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Organizational Social Context: Assessment, Impact, and Intervention for

Change

MCWIC Regional Forum, “Improving Outcomes for Children, Youth and

Families through Sustainable systems Change” (April, 2009)

Anthony Hemmelgarn, Ph.D.Children’s Mental Health Services Research Center

College of Social WorkUniversity of Tennessee

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Presentation ObjectivesPresentation Objectives

Organizational Social Context and the Organizational Social Context and the Socio-technicalSocio-technical modelmodel

Organizational Social Context (OSC) Organizational Social Context (OSC) Measurement SystemMeasurement System

CMHSRC research findingsCMHSRC research findings

ARC organizational interventionARC organizational intervention

Parting ThoughtsParting Thoughts

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Quotable Quotes

“Have you hit him in the mouth? Here, take this paddle and whip him. If it doesn’t work on his rear end, hit him in the head. That’s what my daddy did with me.”

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Which of the following gets the most Which of the following gets the most support in this court system?support in this court system?

Training court officers to work with Boot Training court officers to work with Boot Camp InstructorsCamp Instructors

Training court officers to work with Multi-Training court officers to work with Multi-Systemic-Treatment TherapistsSystemic-Treatment Therapists

A redo of the Scopes Monkey TrialA redo of the Scopes Monkey Trial

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There is ample empirical There is ample empirical research that indicates: research that indicates:

Empirically-Based Practices and Empirically-Based Practices and treatments are rarely adopted treatments are rarely adopted

And if adopted, seldom implemented And if adopted, seldom implemented effectively or with fidelityeffectively or with fidelity

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The Socio-technical Model arguesThe Socio-technical Model argues

The adoption of best practices, fidelity to The adoption of best practices, fidelity to new protocols, adherence to training, etc… new protocols, adherence to training, etc…

Are as much Are as much socialsocial as technical processesas technical processes

Are embedded in an Are embedded in an organizational social organizational social contextcontext

Require changesRequire changes in the social context to occur in the social context to occur

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Culture and Climate are the Key Constructs Culture and Climate are the Key Constructs in Organizational Social Contextin Organizational Social Context

CultureCulture – property of the organization – property of the organization System norms and valuesSystem norms and values ““The way things are done”The way things are done” What is expected and rewardedWhat is expected and rewarded

ClimateClimate – property of the individual – property of the individual Perceptions of work environment’s psychological Perceptions of work environment’s psychological

impact on employeesimpact on employees Affective responseAffective response E.g., “psychological safety”E.g., “psychological safety”

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Rejection or adoption of new technologiesRejection or adoption of new technologies - - Innovative/flexible cultures try & test new thingsInnovative/flexible cultures try & test new things

Assimilation versus accommodation of new technologies Assimilation versus accommodation of new technologies e.g., child welfare assessmentse.g., child welfare assessments

Sustainability and fidelity of new programsSustainability and fidelity of new programs

Positive or negative attitudesPositive or negative attitudes - - Defensive (active/passive) cultures create turnover, low organizational Defensive (active/passive) cultures create turnover, low organizational

commitment, poor service quality, & poor client outcomescommitment, poor service quality, & poor client outcomes

Individual learning/persistence versus apathy/resistanceIndividual learning/persistence versus apathy/resistance - - Associates feeling autonomy, decision controlAssociates feeling autonomy, decision control demonstrate more energy, tenacity, and motivation for actiondemonstrate more energy, tenacity, and motivation for action

What Does Organizational Social What Does Organizational Social Context Create?Context Create?

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The Impact of Organizational Culture The Impact of Organizational Culture and Climate and Climate

Main EffectMain Effect

Mediation EffectMediation Effect

Moderation EffectModeration Effect Change effort Service Outcomes

Culture/Climate

Change effort Service Outcomes

Culture/Climate

Change effort CultureClimate

Service Outcomes

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NIMH Study of Climate - NIMH Study of Climate - (Glisson & Hemmelgarn, 1998)(Glisson & Hemmelgarn, 1998)

InterorganizationalServices

Coordination

ServiceQuality

CountyDemographics

OrganizationalClimate

Service Outcomes(problem levels)

-.12*

-.17* .02.11*

-.05

-.35*-.04

*p<.05

2 = 945.79 GFI = .91 AG&I = .89 CFI = .91 w/ 370 df’s

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NIMH Study of Culture/Climate of Emergency Rooms: NIMH Study of Culture/Climate of Emergency Rooms: Emotional Support NormsEmotional Support Norms

(Hemmelgarn, Glisson, & Dukes, 2001)(Hemmelgarn, Glisson, & Dukes, 2001)

Potential sources of variation in norms F Significant effect

ER experience 3.16 No

Gender .19 No

Profession .22 No

Hospital 10.68** Yes

Comparison 1-2 5.75* Yes

Comparison 3-4 .42 No

Comparison 1&2 vs. 3&4 17.68** Yes

**p < .01

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NIMH Study of Culture/Climate of Emergency Rooms: NIMH Study of Culture/Climate of Emergency Rooms: Emotional Impact PerceptionsEmotional Impact Perceptions

(Hemmelgarn, Glisson, & Dukes, 2001) (Hemmelgarn, Glisson, & Dukes, 2001)

Potential sources of variation in impact F Significant effect

ER experience 3.41 No

Gender 2.55 No

Profession .37 No

Hospital 2.30 No

Comparison 1-2 .26 No

Comparison 3-4 .01 No

Comparison 1&2 vs. 3&4 5.11** Yes

**p < .01

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Organizational Social Organizational Social Context measurement Context measurement

system (OSC)system (OSC)

• Developed by CMHSRCDeveloped by CMHSRC• Nationally NormedNationally Normed• Provides Organizational ProfileProvides Organizational Profile

• Early WarningEarly Warning• Monitoring for ImprovementMonitoring for Improvement

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Organizational Culture

1. Proficiency – expectation that service providers will be competent, have up-to-date knowledge, and place the well-being of clients first

2. Rigidity – expectation that service providers will have limited discretion and flexibility, and closely follow extensive bureaucratic rules and regulations

3. Resistance – expectation that service providers will show no interest in change or new ways of providing services

Organizational Social Context (OSC) Measurement System

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Example of Worst Culture Profile

(approximately 10% of clinics)

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Example of Best Culture Profile

(approximately 10% of clinics)

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19

50.0

45.0

40.0

35.0

30.0

25.0

20.0

worst average best

Culture Profiles

Mo

nth

s N

ew P

rog

ram

Su

stai

ned

New Program Sustainability as a Function of Culture

Research funded by MacArthur Foundation.

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Five Studies to date link Culture to:Five Studies to date link Culture to:

Individualized care Individualized care by 408 service providers in 30 by 408 service providers in 30 social service organizations (Glisson, 1978)social service organizations (Glisson, 1978)

Family-centered careFamily-centered care by 131 service providers in by 131 service providers in four emergency rooms (Hemmelgarn, Glisson & four emergency rooms (Hemmelgarn, Glisson & Dukes, 2001) Dukes, 2001)

Turnover, work attitudes,Turnover, work attitudes, and and service qualityservice quality among 283 caseworkers in 33 child welfare and among 283 caseworkers in 33 child welfare and juvenile justice case management teams (Glisson & juvenile justice case management teams (Glisson & James, 2002)James, 2002)

Service qualityService quality in 15 child welfare teams serving 21 in 15 child welfare teams serving 21 urban and rural counties (Glisson & Green, 2006)urban and rural counties (Glisson & Green, 2006)

New program sustainabilityNew program sustainability in nationwide sample in nationwide sample of 100 mental health clinics (Glisson, Schoenwald, of 100 mental health clinics (Glisson, Schoenwald, Kelleher et al., 2008)Kelleher et al., 2008)

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Organizational Social Context (OSC) Measurement System

Organizational Climate

1. Engagement – service provider perceptions of personal accomplishment, involvement and concern for clients

2. Functionality – service provider perceptions that they receive the needed cooperation and support to do their jobs

3. Stress – service provider perceptions that they are emotionally exhausted and overloaded in their work

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Example of Worst Climate Profile

(approximately 10% of clinics)

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Example of Best Climate Profile

(approximately 10% of clinics)

25

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18.00

15.00

12.00

9.00

worst average best

Climate Profiles

Pas

t Y

ear

Th

era

pis

t T

urn

ove

r R

ate

(%

)

21.00

Past Year Therapist Turnover Rate as a Function of Climate

Research funded by MacArthur Foundation.

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Raw CBCL Total Score

Months following Initial Investigation

0

25

30

35

40

45

4 12 20 28 36

children served by systems with worst climates (least engaged)

children served by systems withbest climates (most engaged)

Results of 3 level HLM

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Organizational Culture and/or ClimateOrganizational Culture and/or Climate

DifferDiffer in organizations providing same service in organizations providing same service

Predict staff Predict staff job satisfaction and commitmentjob satisfaction and commitment

Predict staff Predict staff turnoverturnover

Predict Predict service quality service quality

PredictPredict service outcomes service outcomes

Predict adoption, fidelity, and sustainability to new Predict adoption, fidelity, and sustainability to new treatmentstreatments

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A Need for Organizational InterventionsA Need for Organizational Interventions

Evidence-based organization interventions are Evidence-based organization interventions are needed to improve mental health and social servicesneeded to improve mental health and social services

Improve work environments and reduce service Improve work environments and reduce service provider turnover provider turnover

Support the implementation of evidence-based Support the implementation of evidence-based training, treatments, and other best practices training, treatments, and other best practices

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ARC Organizational ARC Organizational InterventionIntervention

AvailabilityAvailability ResponsivenessResponsiveness ContinuityContinuity

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ARC Guiding PrinciplesARC Guiding Principles

mission-drivenmission-driven vs rule driven – all staff and administrative actions and vs rule driven – all staff and administrative actions and decisions must contribute to children’s well-beingdecisions must contribute to children’s well-being

results-orientedresults-oriented vs process oriented – measure staff and program vs process oriented – measure staff and program performance by improvements in children’s well-beingperformance by improvements in children’s well-being

improvement-directedimprovement-directed vs status quo oriented – staff and vs status quo oriented – staff and administrators continually seek to be more effectiveadministrators continually seek to be more effective

relationship-centeredrelationship-centered vs individual centered – staff and administrators vs individual centered – staff and administrators focus on consumer and stakeholder relationshipsfocus on consumer and stakeholder relationships

participation-basedparticipation-based vs authority based – include line-level staff and vs authority based – include line-level staff and community stakeholders in key program decisions community stakeholders in key program decisions

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Uses Uses 12 “levers”12 “levers” or intervention components or intervention components

Involves Involves all organizational levelsall organizational levels and and community community stakeholdersstakeholders

Requires Requires change agentschange agents who work directly with who work directly with managers, treatment teams and community leaders managers, treatment teams and community leaders

ARC Organizational Intervention ModelARC Organizational Intervention Model

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Twelve ARC Intervention ComponentsTwelve ARC Intervention Components

Leadership Leadership developmentdevelopment

Personal relationshipsPersonal relationships Network developmentNetwork development Team buildingTeam building Information & trainingInformation & training FeedbackFeedback

Participatory decision-Participatory decision-makingmaking

Conflict resolutionConflict resolution Goal settingGoal setting Continuous improvementContinuous improvement Job redesignJob redesign Self-regulationSelf-regulation

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Stages, Components and Phases of the Stages, Components and Phases of the Arc Organizational Intervention ModelArc Organizational Intervention Model

Stages and ComponentsStages and Components PhasesPhasesII

ProblemProblem

identificationidentification

IIII

DirectionDirection

settingsetting

IIIIII

Implement-Implement-ationation

IVIV

StabilizatioStabilizationn

1. Leadership development1. Leadership development xxxxxxxxxx

2. Personal relationships2. Personal relationships xxxxxxxxxx

3. Network development3. Network development xxxxxxxxxx xxxxxxxxxx

4. Team building4. Team building xxxxxxxxxx xxxxxxxxxx

5. Information and training5. Information and training xxxxxxxxxx xxxxxxxxxx xxxxxxxxxx

6. Feedback6. Feedback xxxxxxxxxx xxxxxxxxxx xxxxxxxxxx xxxxxxxxxx

7. Participatory decision-making7. Participatory decision-making xxxxxxxxxx xxxxxxxxxx xxxxxxxxxx xxxxxxxxxx

8. Conflict management8. Conflict management xxxxxxxxxx xxxxxxxxxx xxxxxxxxxx xxxxxxxxxx

9. Goal setting9. Goal setting xxxxxxxxxx xxxxxxxxxx xxxxxxxxxx

10. Continuous improvement10. Continuous improvement xxxxxxxxxx xxxxxxxxxx

11. Job redesign11. Job redesign xxxxxxxxxx xxxxxxxxxx

12. Self-regulation12. Self-regulation xxxxxxxxxx

Par

ticip

atio

nIn

nova

tion

Col

labo

-ra

tion

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Results of ARC Intervention

• ARC reduced turnover (39%) vs control (69%)

• ARC improved climate in both urban and rural teams

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Proportion of Youth Entering Out of Home Placements in State Custody

ARC

No Yes

No 34%(52/152)

22%(31/139)

29% (83/291)

Yes 20%(34/169)

16%(22/136)

18% (56/305)

27%(86/321)

19%(53/275)

23% (139/596)

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HLM Analysis of MST x ARC Interaction Effect on Problem Behavior at 6 months

No Yes

MST

60

55

65

CB

CL

To

tal

Pro

ble

m T

Sco

re

(Clinical Cut Point = 60)

(60.98)(60.89)

(60.85)

(57.55)

Non-ARC counties

ARC counties

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Parting thoughtsParting thoughts

Organizational Social Context has Organizational Social Context has survival valuesurvival value

Social Context can make or break Social Context can make or break technological changestechnological changes

Organizational “Learning” contexts Organizational “Learning” contexts need to be developedneed to be developed

Technological change without Technological change without attention to social context isn’t wise attention to social context isn’t wise

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Contact InformationContact Information

Children’s Mental Health Service’s Children’s Mental Health Service’s Research Center. The University of Research Center. The University of Tennessee Tennessee

865 974 1707865 974 1707

Tony HemmelgarnTony Hemmelgarn ahemmelg@utk.eduahemmelg@utk.edu