Organizational Social Context: Assessment, Impact, and Intervention for Change

1. 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 Work University of Tennessee

2. Presentation Objectives • Organizational Social Context and the Socio-technicalmodel • Organizational Social Context (OSC) Measurement System • CMHSRC research findings • ARC organizational intervention • Parting Thoughts

3. 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.”

4. Which of the following gets the most support in this court system? • Training court officers to work with Boot Camp Instructors • Training court officers to work with Multi-Systemic-Treatment Therapists • A redo of the Scopes Monkey Trial

5. There is ample empirical research that indicates: • Empirically-Based Practices and treatments are rarely adopted • And if adopted, seldom implemented effectively or with fidelity

6. The Socio-technical Model argues • The adoption of best practices, fidelity to new protocols, adherence to training, etc… • Are as much socialas technical processes • Are embedded in an organizational social context • Require changes in the social context to occur

7. Culture and Climate are the Key Constructs in Organizational Social Context • Culture – property of the organization • System norms and values • “The way things are done” • What is expected and rewarded • Climate – property of the individual • Perceptions of work environment’s psychological impact on employees • Affective response • E.g., “psychological safety”

8. What Does Organizational Social Context Create? • Rejection or adoption of new technologies - Innovative/flexible cultures try & test new things • Assimilation versus accommodation of new technologies e.g., child welfare assessments • Sustainability and fidelity of new programs • Positive or negative attitudes - Defensive (active/passive) cultures create turnover, low organizational commitment, poor service quality, & poor client outcomes • Individual learning/persistence versus apathy/resistance - Associates feeling autonomy, decision control demonstrate more energy, tenacity, and motivation for action

9. The Impact of Organizational Culture and Climate • Main Effect • Mediation Effect • Moderation Effect Change effort Service Outcomes Culture/Climate Culture Climate Change effort Service Outcomes Change effort Service Outcomes Culture/Climate

10. Service Outcomes (problem levels) -.12* Organizational Climate .11* -.17* -.05 .02 Interorganizational Services Coordination County Demographics Service Quality -.04 -.35* *p<.05 NIMH Study of Climate - (Glisson & Hemmelgarn, 1998) 2 = 945.79 GFI = .91 AG&I = .89 CFI = .91 w/ 370 df’s

11. NIMH Study of Culture/Climate of Emergency Rooms: Emotional Support Norms(Hemmelgarn, Glisson, & Dukes, 2001)

12. NIMH Study of Culture/Climate of Emergency Rooms: Emotional Impact Perceptions (Hemmelgarn, Glisson, & Dukes, 2001)

13. Organizational Social Context measurement system (OSC) • Developed by CMHSRC • Nationally Normed • Provides Organizational Profile • Early Warning • Monitoring for Improvement

14. Organizational Social Context (OSC) Measurement System 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 rulesand regulations 3. Resistance – expectation that service providers will show no interest in change or new ways of providing services

15. Example of Worst Culture Profile (approximately 10% of clinics)

17. Example of Best Culture Profile (approximately 10% of clinics)

19. New Program Sustainability as a Function of Culture Months New Program Sustained 50.0 45.0 40.0 35.0 30.0 25.0 20.0 worst average best Culture Profiles Research funded by MacArthur Foundation.

20. Five Studies to date link Culture to: • Individualized care by 408 service providers in 30 social service organizations (Glisson, 1978) • Family-centered care by 131 service providers in four emergency rooms (Hemmelgarn, Glisson & Dukes, 2001) • Turnover, work attitudes, and service quality among 283 caseworkers in 33 child welfare and juvenile justice case management teams (Glisson & James, 2002) • Service quality in 15 child welfare teams serving 21 urban and rural counties (Glisson & Green, 2006) • New program sustainability in nationwide sample of 100 mental health clinics (Glisson, Schoenwald, Kelleher et al., 2008)

21. Organizational Social Context (OSC) Measurement System OrganizationalClimate 1. Engagement – service providerperceptions 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

22. Example of Worst Climate Profile (approximately 10% of clinics)

24. Example of Best Climate Profile (approximately 10% of clinics)

26. Past Year Therapist Turnover Rate as a Function of Climate Past Year Therapist Turnover Rate (%) 21.00 18.00 15.00 12.00 9.00 worst average best Climate Profiles Research funded by MacArthur Foundation.

27. children served by systems with worst climates (least engaged) 45 40 Raw CBCL Total Score children served by systems with best climates (most engaged) 35 30 25 36 0 20 28 4 12 Months following Initial Investigation Results of 3 level HLM

28. Organizational Culture and/or Climate • Differ in organizations providing same service • Predict staff job satisfaction and commitment • Predict staff turnover • Predict service quality • Predict service outcomes • Predict adoption, fidelity, and sustainability to new treatments

29. A Need for Organizational Interventions • Evidence-based organization interventions are needed to improve mental health and social services • Improve work environments and reduce service provider turnover • Support the implementation of evidence-based training, treatments, and other best practices

30. ARC Organizational Intervention • Availability • Responsiveness • Continuity

31. ARC Guiding Principles mission-driven vs rule driven – all staff and administrative actions and decisions must contribute to children’s well-being results-oriented vs process oriented – measure staff and program performance by improvements in children’s well-being improvement-directed vs status quo oriented – staff and administrators continually seek to be more effective relationship-centered vs individual centered – staff and administrators focus on consumer and stakeholder relationships participation-based vs authority based – include line-level staff and community stakeholders in key program decisions

32. ARC Organizational Intervention Model • Uses 12 “levers” or intervention components • Involves all organizational levels and community stakeholders • Requires change agents who work directly with managers, treatment teams and community leaders

33. Leadership development Personal relationships Network development Team building Information & training Feedback Participatory decision-making Conflict resolution Goal setting Continuous improvement Job redesign Self-regulation Twelve ARC Intervention Components

34. Stages, Components and Phases of the Arc Organizational Intervention Model Collabo- ration Participation Innovation

35. Results of ARC Intervention • ARC reduced turnover (39%) vs control (69%) • ARC improved climate in both urban and rural teams

36. Proportion of Youth Entering Out of Home Placements in State Custody

37. 65 Non-ARC counties (60.98) (60.89) (60.85) CBCL Total Problem T Score 60 (Clinical Cut Point = 60) ARC counties (57.55) 55 No Yes MST HLM Analysis of MST x ARC Interaction Effect on Problem Behavior at 6 months

38. Parting thoughts • Organizational Social Context has survival value • Social Context can make or break technological changes • Organizational “Learning” contexts need to be developed • Technological change without attention to social context isn’t wise

39. Contact Information • Children’s Mental Health Service’s Research Center. The University of Tennessee • 865 974 1707 • Tony Hemmelgarn • ahemmelg@utk.edu