in a case as a preferred means of resolving conflict. It is our impression that in many instances the conflict revolves around information that is not fully shared with all team members and/or misunderstandings about the roles/authorities/ and responsibilities of team members. We would also envision that as the Division implements teaming for key decisions, these conflicts should decrease as it is our vision that community professionals, as well as parents, children, and foster parents, will feel they are part of the team.

SHARED DECISION MAKING

To summarize the need for shared decision-making:

• Social workers need to be supported in their decision making. They need to know clearly when to seek consultation. They also need to feel and know that supervisors and managers share responsibility for decisions.
• DCFS will establish clear expectations regarding accountability. Staff at all levels need to know which decisions they will share responsibility for.
• We make better decisions when we can consult and review with others. Team decisions are generally better than decisions made in isolation. We will have guidelines and expectations for how and when to consult teams on decisions.

Shared decision making will be systematically employed by DCFS for key decisions, and will take different forms as it is implemented throughout the Division. Shared decision making involves:

• Identifying those decisions that need to be shared with supervisors, area managers, regional administrators, and headquarters;
• A commitment to team decision making whenever possible -including peers, foster parents, professionals from other divisions and community professionals involved in our cases;
• Participation and partnership on cross program treatment teams (wrap-around teams); and
• Sharing tough decisions with the community through the use of consultation teams.

This section is structured in three key areas of shared decision making:

• Decisions Shared within the DCFS Chain-of-Command;
• Team Decision Making within the Division; and
• Shared Decision Making with Community Consultation Teams.

The following comments about shared decision making need to be made:

• This document does NOT attempt to outline every decision that is made on a daily basis by staff at all levels. It does attempt to identify those key decisions that need to be shared.
• Equally important is what is not dealt with---SHARING DOWN. In all areas, where a case specific decision is made at a level higher than the social worker, it is essential that the decision be communicated promptly to the social worker. It is also essential that the social worker, supervisor, and area manager be given the opportunity for review, comment, and understanding of decisions made at a higher level. It is recognized that workload does not permit the RA's to staff all decisions made at their level; it is equally recognized that whenever possible, staff at all levels should be jointly making the decision.
• This document is not meant to be a substitute for supervision. It is recognized that there will be decisions that should be shared but are not on the list. Staff will always need to use common sense and judgement in decision making. There are no magical answers that will ALWAYS guide staff. This document is meant to be a document that will GENERALLY guide staff.
• The authorized decision maker is the person the agency expects to be accountable for the decision listed. It is recognized that we all delegate differentially to staff. The authorized decision maker must be able to explain why they have delegated decision making, and the designee must be aware they are representing the delegator. Decisions to delegate are to be made on the basis of the designee's knowledge and expertise. There needs to be a system in place to do random reviews of the delegated decisions.
• Most regions have Deputies and/or SHPM 4's. These managers may have duties similar to Area Managers. Given the variety of regional organizational structures, we did not differentiate between SHPM 4's and Area Managers. Each region will need to "regionalize" the definition of Area Manager.
• Each region needs to develop their accountability/documentation standards. For example, regarding the "information to" expectations, staff need to know if this is to be shared verbally, in written form, how soon, etc.
• Policies and procedures regarding Child Fatality Reviews, CPT's, CPS-Licensing, and Supervisory Review/Conferences are currently being developed and/or updated. As these policies are issued, Shared Decision Making Guidelines need to be updated.

SHARED DECISION MAKING WITHIN THE CHAIN-OF-COMMAND

Attachment A establishes a minimum baseline expectation for sharing information and decisions with supervisors and regional managers.

Those areas where Tribes need to be informed and given the opportunity to review and/or approve our internal decisions are identified.

TEAM DECISION MAKING

Shared decision making means systematically employing teams for key decision making (Attachment B). Team decision making will provide:

• opportunities for critical thinking and creative problem solving;
• shared responsibility and improved compliance with decisions;
• shared liability; and
• opportunities for quality assurance.

Several key decisions that should be shared by a team (Attachment C) are identified. In some instances, the Division already employs a team decision-making format that will continue. New requirements for team decision making are recommended. The substantial workload impact involved is recognized. Implementation will need to include: a realistic appraisal of current staffings which could be eliminated through the use of team decision making; initial work to establish team composition and structures and decision making protocols; and team building necessary for the establishment and maintenance of successful teams.

The following teams should be established and routinely utilized in each region:

The teams identified in the left-hand column represent new expectations. The teams in the right-hand column currently exist in most areas.

The issues highlighted by Health and Safety reviews require immediate action. Therefore, CPS/Licensing teams are the first priority. Prognostic teams offer the most significant long term benefit to children and families and should be implemented as a high priority. Next, in rank order of descending priority, regions should phase-in implementation of permanency planning team staffings and CPS/Abuse Neglect teams..

Each Region needs to clarify with Tribes and ICWAC the nature of tribal/ICWAC participation in DCFS teams.

Cross-program teams (wrap-around) exist in all areas of the state. These teams are external teams for which DCFS staff are key participants. These teams are generally developed under the auspices of Children's Mental Health statutes and are generally managed by RSN's, and/or education. Team decisions include admissions to mental health facilities and programs and also individual treatment plans. Regions need to develop guidelines clarifying these teams' authority for case planning decisions and for the authorization of DCFS funds. Problem resolution mechanisms also need to be in place for these teams. Regions need to clarify with Tribes and ICWAC the nature of tribal/ICWAC participation in these community teams (as it relates to Indian children in DCFS caseloads).

SHARED DECISION MAKING WITH COMMUNITY CONSULTATION TEAMS

DCFS currently has statutory and policy mandates for several community consultation teams. DCFS needs a format for problem resolution when there is conflict between community and DCFS professionals serving a child or family. The first recommendation is to utilize existing consultation teams, such as CPTs. Recognizing that this will not always be successful, it is also recommended for the "sharing up" of information and decisions involving unresolved conflict with community professionals. At every level, the supervisor, area manager or regional administrator should convene a staffing to include all the professionals involved in a case conflict, as the preferred means of resolving conflict.

POLICY FOR SHARED DECISION MAKING SOCIAL WORKER/LICENSOR WITH SUPERVISOR

POLICY FOR SHARED DECISION MAKING SUPERVISOR WITH AREA MANAGER

POLICY FOR SHARED DECISION MAKING SUPERVISOR WITH AREA MANAGER

POLICY FOR SHARED DECISION MAKING SUPERVISOR WITH AREA MANAGER

POLICY FOR SHARED DECISION MAKING AREA MANAGER WITH REGIONAL ADMINISTRATOR

TEAM DECISION MAKING PROPOSAL
Attachment B

Team decision making shifts the primary responsibility for key case decisions from the individual social worker to a decision making group comprised of involved parties and resource persons. We would anticipate that a shared decision making process will generally be superior to individual decision making because:

• a more thorough review and analysis of information can be achieved;
• a more diverse range of conclusions, options, and solutions can be generated and considered; and
• the likelihood of compliance by all parties affected by decisions is increased when they are involved in decision making.

There are examples of team decision making currently in use around the state, some involving division staff across programs, family members, and professionals representing other community providers and systems. This proposal recommends a more systematic and wide spread use of team decision making in service planning than is currently practiced in the division.

BENEFITS OF TEAM DECISION MAKING:

• provides opportunity for critical thinking and creative problem solving;
• shares responsibility for decisions among all involved parties;
• shares potential liability for unwanted outcomes of decisions; and
• offers an opportunity for quality assurance monitoring.

REQUIREMENTS OF TEAM DECISION MAKING:

• requires a significant investment of time for meeting organization and participation;
• depends on a degree of mutual respect and trust by participants;
• facilitated by an understanding and acceptance of roles by participants; and
• should be experienced as useful by participants, particularly the social worker and family.

PROGNOSTIC STAFFINGS

All children in placement beyond 60 days will be staffed by an internal team including the Area Manager (or designee). The staffing will focus on the case plan and permanency planning goals. Other staffing formats (ICWAC, Administrative Review, Foster Care Citizen Review Board, Wrap-around, etc.) could substitute. A prognostic staffing needs to occur (ideally) 2 to 6 months after placement. Minimal participation would include the social worker, supervisor, area manager (or designee), foster parent, and child if age appropriate. Broader participation is encouraged in these team staffings.

The area manager could waive the staffing if the permanent plan is about to be achieved.
We recommend the Legal Placement CAMIS module be amended to include the date of the prognostic staffing. Staffings need to be documented in CAMIS (SER).

PERMANENCY PLANNING STAFFINGS

Team staffings will occur prior to all Juvenile Court permanency planning hearings when the child is not in the home of choice and not likely to return to the parents within the next 90 days. All legally free children not in their home of choice will be staffed annually (more frequently if appropriate).

Minimal participation includes the social worker, foster parent, child if age appropriate, supervisor, area manager (or designee), and the adoptions supervisor (if termination is one of the plans considered and/or the child is legally free). These staffings could include a variety of other individuals such as representatives from Families for Kids. Other staffings such as ICWAC could meet the requirements. In agreement with the adoptions supervisor, this staffing could be considered the Adoption Review staffing.

In addition to permanency planning issues, these staffings should review special needs of children (such as ECP plans).

CPS/LICENSING STAFFINGS

Team staffings will include:

• licensed foster homes with 2 or more CPS referrals within 6 months;
• founded CA/N in foster care (regardless of risk level) where staff wish to leave children in the home; return children to the home; or utilize corrective action in lieu of revocation;
• licensed homes with a pattern of non-compliance with MLR's or poor care (Area Manager can waiver staffing if a corrective action plan is initiated and compliance is documented).

Minimal participation includes CPS social worker, CPS supervisor, licensor, placement worker (if different from licensor), licensing supervisor, social worker(s) for children in home, Tribe (if involved), licensing area manager (or designee), DCCEL for dually licensed homes, and AAG as appropriate.

Homes which meet the criteria for staffing but are certified by a private agency and licensed by the Regional Licensor will also be staffed. In such cases, the private agency staff will be part of the team.

CPT/INTERNAL CPS--ABUSE NEGLECT TEAMS

Internal staffings if:

• No community CPT available for mandated and/or recommended CPT staffings.
• CPS referrals on placement cases where children are in licensed care and/or relative care supervised by the Department.
• Life endangering neglect.

Minimal participation includes social worker, supervisor, area manager or designee, social worker(s) for other children in home/family, and CPS Coordinator if appropriate encourage workers to staff any complex case where a staffing is desirable.

EXTERNAL COMMUNITY TEAMS

Community Treatment Teams (wrap around):

Regions need to develop guidelines clarifying these teams authority for case decisions and funding. Teams also need a problem solving resolution including a mechanism for resolving disputes between administrators of systems (DCFS, DDD, Juvenile Courts, Mental Health, etc.) Tribes need to be included if a tribal child is involved in these teams. Multidisciplinary teams required by RCW 13.32A will be incorporated into existing community teams wherever possible.

Community Placement Teams:

Regions need to clarify the authority of these teams regarding placement decisions as it relates to DCFS children. Such teams generally determine mental health hospitalization, CLIP, CHAP, etc. placements. Tribes need to be included if a tribal child is involved in these staffings.

FOR ALL TEAMS, REGIONS NEED TO CLARIFY WITH TRIBES AND ICWAC THE NATURE OF THE TRIBAL/ICWAC PARTICIPATION IN TEAMING AND CONSULTATION STAFFINGS.

COMMUNITY CONSULTATION TEAMS

CHILD PROTECTIVE TEAMS

In providing services to Indian children and their families, the service worker considers a child's tribe as the primary resource for consultation and case plan development. For that reason the service worker does not involve ICWAC in specific cases unless:

1. The tribe has failed to respond within 10 days to a written request for involvement, or
2. The tribe has requested and defined what they would like ICWAC to do on their behalf, or
3. The child is an unenrolled Indian and not eligible for tribal membership and/or enrollment, or
4. Case requires a CPT, and no tribal/BIA CPT is available, or
5. The case requires an administrative review, or
6. The tribe has indicated they do not want to be actively involved in the case, or
7. There is reason to believe a child may be Indian but membership has not been verified.

All open DCFS/private agency cases shall be staffed by ICWAC that meet the above criteria.

If the ICWAC functions as a CPT or Administrative Review Team, the ICWAC must meet the mandatory aspects of the CPT/Administrative Review in regards to team membership and team process.

• CROSS PROGRAM CHILDREN STAFFINGS

These teams have their mandate from Children's Mental Health and their mandate and
authority will vary by RSN. Regions need to ensure DCFS staff have clarification regarding these teams' authorities.

REGIONAL SAY TEAMS

• MULTI-DISCIPLINARY TEAMS

• OVERSIGHT COMMITTEES

Recommended Consultation/Review: Any major policy change and/or budgetary change which will impact local communities. Oversight Committee members should be included in Child Fatality Review teams.

CHILD FATALITY REVIEW TEAMS

ADDENDUM TO APPENDIX C
DIVISION OF LICENSED RESOURCES
SHARED DECISION MAKING POLICY
1/12/11

(For non-program specific Shared Decision Making expectations, refer to Appendix C, CA Case Services Policy Manual)

PLEASE NOTE: The Authorized Decision Maker is the person who has the authority to make the final decision. Information from the licensor, or whoever initially receives the information, needs to be shared up the chain of command prior to submitting to the Authorized Decision Maker.