1. 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. 2 Presentation Objectives Organizational Social Context and the Socio-technical model Organizational Social Context and the Socio-technical model Organizational Social Context (OSC) Measurement System Organizational Social Context (OSC) Measurement System CMHSRC research findings CMHSRC research findings ARC organizational intervention ARC organizational intervention Parting Thoughts Parting Thoughts

3. 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. 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. 5 There is ample empirical research that indicates: Empirically-Based Practices and treatments are rarely adopted Empirically-Based Practices and treatments are rarely adopted And if adopted, seldom implemented effectively or with fidelity And if adopted, seldom implemented effectively or with fidelity

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

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

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

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

10. 10 NIMH Study of Climate - (Glisson & Hemmelgarn, 1998) Interorganizational Services Coordination Service Quality County Demographics Organizational Climate 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

11. 11 NIMH Study of Culture/Climate of Emergency Rooms: Emotional Support Norms (Hemmelgarn, Glisson, & Dukes, 2001) Potential sources of variation in normsFSignificant effect ER experience 3.16No Gender.19No Profession.22No Hospital10.68**Yes Comparison 1-2 5.75*Yes Comparison 3-4.42No Comparison 1&2 vs. 3&417.68**Yes **p <.01

12. 12 NIMH Study of Culture/Climate of Emergency Rooms: Emotional Impact Perceptions (Hemmelgarn, Glisson, & Dukes, 2001) Potential sources of variation in impactFSignificant effect ER experience 3.41No Gender 2.55No Profession.37No Hospital 2.30No Comparison 1-2.26No Comparison 3-4.01No Comparison 1&2 vs. 3&4 5.11**Yes **p <.01

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

14. 14 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

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

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

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

20. 20 Five Studies to date link Culture to: Individualized care by 408 service providers in 30 social service organizations (Glisson, 1978) 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) 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) 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) 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) New program sustainability in nationwide sample of 100 mental health clinics (Glisson, Schoenwald, Kelleher et al., 2008)

21. 21 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

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

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

25. 25

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

27. 27 Raw CBCL Total Score Months following Initial Investigation 0 25 30 35 40 45 412 2028 36 children served by systems with worst climates (least engaged) children served by systems with best climates (most engaged) Results of 3 level HLM

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

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

30. 30 ARC Organizational Intervention Availability Availability Responsiveness Responsiveness Continuity Continuity

31. 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. 32 Uses 12 “levers” or intervention components Uses 12 “levers” or intervention components Involves all organizational levels and community stakeholders Involves all organizational levels and community stakeholders Requires change agents who work directly with managers, treatment teams and community leaders Requires change agents who work directly with managers, treatment teams and community leaders ARC Organizational Intervention Model

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

34. 34 Stages, Components and Phases of the Arc Organizational Intervention Model Stages and Components Phases IProblemidentificationIIDirectionsettingIII Implement- ation IV Stabilizatio n 1. Leadership development xxxxx 2. Personal relationships xxxxx 3. Network development xxxxxxxxxx 4. Team building xxxxxxxxxx 5. Information and training xxxxxxxxxxxxxxx 6. Feedback xxxxxxxxxxxxxxxxxxxx 7. Participatory decision- making xxxxxxxxxxxxxxxxxxxx 8. Conflict management xxxxxxxxxxxxxxxxxxxx 9. Goal setting xxxxxxxxxxxxxxx 10. Continuous improvement xxxxxxxxxx 11. Job redesign xxxxxxxxxx 12. Self-regulation xxxxx Participation Innovation Collabo- ration

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

36. 36 Proportion of Youth Entering Out of Home Placements in State Custody ARC NoYes No34% (52/152) 22% (31/139) 29% (83/291) Yes20% (34/169) 16% (22/136) 18% (56/305) 27% (86/321) 19% (53/275) 23% (139/596)

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

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

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