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From top-down to team-based

April 1, 2008
by Ann Borders
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Creating an organization that involves all staff in improving the numbers by ann borders

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:

  • 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.