Managing Innovation to Overhaul a Patient-Care Environment

William McKenna, M.B.A.

Abstract

Innovation in public service organizations must be managed, just as it must be in any business. Howevel; in oldel; large public organ&ations, specific s#'ategies are needed. One such strategy is described in development and impact. The first step was utilizing external demands to create an atmosphere in which change was accepted as necessary. This was followed by a relaxation of top down procedural direction accompanied by persistent concentration on establishing new standards and objectives. The final major component was a management system intended to guide and shape development of innovations into an integrated program effectively addressing the new objectives and standards. *

Innovation is as essential to public service organizations as it is to for-profit businesses. Increasing expectations from the public for accountability in outcome and efficiency demand it. "Management will, therefore, have to learn to run at one and the same time an existing managerial organization and a new innovative organization."~ Drucker suggests the establish- ment of a separate organizational component devoted to development or innovation. In this manner, demands for increased efficiency of operations are not allowed to overshadow efforts to increase effectiveness in achieving program goals through innovation.

The same factors influence the organization's receptivity to change. 2 Resources will normally be devoted to continually existing programs and practices or to making them more efficient. However, where sufficient organizational discomfort exists, change and therefore innovation, is likely.

Katz and Kahn point out that the form change takes is in large part dependent upon the role management plays in creating an atmosphere conducive to change and attentive to the forms it takes) By tapping into non-managerial organizational components, managers are informed of the variety of staff and group reactions and changes. Stanton describes a practical approach for supervisors which provides a framework within which these reactions and performance changes can be shaped and directed. 4

Introduction

At Rochester Psychiatric Center (RPC), an approach which maintained the existing mana- gerial organization while effectively promoting innovation was demonstrated in the develop-

William D. McKcnna, M.B.A. is director for facilily adminislrativc services, Weslcrn New York Children's Psychiatric Ccnter, Wesl Senec~, New York.

* This paper wax plcsentcd at the annual meeting of the Association of Mental Health Administrators in Hollywood, Florida on Scplenlbcr 28, 1987.

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ment and initiation of plans to upgrade the patient care environment. Rather than establish a separate organizational component charged with innovation, existing informal and union struc- tures were tapped for new ideas and approaches. Management closely monitored the inevitable reactions to setting new objectives and standards while resisting the temptation to require strict adherence to formal work procedures. In short, effectiveness in achieving new objectives was given priority over maximizing efficiency in the correction of specific deficiencies.

Raising Expectations Rochester Psychiatric Center is a comprehensive mental health program of the New York

State Office of Mental Health. Currently, the center has 900 inpatient beds. In a survey conducted by the Joint Commission on Accreditation of Hospitals in 1983, the center was found to be overcrowded and lacking provisions for patient privacy. The decor was described as dull and uninviting. In the spring of 1984, the New York State Commission on Quality of Care (CQC), a state watchdog agency, found similar conditions. Their visits, conducted by investigative teams, focused on inpatient living conditions at RPC and at other centers. Their findings at RPC and elsewhere identified practices and conditions which required immediate attention. The most significant result of their visits was the establishment of new environmental expectations for most of the centers surveyed in terms of acceptable patient living conditions.

RPC management quickly developed an initial plan of action to address the identified de- ficiencies. This plan was disseminated through regular management lines with directions for rapid implementation. Meetings were held to discuss the implications of the plan and begin the development of unit, service, and department subplans. Utilizing the existing management systems to address specific problems proved to be expedient and resulted in exposure of additional problem areas as higher expectations and new responsibilities were defined for individuals, units, and departments. However, this approach also generated frustration and resistance among staff who felt the impossible was being asked or that priorities were unclear.

Measuring Responses Regular meetings and heightened administrative focus on the most unacceptable conditions

led to two diverse response patterns: one was a call for solutions from above; the other was a number of uncoordinated efforts by line staff and managers to eliminate identified problems, as it became clear that the existing systems and patterns of staff interaction were not adequately addressing the deficiencies. The calls for solutions from above were met by the existing systems with traditional, standardized programs implemented for specific problems such as clothing management, roach control, and mechanical maintenance. The next phase of the program focused on joint efforts between managers and line staff from different parts of the facility.

The first project was development of plans to spend equipment and supply allocations with specific emphasis on environmental upgrading. This involved staff from treatment units des- ignated to coordinate environmental enhancement efforts, patient representation, and support managers in a humanization committee. The committee discussed ideas, problems, and suc- cesses while also advising on materials and equipment purchases. This utilization of an existing managerial process also served as a vehicle to help define the new expectations. During this time, staff and managers alike complained that new standards were being set and new job tasks assigned while the important work they had been successfully performing was being denigrated in the process; elevating the maintenance of the patient environment in the hierarchy of goals

118 Journal of Mental Health Administration 16:2 Fall 1989

and objectives was viewed by some as damaging. Some protested that the work they were being assigned was inappropriate for them; nurses individually and through their union objected to expectations and assignments which made them responsible for the environmental conditions on their wards. Similarly, housekeeping staff complained that they were held responsible for clean floors, but had no ability to control patient smoking habits which left cigarette butts and ashes all over the floors.

Encouraging Change

From this situation developed a growing dissatisfaction with the "new" status quo and an increased receptivity to change. This receptivity while not overwhelming, was the necessary beginning. As March and Simon suggest: "Individuals and organizations give preferred treat- ment to alternatives that represent continuation of present programs over those that represent change...the individual or organization does not search for or consider alternatives to the present course of action unless that present course is in some sense 'unsatisfactory'. ''2

To capitalize on this atmosphere, in which change was seen as inevitable and potentially positive, a large maintenance and construction program was undertaken to bring tangible change to every ward. It involved staff from as many parts of the organization as possible in designing, producing, and maintaining the environment. Special funds were sought and obtained to un- dertake a space improvement project for every dayroom. Furniture and drapery purchases were coordinated with painting projects and with the use of decorative items and approaches. Within broad guidelines, clinical managers and ward staff took the lead in designing specific projects and coordinating with various support departments. As the first wards were completed, staff were encouraged to visit them and the efforts were publicized at meetings and in hospital publications.

Guiding Innovation

As Katz and Kahn observe, "Two things occur when directives remain limited and unclear because people down the line have no way of getting a fuller explanation. People will give minimal compliance, so as to be apparently observing the letter of the law, or they will test out in actual behavior their own ideas of what can be done. If there is inadequate feedback up the line, this behavioral testing can produce real deviation in organization/tl practice. Such deviation can run from constructive actions in support of organizational objectives to actions crippling and destructive to the organization. ''3

RPC imposed more stringent monitoring requirements than those mandated by OMH Central Office, maximizing the number of people involved. Extensive checklists and duties statements were issued by top management for the staff throughout the organization. This approach meant more people received information on what needed to be done and how well it was being done. It also provided the opportunity to cut back on repetitive monitoring tasks as improvements were made, as well as to maintain an information system capable of identifying actual or potential problem areas and recognizing and rewarding those constructive, creative efforts made by staff at their own initiative.

By this time, the strides in improving the patient environment were substantial, and most major deficiencies had been addressed. Regular external reviews by CQC, OMH Central and regional office staff reflected this progress, but continued to identify areas in need of attention. Prescriptive instructions became less effective in addressing problems, while locally generated, innovative approaches were relied upon to adapt programs and systems to specific wards and issues.

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The educational effect of issuing and debating extensive checklists and job requirements was substantial, and led directly to a demand for more information about the practices, procedures, and performance expectations of other staff and departments. The result of these demands and management actions was an increase in interdepartmental communication and cooperation. Units and support departments began to meet regularly without top management involvement or direction to address areas of mutual concern. New approaches developed, experimentation was common, and variety was prevalent as different groups tackled similar problems without centralized directives. The initial contention that attention to environment somehow detracted form patient care slowly faded.

The identification of added rehabilitative opportunities for patients was a major factor in this attitude shift. As potential patient programs were identified, funds previously used to purchase services from others were reallocated. Sheltered work programs in reupholstery and house- keeping were expanded to the benefit of both the patients performing the work, and those enjoying its output. Treatment programs involving patient attention to personal hygiene, smok- ing, etc. received new impetus.

Institutionalizing the Gains

By all accounts, RPC was making substantial gains. To reinforce the efforts which led to those gains, a patient care envirortment slide/sound show was produced. Staff from units and departments, managers and first-line staff participated in its production. The primary purpose of the slide show was to describe to staff the rationale for attention to the environment and the standards to be maintained. The program, shown first to managers then to all staff, also gave witness to the success achieved in establishing new standards and innovative programs to meet and maintain them.

Special achievements on some wards were noted through the monitoring programs. Review of these achievements revealed that the greatest programs in improving environmental condi- tions was in areas characterized by management support, cooperative efforts between clinical and support staff, and integration of efforts to improve patient living conditions with patient rehabilitative programs.

The natural outgrowth of this observation was the establishment of the Homelike Environ- ment And Rehabilitation Together award program (HEART). The HEART award was given monthly to the ward or patient program area which had been judged to have made the most significant process in improving conditions or maintaining exemplary standards. Ward staff, patients, and the support staff associated with the ward were honored at a ceremony, presented with a plaque, and allocated funds for a social event on each shift. Each staff member and most patients also received a pin in recognition of the achievements. The HEART program not only recognized positive achievements, but also promoted the values central to the overall facility goals regarding patient living conditions.

Summary

At RPC unacceptable patient care and environmental conditions as well as a lack of coor- dinated staff and patient commitment to address those conditions were identified as problems to be addressed. For a time, it was necessary to develop and impose new programs and systems centrally, assuring the standardization which facilitated close monitoring. The feedback sup- ported top-management's evaluation that the status quo was unsatisfactory, especially since new systems demonstrated that better conditions were attainable.

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The success of the RPC environmental beautification program was substantial. It was a product of an organizational environment which encouraged innovation and supported a com- mitment to monitoring and feedback as a mechanism to produce a desired change. As Stanton had indicated, a system of effective supervision that "sets high standards for work performance, accompanied by management's insistence that these standards be met" is usually successful? In this way constructive innovation at RPC was supported, rewarded and publicized while misdirected efforts were redirected through the existing management systems before they went too far afield.

Others are encouraged to use organizational crises as a means to develop improved man- agement systems and innovations which lead to greater effectiveness and productivity and, most importantly, to better patient care.

References

1. Drucker PF: Management Tasks, Responsibilities, Practice. New York: Harper & Row, 1974.

2. March JG, Simon HA: Organizations. New York: John Wiley & Sons, Inc., 1958. 3. Katz D, Kahn RL: The Social Psychology of Organizations. New York: John Wiley &

Sons, Inc., 1966. 4. Stanton ES: Reality Centered People Management: Key to Improved Productivity. New

York: Amacomm, 1982.

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