Name of presentation

Redesigning the Organization: Tools for Growing Self-Directed TeamsNancy FoxVivageChris PernaEden Alternative

1Defining the Need16,000+ nursing homes and 5,800+ hospitals in the U.S.

Most of them structured alike - similar to military brigades with top-down hierarchies, robust chains of command, and a departmental approach to care.

Organizational designs are purposeful interventions that are designed to shape and influence human behavior in a particular direction. (Organizational Psychology: a Scientist-Practitioner Approach, Steve M. Jex)Although there is no regulation telling them to do so, almost all of the 16,000 + nursing homes and over 5800 hospitals in the U.S. have organized their work similar to military brigades. They have pyramidal hierarchies where all decision-making authority is held in the upper most echelons of the organizations, and those few people get to filter decision-making authority down as they see fit. The assumption in these types of organizational architectures is that the people who receive services from these organizations must bend to the will of the organization. They are compelled to fit into the organizations schedules and routines and adhere to their policies and procedures. These organizations have a robust chain of command where any divergence from the schedules or policies must make its way to the highest levels in the organization to get approval. Therefore, change is discouraged, and anyone who does not conform is seen as non-compliant. These organizations also utilize a departmental approach to the delivery of care. There is the nursing department, the dietary department, the housekeeping and laundry departments, the activity departments, and so on. Each of these departments has a department manager and all of the accountabilities in the organization go up this department silo to this department head. So, I may be work along side you and you are accountable to this person and I am accountable to someone else. And those people are not around. They are in their offices, trying to hire people who want to work in this kind of organization!What we do know is that organizational designs are purposeful interventions that actually shape and influence human behavior. 2The Oddest of EthosEthos = The disposition, character, or fundamental values peculiar to a group or team.

The institutional model ethos has been largely shaped by the very organizational structures we have used to shape and influence the behaviors of our employees.

We know that human behavior is a result of context more than character.

And this type of organizational structure has created the oddest of ethos. Here we have some of the most caring people in the world working in our care communities, and they have some of the strangest behaviors. We now know that the institutional model ethos has largely been shaped by the organizational structure we have all adopted because we know that human behavior is shaped more by context than character. We tend to think of character as this all encompassing thing that if you are person of good character then you will always behave in a certain way and if you are a person of low character you will always behave another way. But the truth that behavioral scientists will tell you is that most of the time our behavior is a result of context rather than character. So we have to look at he context we have created through our organizational design if we want to change behavior which is the very definition of culture change changing the way we do things.3The CULPRIT!What behaviors has this design shaped?

If you are ever frustrated with your staffs behavior or ever wonder why they behave in an institutional way here is the culprit. It is the very organizational design we have all used for years. It is why I can go into any nursing home in the world that has this same organizational design and find some of the same behaviors. What are some of the behaviors that have been shaped by this design?4The Institutional Context Top down hierarchy Youll have to ask the nurseDepartmental approach to care Its not my job Hands-on staff rotated Thats not my residentDivision into shifts Night shift left itPunitive culture Excuses Were short today. & I didnt do it.

This type of organizational design has created and institutional context that has shaped many behaviors we dont like or understand. Here are just a few. Because we have used a top-down hierarchy when a resident asks a CNA for something that is not part of the planned schedule or routine in many cases this is the answer they will get.Because we use a departmental approach to care, when a manager asks a housekeeper to help get a resident to the dining room, this is what she might hear.Because we rotate state when a nurse asks a CNA to answer a call light, she might here this.Because we have divided the labor into shifts, day shift always blames night shift, evening shift blames day shift and night shift blames the evening shift. Round and round it goes in a never-ending cycle of endemic unmitigated conflict.And because we have a punitive culture from Washington DC down to the charge nurse on the evening shift, people do not admit mistakes or take responsibility for errors, and we get excuses instead of solutions.Does this sound familiar?5ConstituenciesThe current organizational structure has created a series of constituencies that pit us against each other.Management vs. staffDepartment vs. departmentShift vs. shiftStaff vs. familiesFacility staff vs. corporate staffFacility staff vs. regulatorsThis organizational design has created a series of constituencies that pit us against each other See if any of these sound familiar

6Constituency vs. CommunityConstituency = a group of people who work to promote their own agenda and fulfill their own needs, often to the detriment of people outside their constituency

Community = a group of unrelated people living and working together in shared fellowship toward a common noble aimConstituencies are groups of people who work to promote their own agenda often to the detriment of people from other constituencies.

What we need is an organizational design that will help us come out of our constituencies and come into COMMUNITY>

Up until the last 150 years or so, human beings have been living, working and aging in community. It is this kind of interdependence and cooperation that has made our species successful. But the institutional model organizes work in such a way that it destroys relationships and community instead of creating and enhancing them.7Leadership Leaders must go beyond behaviors and address the contextual issues at the heart of departmental separation and politics.There is perhaps no greater cause of professional anxiety and exasperation- not to mention turnover than employees having to fight with people in their own organization. Patrick Lencioni

(Silos, Politics and Turf Wars, Patrick Lencioni)8Coming out of Constituencies and into CommunityIt begins with leadershipRecognize the very way we have organized our work has created these constituencies and behaviors we dont likeStop clinging to an outdated management theory Scientific Management and the division of labor Frederick Taylor, the father of Scientific Management

Coming out of our constituencies and coming into community begins with the formal leadership recognizing that the institutional culture we dont like has largely been created by the organizational designs we have adopted.In the early 1900s, Frederick Taylor devised a management system call Scientific Management. A key component of Scientific Management was the division of labor, where we take all the tasks that must be accomplished and divide them up into small chunks. This is where workers would do one small task over and over again, day in and day out. This was supposed to create efficiency in the manufacturing plants. 9Meet Taylorasaurus Rex

Looks menacing due to its size, but it takes a long time to decide to do anything. Spinal cord: a pyramidal hierarchy for passing information up and down. A lot gets lost in transit. Taylorism in its extreme form: employees leave their brains & hearts at the door. There are only a few responsible people here! Status: extinct (except in healthcare organizations)

If we look at Taylorism, we see a dinosaur that looks powerful and menacing because of its size, but it is very clumsy and inefficient. Taylorasaurus Rex has a pyramidal hierarchy that information has to pass up and down. A lot of information gets lost in transit. And in its extreme form, Taylorism tells staff to leave their hearts and their brains at the door. Because there are only a few people here who are responsible and capable of making decisions.Car manufacturers figured out 50 years ago that this kind of management doesnt work. This so-called efficiency model is anything but efficient and it is certainly not effective.In health care organizations, we are still clinging to this outdated theory in the hopes that one day it might possibly work.

10We know Taylorism does not work Separates workers from the results of their work Strips them of the opportunity to understand the whole process, participate in a variety of tasks, do the planning, evaluating & improving of work processes all normal aspects of working in community Prevents them from knowing and understanding the residents and families our customers. Strips the meaning out of their work & denies the organization the benefit of their creativity, passion and energy

Taylorism doesnt work. Heres why.11Daniel Pink Drive: The Surprising Truth About What Motivates UsThe course of human freedom has always moved in the direction of more freedom. And there is a reason for that because it is in our nature to push for it.

The secret to high performance and satisfaction - at work, at school, and at home is the deeply human need to direct our own lives.

We are born to be Players, not Pawns.

Daniel Pink, in his book, Drive: The Surprising Truth about What Motivates Us tells us that the need for autonomy and freedom the right to direct our own lives is in our very nature as human beings.

If we look at the course of human history, human beings have always fought and died for more freedom, not less freedom. Daniel Pink says that is because it is in our very nature to push for it. That we are born to be Players, not Pawns.Yet if we look inside our long-term care communities, we find managers who continue to fight against this basic human need, and wonder why they cant keep staff.12Engage & EmpowerOld Culture Thinking:I need to get buy-in of my staff.New Culture Thinking: I need my staff to take ownership.Ownership only comes from having a part in shaping the plan.You can not separate Authority and AccountabilityIf you want people to be accountable, you must give them the authority that comes with it.Empowerment = ARIA

If we are to make the leap to culture change and be successful in the future, formal leaders must change their thinking and understand this most basic human need.

Old-Culture thinking is that a group of managers gather together and come up with an idea. They then have to go out and sell it to their staff. The try to get BUY-IN.

In the new culture, managers understand that they need their staff to take OWNERSHIP. And ownership comes only from having a voice in shaping the plan.

13Is this what we have done? There is nothing more dangerous than to build a society with a large segment of people in that society who feel that they have no stake in it, who feel that they have nothing to lose. People who have a stake in their society protect that society, but when they dont have it, they unconsciously want to destroy it. Martin Luther King, Jr.By putting all of the decision-making authority into the hands of a few courageous people?

Martin Luther King, Jr. understood this human need. He understood that when we build a society ( or an organization or community) where most of the people who live and work in that society dont have a voice or a stake in its success, then we create a place where most of the people unconsciously want to destroy it.Is this what we have done by putting all the decision-making authority into the hands of a few people? Even those people are courageous and committed and tireless in their efforts. Have we given them an impossible task?It is a question that all of us who work so hard toward culture change and person-directed care need to consider. For, until we do, we will be forever trapped in an organizational design that stifles all of our efforts toward creating a truly human community.14A question we asked ourselves:Is the current organizational design serving our highest purpose of creating a caring community?

15We understoodThat we would never be able to achieve deep, sustainable person-directed/person-centered care in the current organizational design.But even more than that, we understood if we are going to be successful in the future, we must unleash the creative energy and passion of each person in our organization.16We began with a VisionOrganizational Redesign using these principles:Push resources and decision-making closer to the residents.Flatten the hierarchy Engage in empowermentSmaller is warmer and easier to changeConsistent assignment of staffGrow team instead of department and shift/ management and staffCross-training & blending of rolesCreate a sense of belonging & ownershipMake the job as big as their hearts. Dr. William Thomas17Self-Directed Work TeamsDefinition: A group of employees who have day-to-day responsibility for managing themselves and the work they do with a minimum of direct supervision. Members of the SDWT make servicerelated decisions and take action on problems.People, not programs or systems are the answer to increased competition in the work environment.Changes caused by customer demands, employee expectations, competition, government intervention, and public pressure are creating an environment where empowered work teams make more sense.Many corporations have used them since the early 1960s

18Growing CapacityWe are going to need GuidesManagers who facilitate the teams growth & development

The worst thing you can do to a team is leave it alone in the dark. I guarantee that if you come across someone who says that teams did not work in his company, its because management did not take an interest in them. James Watson, VP of Texas Instruments19Grant ProjectColorado Culture Change Accountability BoardTo develop and mentor Neighborhood Guides in 5 different Pion managed communitiesThese NGs would then use the same curriculum to develop at least one Neighborhood Team in each of their communities.The grant project was for a one year period from July 2010 to July 2011.Our project continues20Project definitionsNeighborhood a small section of a long-term care community where people live and work together.Neighborhood Guide a person, usually in a management position (but there are exceptions) within the long-term care community, who has education and skills in developing and mentoring high-functioning self-directed work teams. 21Project definitionsSelf-Directed Neighborhood Team A multi-functional, cross-discipline, cross departmental group of consistently assigned staff working across a 24-hour/day-7-day/week time period, both management and non-management, who work together to meet the individual needs and desires of the residents in their neighborhood. Empowerment The moving of both authority and accountability along with resources and information out of the traditional departmental structure and into the neighborhood team. 22Neighborhood GuidesStarted with 21 people from 5 different communities18 managers, 1 weekend nurse, & 2 CNAsCommitted to:4 training sessions over the course of the projectTo use the curriculum as developed to grow at least one Neighborhood Team Developed their own Mission, Vision and Code of EthicsWent to work growing themselves23Growing GuidesFrom Sheepherders to ShepherdsFocused on Self-Awareness and Group Facilitation and Coaching SkillsGuides have to learn how to stop giving answers and start asking questions

24Guide Core BeliefsTheory X (autocratic)Theory Y (democratic)People need to be controlledPeople have self controlPeople need to be motivatedPeople motivate themselvesPeople are not very smartPeople are smartPeople need encouragement to do good workPeople want to do a good jobThe distinctions between Theory X and Theory Y refers not to management styles or behavior, but to assumptions that we have about people.Theory X assumptions handicap a leaders ability in creating an empowered workforce.Theory Y assumptions enables a leaders ability to support SDWTs. 25Guides must play many rolesWe identified 9 different roles into which a Neighborhood Guide must grow and become.As the Teams mature in their own growth, these roles may shift in importance and frequency, but they are all necessary and vital to a teams success.SDWT will always need Guides.Even the highest functioning teams will tend to take short-cuts.

26Guide Roles27Our ChallengeTaking an organic process and making it as linear as possible.We created a road map for the GuidesThe Road Map is divided into 30 one-hour Modules. The art of guiding a SDWT is found in the ability to respond to the needs of the moment.Other than the final 5 Modules, the Guides can reach down and pull up a Module if they need it to address a current issue.28The Road MapModules 1-3 Setting the StageModules 4-6 Creating a Team IdentityModules 7-9 Building Team SkillsModules 10-13 Acting Like a TeamModules 14-16 Performance ImprovementModules 17-19 - Becoming Customer-FocusedModules 20-22 Growing as LeadersModules 23-25 Growing as a TeamModules 26-29 Team Self-Management29Giving them ToolsThe Guides LogA scripted curriculum guide was developed for each of the 30 one-hour Modules.Each Module has a Follow-up from the previous meeting, a Soil Warmer, a Main Topic, a Learning Circle Topic and a Teamwork Growth AssignmentThe Log also includes all the handouts needed for each individual Module.We also included a section on Facilitation Tools and Team Building exercises in the Log

30The Guide KitEach community was given a suitcase with the supplies necessary to facilitate the ModulesA DVD that includes everything in the Guides Log along with any videos used in the curriculumAnd a Video Camera to record each of their Neighborhood Team SessionsEach Guide is also charged with journaling their own journey31Continued SupportQuarterly, one of the project leaders visited each home to observe a team meeting and provide feedback to the GuidesThe project leaders also watch a video of a team meeting and offer feedback to the guidesQuarterly 2-day sessions where the Guides report their successes and challenges and learn from each other, and also receive more Modules.32Lessons LearnedSize MattersDont go it alone train many GuidesConsistency w/flexibilityNot something extra but how we work nowAnyone can be a Guide but have a person of formal authority with youDont be afraid to start over or repeat a module

33Lessons LearnedAdministrator and DON involvementLet the teams decide on meeting times and hold each other accountable for attendanceCome preparedMeet as a team of Guides oftenGuiding a team is not just being at Team Meetings

34Project EvaluationWell-Being of Residents & Staff Baseline and at month 12Conditions of Work Effectiveness Questionnaire-II (CWEQ-II) Baseline and at month 12 Guide self-assessment based on the 9 Guide RolesTraining Evaluations after each session with project leaders

35Results to dateElders Well-Being

36Results to DateStaff Well-Being

37EmpowermentCWEQ-IIStructural empowerment scores prior to initiation of the curriculum ranged from 18.4 to 20.8. At the conclusion of the project scores ranged from19.7 to 22. Scores that fall between 14 and 22 are considered to be moderate levels of structural empowerment.38Neighborhood GuideTraining Curriculum is coming your wayLicensed to the Eden Alternative for national distribution through their team of educators.

www.edenalt.org

39DomainPrePost

Identity16.416.4

Growth14.815.7

Autonomy19.120.3

Security18.920.3

Connectedness18.619.8

Meaning15.515.75

Joy11.512.2

Overall Score114.8120.45

DomainPrePost

Identity13.1313.48

Growth16.617.4

Autonomy17.918.05

Security23.9524.13

Connectedness20.9321.51

Meaning23.3723.57

Joy19.6919.55

Overall Score135.57137.69