Social Work Leadership in Healthcare

Director's Perspectives

Gary Rosenberg, Andrew Weissman

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781135838515
• Edition: 1
• Topic: Betriebswirtschaft
• Subtopic: Business allgemein

In this insightful book, a broad group of social work managers discusses what makes an effective social work administrator. The contributing authors describe their work and work environment, detailing what qualities and traits are needed--within themselves, their co-workers, and their organizations--to be effective and successful now and in the future. Social Work Leadership in Healthcare provides models readers can follow to help improve the social services functions in their own healthcare organizations. The contributing authors discuss issues applicable to the numerous and evolving healthcare issues in urban, center-city, suburban, and rural communities. They provide a stimulating and exciting group of ideas useful to social workers struggling with the same issues in their day-to-day practice. The book acts as a challenge for future social work administrators in healthcare organizations to carry on in the bold, innovative, and compassionate tradition they represent. Today, social work services are faced with a transformation of the healthcare milieu. In the move toward managed and capitated care, social work and other departments are being decentralized, and social work directors are assuming programmatic operational positions in the healthcare arena. Social Work Leadership in Healthcare helps current and future social work leaders in healthcare maintain and expand traditional values and practice commitments in this changing world.

The Effective Health Care
Social Work Director

Margaret Dimond, ACSW
Madelyne Markowitz, ACSW

Margaret Dimond is Assistant Administrator, Emergency Medicine, Henry Ford Hospital, 2799 West Grand Boulevard, Detroit, MI 48202. Madelyne Mar-kowitz is affiliated with the Social Work Department as a Team Leader at Henry Ford Hospital.

INTRODUCTION

Acute care hospitals have undergone dramatic changes in service delivery and reimbursement in the last decade. The alteration in health care organizations is connected to dwindling profits. The financial crisis hospitals have endured has secondarily changed the power and growth of medical social work departments. The goals and services of social work in a hospital setting have been forced to demonstrate economic worth. Timely discharges within DRG guidelines, increasing worker productivity, attending to cost-benefit ratios of service provision, and generating revenues are now common expectations for a social work director (Patti & Ezell, 1988).

There is a direct correlation of decreased governmental and philanthropic funding and new challenges for social work administrators. Marketing social work expertise and positive impact on patient satisfaction is essential for departmental survival (Genkins, 1985). However, though success or failure of a department’s goals is linked to its leader, there is not a plethora of literature to denote which personality types, or managerial styles will be most effective for buoying the survival of medical social work functions. Change is a necessity. If social work leaders wish to transform and mold service delivery, they need to study, examine and adjust all aspects of their operations (Dublin, 1989). Those operations must be in harmony with the strategic plans and goals of the organization.

HFH PRESENT OPERATIONS: A GENERAL OVERVIEW

Henry Ford Hospital is located in Detroit, Michigan. It is a 900 bed urban teaching institution, specializing in tertiary care. The hospital is part of a multi-health corporation, which includes two community hospitals, a psychiatric facility, a substance abuse facility, and two nursing homes. The Henry Ford Health System also has a business arm that operates a home care agency, a durable medical equipment company, and an HMO.

The hospital is managed in a business-like atmosphere at all levels. Managers are evaluated not only on professional competence, but on how well they met their previous year’s budget. This broad orientation to the milieu of the hospital is essential in order to understand the priorities of the social work director, and the operational aspects of the department; “If social work services are to remain an integral aspect of health care delivery, social work administrators will need to develop expertise and skill in operating within the political arena of multihealth systems” (Kenney, 1990).

Currently, nurses and social workers are teamed to perform social work and discharge planning activities. The staff of the department has been dual discipline since 1986. The department operates on a combination of unit- and service-based assignments. The hospital, out-patient clinics, and suburban medical centers have social work coverage. However, the main emphasis within the hospital is discharge planning. The Social Work Department reports through an Assistant Administrator, who also has responsibility for Pastoral Care, EAP, Case Management for Frail Elderly Program, and the Emergency Medicine Department. The administrative reporting structure changed in 1991, when the Director of Social Work was promoted to Assistant Administrator. Prior to that time, the department reported to an Operations Vice President.

The current arrangement of reporting relationships is working well, as there is a familiarity of operations, personnel, and political dilemmas. The mentoring role between the Assistant Administrator and the new Director has proved a valuable orientation piece. The Director has some historical sense of process and problem development. She has also had the advantage of being versed first hand on some short-term priorities versus guessing at where to place her energies in the first six months of her tenure. Though the Administrator and Director have different interpersonal styles, there is agreement on operations priorities. “With a clear understanding of both your boss and yourself, you can usually establish a way of working together that fits both of you, that is characterized by unambiguous mutual expectations, and that helps both of you be more productive and effective … above all, a good working relationship with a boss accommodates differences in work style” (Gabarro, Kotler, 1987).

During the last five years, the Social Work Department has faced developmental and maintenance opportunities, as well as perceived and real threats. The department is currently comprised of over forty staff members. Despite fiscal reductions and hiring freezes, the staff has doubled in size since 1988. The staff number alone is only one indicator of other innovations, achievements, and visions. One could safely say that the department has been re-cieated to meet future expectations rather than only reacting to current demands. The transition from a department fraught with low morale and productivity to employee empowered decision making occurred by careful planning. Compromise, communication, and competent leadership were incremental ingredients to the re-tooled approach. However, it is difficult to claim a good outcome without first examining process changes (Deming, 1982). To exemplify process and operational change, key quality standards must be a priority. In explaining the case study of Henry Ford Hospital’s Social Work transformation, the integral theme is quality improvement, increased employee satisfaction, and productivity (Walton, 1986).

The health care manager must make certain that all of her or his assigned human resources are providing the health care organization with premium productivity and high level performance in a long-term mutually beneficial manner. This mutual benefit should extend to every level of the organization. That is to say, each employee should feel motivated by his or her manager as well as satisfied with the opportunities for skills development on the job; the manager should benefit from the synergistic effect of an entire group of inspired professionals working cohesively; and the organization should reap the benefits of all professional contributions. (Lombardi, 1992)

The aforementioned quote is reminiscent of theory taught in health care administration graduate courses. In reality, the statements incorporate the vision and accomplishments gleaned in the Department of Social Work at Henry Ford Hospital in the late 1980s to present day operations. However, change is decidedly difficult and tracing the historical events leading to change will be helpful for a more complete understanding of the Henry Ford Hospital experience.

BACKGROUND OF CHANGE

Both authors have been members of the Social Work Department for a number of years. The first author began as a line staff on the Neuro—Surgery Service, was promoted to supervisor in 1986, promoted to Director of Social Work in 1988, and now holds the position of Assistant Administrator, with responsibility for the Social Work area. The second author has held both in- and out-patient clinical positions, moved into an AIDS research-oriented position in 1988, and was promoted to clinical team leader in 1991. She has responsibility for supervising five specialty staff, and coordinating the student internship program, which averages 15 graduate students per year. The authors are confident that they are gifted with both survival skills and the flexibility to withstand political fire-fights. It is the authors’ belief that the transformation of the department must be traced to the late eighties, when staff were challenged with unprecedented tasks which required flexibility and trust.

A change in management at the director’s level in 1988 spurred staff to a natural synergy for change. The previous director had begun to bring the department past the post-1983 DRG shock waves that began to emphasize accountability with discharge planning. In order to position the department for the rapid policy updates associated with organizational shifts, some operational decisions in social work were made without wide spread staff input. The changes were clearly made to advance the discharge planning function of the department (e.g., initiating referral boxes on each nursing unit). However, staff were ingrained in established habits and behaviors, thus felt somewhat threatened by practical work flow modifications. “What employees resist is usually not technical change, but social change-the change in their human relationships that generally accompanies technical change” (Lawrence, 1987).

Hence, employees perceived themselves as victims during an essential health care transformation process in the mid-1980s. Because conflict between employee views and management actions was a sporadic but recurrent theme, employee morale and the sense of teamwork was impacted.

Conflict in the health care workplace can be a most damaging force when employees find a source of conflict and, in their collective perception, the manager does not resolve it quickly, resolutely, and clearly, the conflict can fester and hamper productivity and quality of care. (Lombardi, 1992)

Thus, in 1988 when management transition took place in the Social Work Department, employees were in need of an approach that encouraged teamwork, collaboration, and empowerment. The search was conducted for a new director, and the internal candidate was appointed. At the time of the promotion, it was obvious what not to do, and less clear how the department should be rejuvenated.

The first task of the new leadership was to establish credibility and vision with staff. “The function of supervision and the function of leadership are synonymous: empowering or influencing others to accomplish some organizational aim or goal” (Dublin, 1989). Until trust in leadership is established, staff will continue in a mode of distrust and will not engage in risk taking behavior to stray from established norms.

Staff focus groups were formed to elicit staff input on major issues, and problem solving approaches to resolve those issues. Staff were initially leery, and commented that their views wouldn’t be taken seriously. However, utilizing quality methods to establish criteria for the focus group outcomes, and provision of education on flowcharting process change, proved useful to staff in terms of the seriousness of the project (Deming, 1982). Group priorities were presented in staff meetings following completion of the projects. The ideas were directly related to department operations (e.g., paperwork, caseload mix, staff cohesiveness). The ideas were transformed into departmental goals, and ultimately achieved within one year. The focus group achievements were the first step in the departmental transformation. “Managerial behaviors that have received empirical support for their contribution to worker performance include: the setting of objectives, feedback or knowledge of results, and worker participation in decision making” (Granvold, 1978).

The trend of employee participation was well received by staff, and ensuing operational decisions were patterned by a shared governance approach. Other departmental reporting relationships were conducted in a similar manner (e.g., EAP Program).

CORRELATION OF MANAGEMENT STYLE
AND DEPARTMENTAL STRUCTURE

“The essential qualities of leadership and the acts that define a leader: the ability to hear what is left unspoken, humility, commitment, the value of looking at reality from many vantage points, the ability to create an organization that draws out the unique strengths of every member” (Kim, Mauborgne, 1992). The quote is a quintessential epitaph that every successful manager would like engraved on a retirement plaque. However, reality dictates that many people manage, few people lead.

Management philosophy and practice directly patterns day to day operations for a department. One only has to look at history to derive that an autocrat utilizes fear, a democrat operates on group buy-in. Participatory management, falling somewhere in the middle, solicits group input, but also takes the brunt of some needed executive decision-making consequences.

At Henry Ford Hospital, it seemed that the only management approach for the staff would be a tough yet encouraging one. Staff needed to begin setting goals for the future. The prerequisite to any significant departmental change was management of interpersonal conflict in the department, and promotion of positive morale. ‘The health care manager in a progressive organization must do more than employ a set of motivators and shared values to lead staff effectively toward desired goals. The manager must also manage the dynamics of conflict, change, and cultural differences to maximize staff performance” (Lombardi, 1992).

Nevermind who the department’s internal and external customers were. Staff did not care about customers, or productivity, or any standard of care; their reactions were in the mode of self-protection, defensive and reactive interactions. Thus, the first task of the new leader was to: open communication, change the “low hanging fruit” problems, and to re-establish standards of care.

The philosophy employed was one of understanding the pain and frustration the staff felt, and providing action plans with measurable outcomes in short time frames to address the frustration. “Management must feel pain and dissatisfaction with past performance, and must have the courage to change” (Deming, 1982). Group participation led to venting, healing, and eventually planning for the department’s destiny.

In a methodical manner, the department structure was transformed to incorporate a shared governance concept. The essence of shared governance is shared decision making and employee empowerment. Several standing committees were created to address central operational procedures and problems. Examples of some committees are: documentation, community liaison, early discharge initiatives, and quality improvement. The committees were a resounding success, and served to promote change that was employee driven. “As they work together to improve quality, workers and management build mutual respect and trust” (Scholtes, 1988).

The present structure is affiliated with the now popular quality theories. Change and process improvement begin with those closest and most knowledgeable to the process. Essentially, it is a paradigm shift from “top down” decision making to “bottom up” collaboration. The director no longer dictates protocol; rather, he or she coaches the staff to create and maintain protocol; if this task can be achieved, then increased employee quality of work, productivity and efficiency will be accomplished (Walton, 1986).

Within two years of establishing a committee structure, and creating teams in the department, several measurable outcomes were traced. Using the departmental information system, and quality assurance monitors, data was compiled on: increased productivity, decreased discharge delays, increased patient/physician satisfaction with social work services, and increased staff satisfaction with their jobs.

To say that the transformation was not labor intensive would be false. However, the work in the short term facilitated payoff in the long term. “Where once there may have been barriers, rivalries, and distrust, the quality company fosters teamwork and partnerships with the workforce and their representatives” (Scholtes, 1988). To establish solid goals and lead staff to achieve those goals is the vision to see a future, and the political and emotional strength to create the roadmap of change complete with data to substantiate the positive outcomes. Once change can be achieved, the opportunities are endless. Staff education, departmental collaboration, research, and innovative programming were the benefits realized by the Henry Ford Social Work staff, after some painful growth.

ORIENTATION, SUPERVISION
AND CONTINUING EDUCATION

Initially, the Social Work and Discharge Planning Department orientation program was sketchy and haphazard. It often consisted of the newly hired social worker beginning to intervene with patients within the first few days of employment. Departmental orientation for new social workers and discharge planners evolved into a uniform program that takes approximately two months to complete. The social work director, in collaboration with new and experienced line staff, developed this program.

The general competence of new social work entrants to health care settings may be viewed with some suspicion; that is, the degree to which they have been educated and prepared in schools of social work to assure a professional role in a specialized area m...