From top-down to team-based: creating an organization that involves all staff in improving the numbers.

Something needs to change, but what?

Two-and-a-half years ago, leaders at Cummins Behavioral Health Systems, Inc., an eight-county mental healthcare organization in Central Indiana, considered this question as they looked for ways to bolster lackluster performance. With a traditional organizational structure, Cummins had all the problems associated with a pecking order that included up to six layers of management. Even though supervisors received leadership training and information about priority issues, essential knowledge was not always passed along to frontline staff. Morale suffered when employees didn't understand the reasons behind organizational decisions, and performance targets were not met as consistently as desired.

After reviewing various options, Cummins' leaders decided to shift gradually to a team-based organization. High-performance team training was provided; pilot projects were implemented; and initiatives to transform the corporate culture were undertaken.

In terms of organizational structure, the traditional upside-down "tree" evolved into a circle within a larger circle. The outer circle includes administrative and support functions and personnel, and the inner circle includes the customers and the teams directly serving those customers. At each new staff orientation session I communicate our belief that "If you are not serving the customer directly, then Job #1 for you is to serve the people who do."

Cummins' leadership realized that staff needed new tools and processes if they were to succeed. Cummins' first step was to train staff on a three-stage operations-review methodology. Two nonmanagers (therapists, case managers, or support staff) were selected from each team to serve as the operations data manager and fiscal data manager. They received specialized training in data analysis, internal reporting, performance improvement, and strategy development. Staff also learned the three components of an operations (ops) review:

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* Pre-ops preparations. Data managers review performance reports on goal attainment, team benchmarks, clinical outcomes, financial performance, demographics, and other key information. Variance analyses are conducted, root causes examined, and improvement strategies formulated.

* Ops review meeting. The entire team participates in this monthly meeting. Data managers present key findings from the pre-ops analyses, point out successes, identify areas needing attention, and begin strategy discussions. Instead of minutes, a results-oriented action plan documents the team's decisions, actions to be taken, timelines, and those accountable.

* Post-ops activities. Between meetings, employees accomplish tasks described in the action plan.

Crystal Turchi, a therapist and data manager at Cummins' Terre Haute office, says:

What I like about ops reviews is that they're action-oriented.

They're "by and about" our team and the people we serve. If the action

plan has my name on it, you'd better believe that I'll get the

assignment done, because I know that the first agenda item will be the

previous meeting's action plan. The recorder ticks off the action

items and we don't give excuses--we say either "achieved" or "not

achieved"!

Benefits of a Team-Based Approach

After the first full year of implementation of the team-based approach, we have seen results in the following areas.

Shifting the locus of control. With team-based ops reviews, the locus of control shifts from explaining outcomes to external managers to having internal accountability and self-initiation of improvement actions. Team members ask themselves questions such as, "Our productivity was down 7% last month, especially in addiction services. How can we improve?" Performance is addressed on a peer-to-peer basis--with candor and ease that didn't exist when the same message came from outside managers.

Improving fiscal performance. Over the past year, net income improved $1.06 million compared to the previous year--with 29 fewer employees. The average units of service per employee increased 10%. Because staff now better understand the impact of personnel costs on the bottom line, the ubiquitous "we need more staff" theme has shifted to "how can we manage with the people we have, as it costs too much to add new employees."

Improving benchmark performance. Improvement was shown on 80% of organizational benchmarks common to the previous year. For example, collections at the time of service increased 30%.

Increasing use of best practices. Since information is shared from the ops reviews, organizational knowledge has increased regarding best practices that might have gone unnoticed otherwise. Examples include a pilot project to offer a free orientation group prior to intake (reducing no-shows by 60%), case manager resource allocation methodology, a therapist-support staff team approach to intakes, and a new process for psychiatrists to make internal referrals.

Increasing commonality and transparency of data. By creating a structure and conduit for providing data common to all and consistently interpreting the data, staff have the means to evaluate their clinical, fiscal, and operational performances--and to compare personal performance data (as well as team data) with other staff (and teams) at Cummins. Those struggling to achieve a particular benchmark can call upon an individual or team who has been successful in that same area.

Identifying talent. An unanticipated side effect of the ops reviews has been the identification of previously hidden talent within the organization. Over the past year, at least six promotions were linked to observations of staff members' positive contributions during ops meetings.

Educating executives. Ops reviews have proved to be genuine eye-openers to the executive liaisons that work with staff teams. Each month executives learn valuable information about internal and external performance obstacles, communications, unnecessary work, glitches in systems and processes, and how organizational decisions impact staff and consumers.

Impacting organizational culture. Arguably the most significant outcome has been a positive shift in the corporate culture. Individual and team confidence and energy have increased as positive trend lines are sustained. Partnerships between executives and local staff have enhanced trust and promoted rapid action toward the implementation of new ideas and solutions.

Critical Success Factors

We have found the following to be important to creating a successful team-based organization.

Creating a continuous learning environment. This approach is relatively inexpensive, as it uses in-house resources exclusively, but human capital investment is essential. Learning opportunities come from didactic training, evaluating performance-improvement strategies, and the exchanges during the ops-review process.

Understanding the learning curve. For new implementations, staff need approximately six months to fully understand the myriad metrics used to evaluate outcomes. Data management is a work in progress: New staff come onboard; new metrics are created; and existing measures may be modified.

Establishing decision-making authority. Teams require a clear understanding of expectations and limits. Each team has a written decision-making matrix and receives ongoing coaching from executives during ops-review sessions.

Conclusion

Involving frontline staff as data managers and participants in a three-phase ops-review process has resulted in significantly improved fiscal and clinical outcomes organization-wide. Frontline staff's focus has shifted from defending results to initiating performance-improvement strategies on their own. I conclude with the words of Linda Kincaid, a staff member in our New Whiteland office, who sums up our approach nicely:

The whole operations-review process helps me understand how my job

impacts Cummins, and it makes me feel like I'm an important member of

our team, not just the pretty face up front! It gives me a chance to

give my input and know that it's as important for me to participate as

it is for the executive liaison or the CEO. By learning about how we

operate and what the facts and figures show, we can take pride in what

we have accomplished--and it makes us want to do even more.

Cummins Behavioral Health Systems, Inc., is a member of the Mental Health Corporations of America. For more information, e-mail aborders@cumminsbhs.org. Photography: Mike Stutler.

ABOUT THE AUTHOR

Ann Borders is President and CEO of Cummins Behavioral Health Systems, Inc, serving eight counties in Central Indiana. In 2007 she was recognized as a Behavioral Health Champion by Behavioral Healthcare.

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