Comprehensive trauma-informed organizational change at an academic medical center in South Texas

Abstract

Background

Exposure to trauma is widespread and has significant implications for health outcomes and healthcare delivery. Comprehensive Trauma-Informed Care (TIC) recognizes the prevalence and impact of trauma and seeks to create policies, practices, and environments grounded in safety, trust, collaboration, choice, and empowerment. University Health, a large academic medical center in San Antonio, Texas, launched a comprehensive initiative to embed TIC principles system-wide, positioning itself as both an educator and a provider of trauma-informed practices.

Methods

Guided by the 10 key development areas defined by the Institute on Trauma and Trauma-Informed Care (ITTIC), University Health initiated its comprehensive TIC transformation in 2020. The organization established an internal Trauma-Informed Care Workgroup, provided staff and community training, integrated TIC into organizational policies and procedures, created peer support and wellness initiatives, and implemented trauma screening and treatment protocols. Evaluation methods included biennial administration of the TICS-10 (Trauma-Informed Climate Scale) and qualitative feedback from Schwartz Rounds participants.

Results

Over five years, University Health trained more than 130 TIC Advocates, updated over 90 policies with trauma-informed language, and launched programs supporting staff well-being and patient-centered care. In 2024, University Health became the first major health system in Bexar County to earn local Level 1 TIC certification. TICS-10 scores improved from 34.1 (low) in 2020 to 35.0 (moderate) in 2024, indicating progress in creating a trauma-informed work environment. Schwartz Rounds sentiment analysis showed 71% of comments were positive, highlighting increased empathy, connection, and validation among staff members.

Conclusions

University Health’s experience demonstrates that comprehensive, system-wide trauma-informed transformation is achievable in large healthcare settings. Through leadership support, cross-departmental collaboration, and intentional policy and practice change, TIC principles were embedded into organizational culture. An impartial certification process and program evaluation data validated the impact of the initiative, although continued efforts are needed to assess long-term outcomes on patient care and staff well-being. This case study offers a replicable model for other health systems pursuing trauma-informed organizational change.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-025-13381-6.

Background

Trauma

Trauma within healthcare settings reaches beyond the physical injuries often immediately associated with the term. Emotional, psychological, and intergenerational trauma profoundly influences sense of self, well-being, and interactions with healthcare systems. The Substance Abuse and Mental Health Services Administration (SAMHSA) defines trauma as “an event, series of events, or set of circumstances experienced by an individual as physically or emotionally harmful or life-threatening with lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being” [1, 2].

The prevalence of trauma is high nationally and rising over time. In 1995, the National Comorbidity Survey reported that 61% of men and 51% of women in the United States have experienced at least one traumatic event [3]. More recently in 2013, data indicated that nearly 90% of adults in the U.S. experience at least one form of trauma [4]. A large-scale analysis showed that 61% of participants reported having at least one adverse childhood experience (ACE), with some populations, such as racial or ethnic minorities and lower-income individuals, experiencing higher burdens [5]. In the context of trauma, ACEs are potentially traumatic events that occur in childhood such as experiencing or witnessing violence, abuse, or neglect or growing up in a household with substance use, mental illness, or instability [2, 6]. Exposure to traumatic stressors, including ACEs, is linked to a myriad of negative physical and mental health outcomes [1, 7]. Health systems directly observe how adverse childhood experiences and adverse community environments (the pair of ACEs) can contribute to the development of chronic conditions, such as diabetes and asthma [8, 9]. While treating these conditions is a core responsibility of healthcare organizations, addressing the upstream factors leading to poor health outcomes is equally important.

Trauma-Informed care

In recent years, Trauma-Informed Care (TIC), has become a public health priority in organizational, statewide, and national discourse. TIC recognizes the existence of trauma and its negative impact on children, youth, and adults. This universal approach inspires a shift in healthcare delivery from “What’s wrong with you?” to “What happened to you?” [10] by promoting safe and healing environments that realize the impact of trauma; recognize symptoms of trauma; respond holistically; and actively seek to avoid re-traumatization [1]. At the system level, TIC is grounded in five key principles: choice, collaboration, empowerment, safety, and trust [11]. These principles are the building blocks for all aspects of successful organizational culture transformation, including ongoing leadership buy-in and support, policy and practice change, and staff wellness programming.

In the healthcare setting specifically, TIC acknowledges that the service delivery of healthcare may unintentionally create or exacerbate trauma and therefore aims to mitigate that effect on patients and staff. While the application of TIC practice varies across healthcare institutions, ranging from ACE screening and tailored interventions for certain vulnerable populations [12] to complete hospital systems transformation, the authors of this manuscript argue that a universally applied, comprehensive approach offers the best opportunity for sustained trauma-informed culture change.

A Trauma-Informed community approach

In Bexar County, Texas, the TIC movement initially started with a focus on preventing and mitigating ACEs among children in San Antonio. This vision quickly gained momentum, and the South Texas Trauma-Informed Care Consortium (STTICC) was created in late 2018. The consortium was composed of twelve sectors of organizations including schools, hospitals, behavioral health organizations, judicial systems, philanthropic organizations, child welfare organizations, and faith-based communities. These organizations began meeting regularly to develop a plan for educating their staff on what it meant to be trauma-informed, why it was important for both clients and staff, and ultimately to chart a path to a certified Trauma-Informed San Antonio/Bexar County. With so much interest across organizations that provide a large variety of services, and significant variability in what organizations deemed “trauma-informed,” the Consortium decided it was imperative to create a formal process that defined a set of guidelines and standards for being trauma-informed, regardless of the specific services an organization provides in the community.

To accomplish this, the Consortium created a three-component plan: (1) the STTICC, which focused on helping organizations understand why being trauma-informed was critical; (2) an educational entity focused on what it means to be trauma informed and where interested individuals and organizations could obtain training and education and (3) a certifying entity that would develop TIC standards and certify organizations meeting those standards. The Ecumenical Center for Education, Counseling, and Health was chosen as the certifying entity, charged with creating local certification requirements based on the SAMHSA framework and assessing those competencies for community organizations to earn this designation.

University Health, the county public hospital system and the only Level I trauma center for both adults and pediatrics in the region, employs more than 12,000 staff members and includes a comprehensive network of two hospitals, over 30 outpatient clinics, three urgent care clinics, five dialysis centers, three ambulatory surgery centers, and six school-based health clinics. In 2024, University Health completed over 485,000 preventive and urgent care visits, 475,000 specialty care visits, 125,000 emergency visits, and approximately 40,000 hospital discharges. Given this large community reach, University Health agreed to partner with the City of San Antonio to address the need for a trauma-informed educational entity (number 2 above) and to create an Institute for Trauma-Informed Care. This team provides education, training, and technical assistance to individuals and organizations in the community during their trauma-informed certification journey. However, University Health recognized that to be an educational leader for TIC in the community, it was necessary to transform the culture of the health system to become trauma-informed as well. Consequently, we launched our own internal Trauma-Informed care initiative and pursuit of local certification in 2020.

A core tenet of the mission of University Health is the improvement of community health through high-quality, compassionate care. Central to this commitment is recognizing the influence of non-medical drivers of health and personal experiences on patient interactions with the healthcare system. Leading with compassion encourages patients to share a more comprehensive view of their lives, including difficult or traumatic circumstances they may have encountered [13].

Leadership buy-in and organizational support

University Health has been engaged in the countywide trauma-informed movement since its inception. The organization’s Chief Medical Officer (CMO) played a pivotal role by championing both University Health’s community-focused education and training efforts while prioritizing an institutional focus on Trauma-Informed Care. With support of the President/CEO, the CMO advocated for a dedicated leadership position within University Health to guide the internal journey. The decision to create this role – the Director of Trauma-Informed Care – was not driven by external mandates, but rather by an internal recognition of our obligation to become a trauma-informed organization to represent the highest standard for healthcare organizations across the nation. As a Level I trauma center that serves all of south Texas, our leadership also saw an alignment between Trauma-Informed care and our mission to provide compassionate, community-focused, and evidence-based care, particularly for those who experience trauma. Organizational buy-in was achieved by framing Trauma-Informed care not as an initiative, but as a long-term cultural transformation aligned with patient safety, staff wellness, and health equity. Because of this strategic alignment, funding was allocated from operational budgets, reflecting a deliberate investment in institutional values and sustainability. Senior leadership support from the President/CEO and Chief Medical Officer signaled a strong organizational alignment with trauma-informed principles from the top.

When the COVID-19 pandemic began, the newly appointed Director of Trauma-Informed Care engaged leaders across clinical and non-clinical areas, illustrating first how TIC practices could support staff at work and in their personal lives. Staff then began to understand how they could apply these same practices in caring for patients. Adverse experiences from the COVID-19 pandemic, which affected both patients and staff, fueled internal Trauma-Informed Care efforts.

University Health also recognized the importance of examining whether our own work environments were trauma-informed. Obtaining baseline assessments of where and how the organization was already providing Trauma-Informed care versus areas where there were opportunities for improvement was essential. These assessments included observations of our physical spaces (lighting, signage, artwork, etc.), an understanding of what processes were in place to keep patients and staff physically and emotionally safe after a traumatic event, and a review of the language used to describe trauma in policies, training modules, internal communications channels, and medical records. This ongoing process has continued to reveal policies, procedures, and practices that benefit from a trauma-informed lens.

Framework for Trauma-Informed organizational change

Trauma Informed Care places choice, collaboration, empowerment, safety, and trust at the forefront of all interactions. Trauma-informed organizations train staff to recognize the ubiquitous nature of trauma and to form positive, supportive, and trusting relationships with their clients and colleagues to improve customer service. However, while many organizations implementing Trauma-Informed Care focus exclusively on this training aspect, University Health knows that true trauma-informed culture change demands a more holistic approach. Comprehensive Trauma-Informed care approaches require organizations to take an intentional look at policies and procedures, to modify physical environments, to engage participants in collaborative decision-making, and to prevent secondary traumatic stress in their staff.

The Institute on Trauma and Trauma-Informed Care (ITTIC) was created by the University at Buffalo School of Social Work in 2012 out of the need for additional trauma-related services and training within the Buffalo, NY, community at large. Since then, ITTIC has become a nationally recognized leader in the field of Trauma-Informed Care and was identified by University Health as a key stakeholder to provide guidance and expertise. In January 2020, University Health invited the ITTIC team to visit San Antonio and to provide their insight on creating a trauma-informed health system. Over the past five years, University Health has partnered with ITTIC and has used their Trauma-Informed Organizational Change Manual as the primary framework for its internal transformation process [11]. The comprehensive approach by the ITTIC aligns with findings from previous studies that emphasize the need for integration of TIC principles at all levels of an organization to achieve sustained change and improved health outcomes [12, 14].

Purpose

This journal article aims to document the journey of implementing trauma-informed culture change across a large healthcare organization through a structured and intentional process. By sharing best practices and lessons learned, it provides valuable insights for organizations and communities seeking to create safer, more supportive environments. Emphasizing the importance of a collective, community-driven approach, this article also highlights how collaboration and shared commitment can lead to meaningful, sustainable transformation.

Methods

University Health followed the 10 key development areas outlined by ITTIC for trauma-informed organizational change:

1. Leading and Communicating

2. Building a Trauma-Informed Workplace

3. Training the Workforce

4. Addressing the Impact of the Work

5. Establishing a Safe Environment

6. Screening for Trauma

7. Treating Trauma

8. Collaborating with Others

9. Reviewing Policies and Procedures

10. Evaluating and Monitoring Progress

Over the past five years, University Health has made significant progress toward all ten of these key development areas. These efforts ultimately led to the organization earning local TIC certification through the Ecumenical Center. Although there is no general consensus on what constitutes a Trauma Informed Organization [15], the local Bexar County certification process provided an innovative, consistent, and meaningful way to externally validate the organizational commitment to the work of becoming a trauma-informed healthcare institution.

Leading and communicating

Gaining support from executive and department leaders throughout the organization was a crucial first step in changing the culture. In March 2020, an internal Trauma-Informed Care Workgroup composed of over 40 individuals from different departments, both clinical and non-clinical, was established to help create the vision and strategy for Trauma-Informed Care at University Health. Workgroup members and other internal stakeholders also serve on subgroups dedicated to specific projects within each of the ten key development areas.

The Workgroup established an official Trauma-Informed Care definition and purpose statement for University Health:

“University Health strives to create a safe, welcoming, and supportive environment where patients and staff are empowered to take part in their own wellbeing. In addition to treating the symptoms of trauma through best practices, University Health integrates trauma-informed approaches into our policies and daily practices, while actively reducing re-traumatization. 

University Health also recognizes that our staff may become traumatized, not only through the compassionate work that they do each day, but also as a result of outside stressors in their daily lives. University Health is committed to providing our staff with ongoing supportive programming to mitigate the effects of trauma, including emotional stress resulting from secondary trauma and compassion fatigue.”

Informative Trauma-Informed Care communication to all staff members through internal newsletters, a dedicated Trauma-Informed Care intranet page, and brief presentations at department huddles helped maintain staff engagement and involvement in this work. In addition, public-facing blogs and local news appearances publicly highlighted the University Health trauma-informed approach to care.

Trauma-Informed Care has also been the impetus for many collaborative and innovative projects. For example, a major need identified by Trauma-Informed Care Workgroup leaders was a peer support program in which trained staff members embedded in each department provide a listening ear when their peers are in distress and help them navigate to appropriate support resources. The Compassionate Assistance for Resilient Employees (CARE) program is currently in development, with plans for multiple levels of response from one-on-one individual support to system-wide emotional support during an emergency activation.

Building a Trauma-Informed workplace

Acknowledgement of Trauma-Informed Care as an organizational priority begins during the hiring and orientation process. Trauma-Informed Care has far-reaching implications across all University Health service lines and applies to all staff members: new and seasoned, clinical and non-clinical, and those working in the inpatient, outpatient, and business settings. Therefore, relevant Trauma-Informed Care education has been incorporated into required annual competency modules for all staff (both clinical and nonclinical), the organization’s onboarding experience for all new employees 90 days after hire, and into orientations specifically tailored to new nurses, medical technicians, and medical residents,.

In 2023, a Trauma-Informed Supervision course began to be offered quarterly to any leader who supervises an employee. This supervision model promotes dedicated time for conversations with employees to discuss their growth and development, personal and professional goals, challenges they may be facing, and how they are practicing self-care. To date, 114 leaders have taken advantage of this course, which also offers two helpful resource takeaways related to hiring and staff performance. While interview questions about job skills and experience are invaluable, understanding how candidates respond to difficult situations and maintain a healthy work-life balance is also vital to building a trauma-informed workforce. The creation of a Trauma-Informed Interviewing Guide for Hiring Managers not only provides tips for creating a safe and comfortable interview environment, but also highlights targeted interview questions to understand potential candidates in a meaningful way. In collaboration with Human Resources, a Trauma-Informed Performance Coaching tip sheet was developed to guide productive and transparent conversations with employees when a change in performance is initially noted, rather than waiting until a formal performance improvement plan is necessary.

Training the workforce

Since December 2020, University Health has trained over 130 Trauma-Informed Care Advocates. These individuals serve as departmental champions who educate staff members on a comprehensive curriculum, including but not limited to adverse childhood experiences, trauma-informed language, practical applications of TIC in the healthcare setting, and effective ways to reduce re-traumatization. Trauma-Informed Care Advocates are also empowered to lead a project within their departments using the skills acquired during training. These projects focus on improving patient interactions or creating opportunities for individual or institutional staff wellness.

Internal and external partnerships enhance the types of trauma-informed education that University Health staff members receive. Internally, the Environment of Care and Protective Services departments have incorporated TIC into training modules like Code White: How to Survive an Active Shooter and Workplace Violence Prevention. The Training the Workforce subgroup has also developed an online training module on boundary setting for healthcare workers titled “Empowered to Set Healthy Boundaries.” This training highlights the Trauma-Informed care principle of empowerment to enhance workplace productivity and relationships and reduce re-traumatization both between supervisors and employees, and among coworkers. Motivational Interviewing, a technique used to elicit change in patients, is a trauma-informed approach that emphasizes empathy and encourages belief in the ability to make healthy lifestyle choices. University Health partnered with an external clinical psychologist who specializes in Motivational Interviewing to train our diabetes educators, case managers, and social workers in the ambulatory setting on this skill.

Addressing the impact of the work

This key development area aims to increase workforce awareness of how to prevent and/or manage the possible negative impacts of healthcare work and encourages implementation of organizational practices to support the workforce and promote resilience. University Health has utilized Trauma-Informed Care principles to prioritize resources and programming that promote healing and resilience for our staff. In collaboration with the Spiritual Care department, University Health now has 22 recharge rooms across University Hospital, outpatient clinics, and business sites. These rooms are one-person use quiet spaces specifically designated for team members to relax, decompress, and rest during the workday.

As part of our broader Trauma-Informed care strategy, Schwartz Rounds were implemented to support workforce wellness, reduce secondary traumatic stress, and promote psychological safety. In 2020, University Health became a member of the Schwartz Center for Compassionate Healthcare to offer Schwartz Rounds, multidisciplinary conversations about the social and emotional aspects of caregiving. Fifty sessions have since been hosted with over 1,700 attendees, creating opportunities for community, connection, and resilience among our team members. Facility-wide Schwartz Rounds are offered regularly at University Hospital and two large outpatient clinics. Departments at any University Health facility can request unit-based Schwartz Rounds tailored to their needs. Physician trainees, specifically residents and fellows, have also found these unit-based rounds to be helpful as they navigate their early years as practicing physicians. Feedback from participants consistently highlights the value of Schwartz Rounds in normalizing vulnerability, reducing isolation, and reinforcing a culture of empathy.

Establishing a safe environment

Trauma-informed environments give us the opportunity to successfully self-regulate our behaviors in productive ways and to create a sense of belonging. At University Health, we strive to create trauma-informed environments that are physically and emotionally safe. Since 2023, University Health has hosted the Start by Believing Campaign, a global awareness campaign designed to end the cycle of silence and change the way we respond to sexual assault, domestic violence, stalking, and child sexual abuse. Campaign events are hosted at several University Health locations during Sexual Assault Awareness Month in April, encouraging staff to “take the pledge” to start by believing when someone discloses that they have been assaulted. When healthcare workers compassionately listen to survivor stories, survivors are more likely to have positive health outcomes and pursue the road toward justice and healing. During this annual campaign, staff members can take additional training on this topic for continuing education credit; they are also educated on the local resources available for survivors of violence and assault.

The University Health Wellness Committee was established in 2023 to inspire and empower staff members to take an active role in their own health and wellness. Four successful Wellness Weeks have been hosted thus far, bringing external vendors and internal support teams together to offer a variety of wellness events for staff, including massages, meditation, aromatherapy, yoga, arts and crafts projects, reflective writing activities, lunch and learns on a wide variety of topics, and sensory rooms. With feedback from staff, we anticipate that Wellness Weeks and à la carte departmental and individual wellness opportunities will continue to expand.

Our Salud-Arte: Art of Healing program endorses trauma-informed design [16] by ensuring that our facilities intentionally incorporate artwork of all kinds, often by local artists. It also creates regular opportunities for staff, patients, and visitors to engage in art activities that they can take with them or are publicly displayed. The Director of Trauma-Informed Care has been an active member of the Art Committee to ensure that new pieces that are curated for our facilities promote healing and do not inadvertently re-traumatize.

Screening for and treating trauma

A trauma-informed health system takes a universal precautions approach, assuming that all patients have experienced, or may be currently experiencing, some type of trauma. Our trauma teams provide emergency, life-saving care to patients during perhaps the most difficult days of their lives. Yet, trauma does not always disappear after physical wounds have healed. Emotional, psychological, and generational trauma may persist for months to years after the traumatic incident. For this reason, University Health strives to connect patients with behavioral health services and survivor support resources at the earliest possible stage.

Age-appropriate screening tools are available in the electronic health record to assess patients for mental health needs in the hospital and outpatient settings when appropriate, regardless of the type of trauma with which they initially presented. If a University Health patient screens positive, they have direct access to mental health services through a licensed counselor embedded in the Trauma Follow-Up Clinic or through behavioral health providers at an outpatient location most convenient to where they live. They also have the opportunity to join the Trauma Survivors Network, a community of survivors who can connect with one another and rebuild their lives after a serious trauma. For individual staff support, University Health provides an on-site mental health counselor with in-person or tele-health availability, including evening appointments, to accommodate staff schedules and needs at no cost to the employee.

Collaborating with others

Collaboration is one of the five key principles of Trauma-Informed Care; thus, establishing relationships with external organizations and across University Health departments is imperative to provide the highest quality care possible. Internally, several initiatives benefiting patients and our community as a whole have involved Trauma-Informed Care collaboration. The Patient Safety Status Project revamped pathways for patients to protect their confidentiality and/or restrict visitation in the hospital if they feel unsafe after experiencing a traumatic event. Operational Excellence, Patient Access/Registration, Protective Services, and the Epic electronic health record team were just some of the many departments involved in creating transparent, trauma-informed processes that preserve patient anonymity while informing care teams to take extra precautions to maintain safety. In December 2024, the Institute for Public Health and Trauma-Informed Care teams co-hosted the “Health Equity in Action: Transforming Health through Trauma-Informed Care” event. This event included an interactive strategy session to identify and develop trauma-informed priorities and strategies for the Health Equity through Action and Leadership 2025 Strategic Plan.

In the last year, University Health has also partnered with Boston’s Brigham and Women’s Hospital to implement a Trauma-Informed Care Plan (TICP) [17] for patient populations with a significant history of trauma. The TICP, developed by Brigham and Women’s, assesses patient preferences, strengths, and coping skills, as well as the impact of past traumas on their health and how they engage in healthcare services as a result. This information is initially collected through a conversation between the patient and a trusted provider and then made available to their other healthcare providers through the electronic health record. The TICP avoids re-traumatization at future visits and improves healthcare delivery in ways that are meaningful and impactful to both the patient and members of the healthcare team. University Health will soon launch a research study with several other health systems nationally to implement and analyze the effects of the TICP. Our study will initially focus on patients who are pregnant and seeking substance use recovery in one of our outpatient clinics, with opportunities to expand to other clinics and service lines in the future.

Reviewing policies & procedures

To establish and sustain trauma-informed culture change, it is important that all organizational policies and procedures are reviewed with a trauma-informed lens. In 2021, review of corporate, human resources, and clinical policies for trauma-informed, person-first language began. Since then, over 90 policies have been updated with trauma-informed language recommendations that impact both patients and staff. For example, the policy previously titled “Management of Suicidal Behavior” was updated to “Suicide Prevention,” and all instances of the term “suicidal patient” in this policy were replaced with “patient at risk for suicide.” In relation to promoting psychologically safe environments for staff, a section on the importance of staff debriefing was added to the Suicide Prevention policy, and staff and provider support resources were embedded into our Workplace Violence Prevention policy.

The Director of Trauma-Informed Care serves on the Medical Operations Policy Review Committee and also developed a Trauma-Informed Care Policy Thesaurus to empower all University Health policy owners and reviewers to develop policies that set clear expectations while also reflecting our commitment to maintaining safe, supportive environments. In 2023, a major milestone was reached with the approval of a specific corporate Trauma-Informed Care policy for the organization. This policy acknowledges the impact of past and existing trauma on all staff members and persons served by University Health and solidifies our commitment to creating healthcare environments that avoid re-traumatization and promote healing.

Evaluating & monitoring progress

In September 2020, University Health administered a baseline survey to determine our status as a trauma-informed organization; subsequent surveys have since been conducted biennially in 2022 and 2024. All University Health staff receive the Trauma-Informed Climate Scale (TICS-10) survey developed by The ITTIC at the University at Buffalo School of Social Work. The TICS-10 is a reduced version of the Trauma-Informed Climate Scale [18], based on Harris and Fallot’s [19] five values of TIC. The TICS-10 has been validated in research [20]. Overall results are scored from 10 to 50 to indicate whether an organization exhibits a low (< 35), moderate (35–39), or high (40–50) trauma-informed work environment. University Health staff are asked for their perceptions of their work environments through responses to 10 Likert scale questions related to each of the five principles of TIC.

While the TICS-10 survey is the primary tool used to measure impact within our workplace environments, we cannot discount the importance of metrics tied to the trauma-informed projects by key development area subgroups, as well as a variety of metrics tracked in other areas of the organization that may not be directly correlated to, but can certainly be influenced by, the practice of Trauma-Informed care. A brief summary of the outcomes of TIC initiatives, by key development area, is outlined in Table 1.

Table 1.

TIC key development area summary

Key Development Area	Main Initiatives	Summary of Efforts	Associated Metrics to Assess Success (if applicable)
Leading and Communicating	• TIC Workgroup • Development of Organizational TIC Definition and Purpose Statement • TIC in Internal Communications	Bringing key stakeholders across a wide range of departments together to develop the vision and strategy for TIC, while communicating frequent opportunities for staff involvement in TIC implementation	• TIC Workgroup members represent diverse departments, facilities, and job roles (both clinical and nonclinical) • “TIC Talk” blog posts published once per month on intranet
Building a Trauma-Informed Workplace	• Incorporation of TIC into new hire orientation, onboarding and annual employee competencies • Trauma-Informed Supervision course for leaders who supervise employees • Trauma-Informed Interviewing Guide for Hiring Managers • Trauma-Informed Performance Coaching Tip Sheet	Reinforcement of a trauma-informed culture through early connections with new hires and linkage to existing organizational mission, values, and standards Creation of resources that encourage leaders who supervise other employees to take a trauma-informed approach to hiring and difficult conversations related to performance	• 100% of annual competencies include at least one TIC reminder • Number/percent of leaders (supervisors and higher) within organization who complete Trauma-Informed Supervision course
Training the Workforce	• TIC Advocate Program • Motivational Interviewing Training • Setting Boundaries Training	Establishing departmental TIC champions to train staff members and lead TIC-focused patient or staff support improvement projects Creating opportunities for staff to engage in training related to topics that embody Trauma-Informed care principles and culture	• Percent of University Health departments with an active TIC Advocate • Number/percent of social workers, nurses, and educators who complete Motivational Interviewing training • Number/percent of staff members who complete “Empowered to Set Healthy Boundaries” Training
Addressing the Impact of the Work	• Recharge Rooms • Schwartz Rounds	Staff support resources that allow opportunities for self-care and self-reflection, shared vulnerability, connection, belonging, and resilience	• Recharge room utilization rates • Number of attendees at facility-wide Schwartz Rounds • Number of unit-based Rounds requested annually • Percent of Schwartz Rounds attendees who have attended 5 + Rounds • Positive feedback on Schwartz Rounds evaluations (Likert scale questions + open-ended comments)
Establishing a Safe Environment	• Annual Start by Believing Campaign • Wellness Committee and Wellness Weeks • Partnership with Salud-Arte: Art of Healing program	Internal and external partnerships that promote trauma-informed approaches to patient disclosures of trauma, opportunities for staff members to engage in wellness activities, and creative ways to build more supportive physical environments that promote safety and healing for all who engage with the health system	• Number of attendees at each Start by Believing campaign event • Number of staff members who engage in Wellness Week activities • Positive qualitative feedback on Wellness Week evaluations
Screening for and Treating Trauma	• Age-appropriate screening tools available in the electronic health record • Direct access to mental health services • Trauma Survivors Network • On-site mental health counselor for staff members	Screening patients for trauma using age-appropriate screening tools and connecting those who screen positive with behavioral health services and survivor support resources Ensuring healthcare staff have access to counseling services	• Percent of patients screened for trauma in inpatient and Trauma Follow-Up clinic settings • Percent of patients with positive screen referred to mental health services or provided with community resources • Number of patients who are connected with the Trauma Survivors Network annually • Number of unique staff members that utilize on-site counselor annually
Collaborating with Others	• Patient Safety Status Project • Exploring intersections between TIC and Public Health through collaborative projects and events • Multi-site IRB Research Study on embedding a Trauma-Informed Care Plan (TICP) in the electronic health record	Establishing relationships with external organizations and across University Health departments to provide high-quality care, including initiatives to preserve patient anonymity and safety, promote health equity, and avoid re-traumatization	• Number/percent of patients with safety concerns who utilize confidential or restricted visitation status • Percent of participants (patients and providers) who report that the TICP was useful/impactful in reducing re-traumatization
Reviewing Policies & Procedures	• Review of new and existing corporate, human resources, and clinical policies for trauma-informed language • Trauma-Informed Care Policy Thesaurus • Trauma-Informed Care policy	TIC department involvement in incorporating trauma-informed language that is person-first, inclusive, transparent, and avoids shaming/blaming into organizational policies, while empowering policy owners, writers, and reviewers to do the same using a “TIC Thesaurus” as a reference tool Solidify commitment to trauma-informed policy change with a corporate policy specifically focused on TIC	• Number/percent of internal policies reviewed for trauma-informed language
Evaluating & Monitoring Progress	• Biennial TICS-10 Trauma-Informed Work Environment Survey • Metrics for other internal trauma-informed projects/programs	Measuring the impact of TIC initiatives through staff perception surveys and project-specific metrics	• TICS-10 organizational score continues to trend upward over time • Percent of individual peer support requests responded to within 48 hrs • Percent of unit/department level peer support requests responded to within 72 hrs

Results

Biennial TICS-10 Trauma-Informed work environment survey

In 2020, 1,571 staff members out of 8,481 total employees (19% response rate), including clinical, non-clinical, and management staff, completed the TICS-10 survey. At baseline, our overall organizational score was 34.1, indicating a low trauma-informed environment, one point away from moderate. In 2022, after two years of systematic TIC communication and over 100 TIC Advocates trained, 1,138 staff members out of 8,838 total employees (13% response rate) completed the survey. For this second survey, our overall organizational score dropped four points to a score of 29.0. Our most recent TICS-10 survey was conducted in 2024 with 632 respondents out of 11,316 total employees (6% response rate). Results revealed an overall organizational score of 35.0 in the moderate trauma-informed environment category.

The drop in score at the second time point is likely due to a combination of factors, including the negative impacts of the COVID-19 pandemic and a common phenomenon known as the Dunning-Kruger effect, a cognitive bias that causes people to overestimate their abilities, especially in areas where they lack knowledge or skill [21]. Prior to the baseline survey and subsequent significant education, training, and communication on Trauma-Informed Care, staff may have overestimated our status as a trauma-informed organization. After two years of progress and more widespread understanding of what it really takes to become a trauma-informed organization, the work required to reach our goal may have become more evident to staff respondents.

Results from a one-way ANOVA indicated a statistically significant difference in TICS-10 scores between 2022 and 2024 (F(1, 1768) = 306.13, p <.001). The average score in 2024 (M = 35.28, SD ≈ 9.00) was notably higher than in 2022 (M = 28.57, SD ≈ 6.93), suggesting measurable growth in staff perceptions of Trauma-Informed care practices across the organization. While the increase in mean scores is encouraging, it is important to interpret these findings in the context of low response rates and potential sample variability (Fig. 1).

Fig. 1.

TICS-10 Scores Trendline by year (biennial survey)

Schwartz rounds qualitative data

One of the most successful programs in measuring the trauma-informed environment at University Health is Schwartz Rounds. While increasing trends in attendance and participation rates quantitatively show success, the real progress toward a culture that values vulnerability and resilience is demonstrated in the qualitative evaluation data from these rounds.

A sentiment analysis of responses to one of the free text questions on the Schwartz Rounds evaluation, namely: “Do you have any other comments or feedback?” was conducted using Google’s Gemini 2.0 Flash AI model with evaluation data from May 2021 – January 2025 (see Appendix 1 for evaluation form). Gemini was prompted to identify the overall sentiment for each evaluation comment, provide a summary of the most common sentiments and a breakdown of the top issues causing negative sentiment, and classify comments into positive, negative, neutral, or mixed (contains both positive and negative elements) categories. The analysis of survey responses from Schwartz Rounds participants revealed an overwhelmingly positive reception of the sessions. Out of 291 comments analyzed, 206 (71%) were classified as positive, 45 (15%) as neutral, 21 (7%) as mixed, and 19 (7%) as negative. The sessions were frequently described as a safe space for sharing and healing. Gemini summarized and organized positive comments into the following categorical groups:

• Comfort and Connection: Many commenters highlighted that Schwartz Rounds helped them feel less alone in their struggles and more connected to their colleagues. This reflects the TIC principles of safety and trust, as participants experienced the space as emotionally secure and supportive. The sense of shared humanity fostered during sessions also supports the principle of collaboration by strengthening interpersonal bonds across disciplines.

• Appreciation and Empathy: The sessions fostered a greater appreciation for the work of others and increased empathy toward colleagues and patients. This aligns with the TIC principle of collaboration, as it nurtures mutual understanding and team cohesion. It also contributes to the principle of trust, as colleagues begin to see one another as partners in the workplace and in patient care.

• Impact and Inspiration: Attendees felt moved, touched, and inspired by the stories shared. These moments of resonance can be linked to the TIC principle of empowerment, as hearing others’ stories often validates personal experiences and encourages emotional expression. When staff are inspired by one another, it supports a culture that values the principle of choice in how individuals engage and reflect.

• Validation: Participants felt seen, heard, and validated in their experiences and feelings. This theme most strongly reflects the TIC principles of empowerment and trust, as individuals are affirmed in their experiences without judgment.

A small number of negative comments pointed to areas for improvement, including difficulty hearing speakers due to technical issues, limited interaction opportunities, low attendance of male staff members, and a lack of clear focus in some discussions. Overall, the analysis highlights the value and emotional significance of Schwartz Rounds in creating a supportive, reflective space for healthcare professionals.

Local TIC certification

University Health officially earned Level 1 Trauma-Informed Certification from the Ecumenical Center for Education, Counseling, and Health in October 2024. The impartial certification process involved three main elements: an initial organizational self-assessment, a desk review, and site visits to University Health facilities. Desk review requirements were broken down into five domains related to the following: Physical & Interpersonal Safety; Transparency & Trustworthiness; Respect & Empowerment; Collaboration & Policy; and Skill Building & Emotional Intelligence. Because these requirements were based on the SAMHSA Trauma Informed Framework, they mirrored the five key principles as well as elements of the ten key development areas set by ITTIC, allowing for a smooth transition into the submission process. A thorough compilation of more than 300 documents was submitted by University Health in support of 111 Trauma-Informed care requirements.

The Ecumenical Center completed four site visits representative of all types of University Health facilities: inpatient, ambulatory, and business sites. Site visits included meetings with high-level leadership at each location, tours of the facility, and in-depth discussions with Trauma-Informed Care Advocates. University Health is now the first major health system and largest organization to officially be designated as a trauma-informed organization in Bexar County.

Discussion

Over the course of five years, University Health successfully implemented the 10 key development areas as recommended by the ITTIC to achieve trauma-informed organizational change. The quantitative results of the TICS-10 staff survey, which improved to a moderate trauma-informed environment score of 35.0, and the positive qualitative responses from the Schwartz Rounds evaluations reflect the internal perceptions of this change. Externally, certification as a trauma-informed organization by the Ecumenical Center validated University Health as a healthcare leader in this emerging field. While our certification reflects our organizational commitment to Trauma-Informed Care, the work continues. We anticipate that increasingly higher levels of local TIC certification standards will be released, but our journey will always be broader than a set list of standards. University Health will continue to strive toward our vision of becoming one of the most trusted health institutions in the nation by maintaining and building on our status as a trauma-informed organization.

While we are proud of the substantial progress that has been made to implement TIC at University Health, significant gaps remain in evaluating the effectiveness of trauma-informed culture change comprehensively. Additional research and investment are needed to assess the long-term impact of TIC initiatives on both patient health outcomes, patient satisfaction, and staff well-being. The potential for TIC to shape healthcare environments is immense, but without sufficient data to demonstrate its full benefits, widespread adoption remains a challenge.

A notable limitation of our evaluation efforts was the low response rate to the biennial TICS-10 staff surveys conducted in 2020, 2022, and 2024. This may be partially attributed to survey fatigue, a common challenge in large healthcare systems where staff are frequently asked to complete multiple surveys throughout the year. Additionally, our outreach strategy was limited to internal channels such as the weekly email newsletter and the staff intranet, which may not have reached all employees effectively. This limited communication approach may have contributed to sampling bias, as individuals who already had a strong interest in Trauma-Informed care or who routinely engage with internal communications were likely overrepresented among respondents. Expanding communication methods—such as direct outreach by leaders, unit champions, or in-person prompts during huddles—may improve both response rates and sample diversity in future assessments.

One of the most common challenges in TIC implementation is offering training and education to an already overburdened healthcare workforce. While training is essential, the time and effort required for meaningful education and practical application is a barrier. A comprehensive trauma-informed healthcare approach must reach beyond education to include robust process improvement projects and holistic approaches to care from a trauma-informed lens. Leadership buy-in is critical, and without adequate support systems in place, efforts may fall short of fostering sustained organizational change. Future efforts should ensure that Trauma-Informed care initiatives extend beyond training and consider a more holistic approach to the organization’s core functions: from hiring of staff and monitoring of desired trauma-informed staff behavior, to the provision of services.

We recognize that University Health’s experience may not be fully generalizable to all healthcare settings. Our involvement in a robust, countywide Trauma-Informed care initiative provided unique opportunities for shared learning, collaboration, and momentum that may not be readily available in other regions. Institutions without similar community-based movements may face additional challenges in building awareness or securing buy-in. However, trauma-informed transformation remains achievable in standalone settings by benchmarking against other health systems, using University Health’s internal Trauma-Informed care transformation as an example. Aligning initiatives with other internal priorities such as patient safety, staff wellness, and health equity may be helpful to start the process. Even in the absence of a regional initiative, organizations may build internal capacity by engaging multidisciplinary champions and starting with smaller-scale projects such as peer support or policy review for trauma-informed language. Our experience suggests that strategic alignment with organizational values and visible leadership support are more critical to success than the presence of external infrastructure alone.

Another key area for improvement is the need for national certification standards for trauma-informed organizations, perhaps even specific to healthcare settings. As noted by Melz et al. in their 2019 research review: “Of the 20 studies that defined TI (Trauma Informed) or described related principles or components, 13 referenced elements of a well-known framework developed by SAMHSA. Some studies used SAMHSA’s framework on its own, while others combined it with other definitions, such as the one created by NCTSN (National Child Traumatic Stress Network)” [15]. While geographic-specific initiatives provide an important and consistent framework for the system they represent, a nationally recognized certification would drive consistency, accountability, and widespread adoption of best practices across healthcare institutions and other organizations.

Conclusion

TIC serves as a catalyst for numerous related initiatives, including development of frameworks to advance health equity, staff wellness and peer support programming, and efforts to improve patient safety and patient satisfaction. By integrating the five TIC principles into these initiatives, healthcare organizations can create safe and supportive environments that benefit both staff and patients. For staff, these principles may contribute to a more flexible and resilient workplace, helping to reduce burnout and promote professional wellness [22]. Prioritizing safety and trust allows team members to feel more confident in their roles and better equipped to build meaningful, patient-centered relationships. For patients, this may help foster a sense of security, reduce fear and anxiety, and increase engagement in care. Offering choice and supportive collaborative decision-making can lead to more personalized and effective treatment, which in turn can support adherence to care plans [23].

Meaningful collaboration with the broader community is also vital to the sustainability of trauma-informed approaches. Providing opportunities for community members to inform education, participate in committees/advisory boards, and influence decision-making ensures that TIC efforts are informed by lived experience and responsive to the needs of those they serve.

While University Health’s experience was shaped by unique community partnerships and internal investment, the strategies used—anchoring TIC in mission, aligning efforts with organizational priorities, and securing leadership support—can be adapted by institutions across diverse healthcare settings. Trauma-informed care is not a checklist but a cultural commitment, and its impact depends on intentional, sustained implementation across all levels of an organization.

Abbreviations

TIC

Trauma-Informed Care

ITTIC

Institute on Trauma and Trauma-Informed Care

TICS-10

Trauma-Informed Climate Scale

SAMHSA

Substance Abuse and Mental Health Services Administration

ACEs

Adverse Childhood Experiences

STTICC

South Texas Trauma-Informed Care Consortium

CARE

Compassionate Assistance for Resilient Employees

TICP

Trauma-Informed Care Plan

NCTSN

National Child Traumatic Stress Network

Authors’ contributions

SAS led University Health’s Trauma-Informed care initiative and the organizational certification process. She drafted the main manuscript sections (Background through Results), wrote the abstract, created Figure 1, prepared and formatted Table 1, and coordinated references using EndNote.CMB initiated the trauma-informed movement in Bexar County and authored the “Trauma-Informed Community Approach” subsection and the paragraph in the Discussion on national certification standards.PAA drafted the initial versions of the Conclusion and Discussion sections and the first draft of Table 1.CKO conducted a brief literature review and revised the Background section with additional citations and contextual content.SRS co-authored the “Screening for and Treating Trauma” subsection in the Methods and contributed to grammatical and formatting edits across manuscript drafts.REW compiled Schwartz Rounds evaluation data, conducted sentiment analysis using Gemini, and provided manuscript recommendations and editorial feedback.SET edited one of the final drafts and provided recommendations.BJA, University Health’s Chief Medical Officer, established the Trauma-Informed care department, served as the primary executive sponsor of the initiative, and was the final editor and approver of the manuscript.All authors read and approved the final manuscript as submitted.

Funding

This work had no external funding.

Data availability

The datasets used and/or analyzed in this manuscript are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

Project submitted to the University of Texas Health Science Center at San Antonio IRB Self-Certification Tool for Non-Regulated or Non-Human Subjects Research on the following website and determined to not require IRB review: https://uthscsa.edu/research/about/directory/irb. Per federal regulations, the project is not regulated research as defined under 45 CFR 46.102; therefore, obtaining informed consent for the TICS-10 surveys and Schwartz Rounds evaluations was deemed unnecessary by the University of Texas Health Science Center at San Antonio IRB. The TICP research study referenced in this manuscript is in the planning phase at the time of publication, and has not yet been submitted for IRB approval.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.