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Joining forces: a crosswalk of the human services value curve with organizational culture and climate.

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As we evolve in our working partnership with APHSA's Organizational Effectiveness team and the University of Tennessee's Center for Behavioral Health Research (CBHR), formerly the Children's Mental Health Services Research Center, we have discovered great synergy in our respective efforts for supporting agency performance. These include APHSA's efforts to help agencies progress through stages of the Health and Human Services Value Curve, and CBHR's efforts to help agencies improve by addressing their organizations' cultures and climates.

The Value Curve is a lens--a way of looking at what we do from the point of view of our consumers--and its four levels represent ways of engaging consumers and their communities that result in greater impact as organizations move up the Value Curve. At the first level, called the regulative level, the key word is "integrity." Consumers receive a product or service that is timely, accurate, cost effective, and easy to understand. Next, at the collaborative level, the key word is "service." Consumers have an easier time of it when they "walk through a single door" and have access to a more complete array of products and services because programs, and even jurisdictions, are collaborating to make it happen for them.

At the integrative level, the key term is "root causes." Products and services are designed using consumers' input so that we address their true needs and even begin to reach "upstream" to address causal problems rather than "treating the symptoms." At the generative level, the key term is "bigger than the family." Root- cause analysis is done at a "population-wide level," resulting in prevention strategies and other forms of support broader than those an individual or family would receive directly. (1)

Organizational culture and climate is another potent lens that human service organizations can use to look at their performance and improve their outcomes. APHSA's partners at CBHR have been building that case for more than 20 years, demonstrating the substantial impact of organizational culture and climate on the effectiveness of human services. (2) Their work demonstrates that: (1) human service agencies vary widely in their organizational culture and climate profiles, (2) agencies with positive profiles have substantially better outcomes, and (3) agencies can improve their turnover, EBP/EBT implementation, client, and other outcomes through strategies that improve their cultures and climates.

The CBHR uses its Organizational Social Context Measure (OSC-M) to profile agencies across dimensions of culture and climate that have been shown to be important to the successful functioning of human service organizations. Taken together, these dimensions encapsulate key aspects of an agency's "personality" and offer insights that can be used to improve performance metrics.

As an example of the synergy between our two models, the following crosswalk describes proficiency, one of the dimensions of culture, in the context of the Value Curve. In proficient cultures, staff shares expectations that it will be responsive to the unique needs of its clients and have up-to-date knowledge and practice skills. (3) Broadly, we expect proficiency levels to rise as organizations advance to higher levels on the Value Curve.

The Regulative Level and Proficiency

The regulative level for organizations is about building a stable and reliable infrastructure, and while the value proposition is foundational and compliance oriented, much of the cultural focus is internal. This includes laying out standards and processes for how the organization will operate, creating greater certainty, and establishing a framework to achieve efficiency. These are essential organizational capabilities; without them, there is chaos and failure.

Unfortunately, organizations at this level can easily elevate order and "covering the bases" to be ends rather than means. When this happens, proficiency drops dramatically. Phil Basso encounters this often in his fieldwork, and coined the term "bad regulative" for this approach (see his article in April's Policy and Practice, "Travels with the Value Curve").

A number of years ago Anthony Hemmelgarn helped conduct 25 focus groups from one end of a state to the other. More than 200 child welfare managers participated. The goal of each session was to answer a single question: "What needs to be measured to determine staff success?" The answers, over and over, were about process: how many clients were contacted, how many seen, paperwork completed on time. In and of themselves, there is nothing wrong with such responses. But not a single manager suggested anything related to clients getting better, and a laser focus on this is essential for high proficiency. This child welfare system was paying little attention to addressing its clients' needs. Proficiency, we can safely assume, was extremely low.

Human service systems often rely on standardized case management practices, such as requirements to visit families so many times per week, in a sincere effort to improve quality of care. But such tactics run counter to proficiency. "One size fits all" policies are, in fact, unresponsive to clients' unique needs. Case managers' time and other valuable resources are routinely wasted. Morale suffers.

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It must also be noted that many of the regulatory requirements that agencies confront are externally applied and beyond the control of agency leaders and staff. They must meet funder requirements. They must comply with legal mandates. While uniformly well intended, such external pressures often result in barriers to increasing proficiency. This is particularly true when compliance is enforced negatively or in a punitive fashion.

The Collaborative Level and Proficiency

At this level, organizations are concerned with connecting across programs and agencies to improve efficiency and effectiveness. More proficient organizations are likely to work toward meaningful client outcomes that cut across internal silos. They are more likely to involve teams and personnel at all levels in improvement-driven activities such as Continuous Quality Improvement. There is more emphasis on the efficacy of front-line staff as well as support for the frontline staff to learn from their errors, mistakes, and problems.

At the most important end of human service organizations--the front line--staff must feel safe and confident in its ability to achieve outcomes centered on client well-being. As skills develop internally, safety increases for trying new approaches, and efficacy in helping clients builds; attention to effectiveness for clients increases along with proficiency. Front-line staff must also be able to work closely together within its own teams, and the teams must have the skills and tools necessary to effectively interact and problem solve with other programs and departments, and with external organizations and stakeholders.

Such work increases the probability that programs and organizations will reach out and work with others in the community. As with individuals, a sense of efficacy increases confidence and openness to relating to others. Effective teams with a clear sense of purpose, organizational support, and a sense of their competence to improve their clients' well-being provide platforms for broadening the network of relationships required to reach higher levels of the Value Curve.

However, collaboration has its own traps. Similar to the regulative level, an overemphasis on process can undo proficiency. For example, spending considerable time and effort negotiating collaborations across programs and organizations can consume resources better directed toward clients. Collaboration can also become its own end rather than a means, leading to excessive focus on collaboration-driven sharing (e.g., paperwork) and miss the boat on solving real barriers to client care.

An additional concern is that the research on collaboration as a way to improve client outcomes is mixed. Moreover, collaboration can be seen by communities as a panacea to address a lack of resources. Basically, let's have this poor program work with that poor program, and we won't need to increase funding for this service. This happens frequently in communities, and is a harmful side of collaboration.

In Basso's fieldwork he has, at times, discovered that agency leaders view themselves as operating at the Integrative level, but then cannot demonstrate related methods for family-centered engagement, comprehensive risk assessment, root-cause analysis tools and metrics, or related caseworker skill-building, suggesting the move to a collaborative mode was targeted to streamlining business processes only. Proficiency through the Value Curve's Collaborative stage still requires sufficient resources to get the desired value and set the stage for further progress.

The Integrative Level and Proficiency

The distinguishing characteristic of this level is pulling clients into the problem-solving process. In organizations that achieve this level, proficiency is likely to be high. Integrating clients into the process means letting go of power and transferring it to the clients. Teams and programs with the confidence, skill, and support necessary to do this will have high proficiency levels.

The integrative level also requires rethinking casework practice and the use of technology and data. The historical failure rate for such endeavors in child welfare is alarmingly high. Why? Because these types of changes are almost always applied from the top down, assuming that it will be beneficial for front-line case managers and their clients. Little thought is given to the perceived impact on the front line.

The OSC Measure and ARC (availability, responsiveness, and continuity) change strategy are built on the socio-technical model of change. This model argues that technological change is as much a social process as a technological one. In sum, inattention to social issues and concerns (organizational culture and climate) dooms technological change. This is a primary cause of the numerous technological failures in child welfare. Organizations at the integrative level will necessarily have positive cultures and climates, including proficiency. This foundation is essential for organizations to address the sweeping challenges required to achieve this level.

APHSA's Organizational Effectiveness (OE) practice model and toolkit focuses on guiding a process whereby the organization's own staff generates solutions by first defining a desired state, assessing current strengths and gaps, determining the root causes for gaps, and then setting in motion solutions that are well-supported in implementation and ongoing monitoring, forming a learning cycle. This approach--similar to an integrative casework approach--is designed to build proficiency while establishing a sound structure and process for improvement and goal attainment.

The Generative Level and Proficiency

This level moves to a broad, community-based conceptualization of service delivery and addressing risk factors at a population level, through co-creating new capacity in the community as a whole, and through joint advocacy efforts that affect general beliefs and norms that may enable or impede progress. To achieve this Value Curve stage, multiple organizations will need to come together. They will have to share a great deal. They will have to trust each other. They will have to share a common vision. Funders, particularly federal and state governments, will have to re-conceptualize what they want to fund.

Frankly, it is hard to envision this in most communities. At the same time, when it comes to the culture of community leaders, partners, and consumers of health and human services, this stage is most appealing as the desired state of things. Head issues off at the pass by working on them upstream. Pay me now instead of paying me later. Build a community that evens the playing field for people and helps them reach their full potential. It is fair to say that high proficiency will be a prerequisite across all participating organizations to reach the generative level. And, both the expectation of proficiency and proficiency itself will be prerequisite for funders and other stakeholders.

What is certain in human services is that the problems being addressed are numerous, highly complex, and difficult to solve. This article demonstrates that our respective models add value to the other, and we believe this can benefit the organizations we work with. From our perspective, combining these two lenses leads to a better focus and clearer solutions than either lens alone.

The Human Services Value Curve

Regulative Business Model: The focus is on serving constituents who are eligible for particular services while complying with categorical policy and program regulations.

Collaborative Business Model: The focus is on supporting constituents in receiving all services for which they're eligible by working across agency and programmatic borders.

Integrative Business Model: The focus is on addressing the root causes of client needs and problems by coordinating and Integrating services atan optimum level.

Generative Business Model: The focus Is on generating healthy communities by co-creating solutions for multi-dimensional family and socioeconomic challenges and opportunities.

Reference Notes

(1.) See the Human Services Value Curve at http://aphsa.org/content/dam/ aphsa/Toolkit/Human%20Services%20 Value%20Cu.rve%209-5-14.pdf

(2.) Glisson, C., Hemmelgarn, A., Green, P., & Williams, N. (2013). "Randomized Trial of the Availability, Responsiveness and Continuity (ARC) Organizational Intervention for Improving Youth Outcomes in Community Mental Health Programs." Journal of the American Academy of Child and Adolescent Psychiatry, 52(5), 493-500.

(3.) Williams, N. J., & Glisson, C. (2013). "Reducing turnover is not enough: The need for proficient organizational cultures to support positive youth outcomes in child welfare." Children and Youth Services Review, 35:11,1871-1877.
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Author:Hemmelgarn, Anthony; Basso, Phil
Publication:Policy & Practice
Geographic Code:1USA
Date:Jun 1, 2016
Words:2128
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