Leadership and Administration
Leadership for the 21st Century is doing more with shrinking resources and managed care.
Not since the industrial revolution of the late nineteenth century has society seen such dramatic change in both the workplace and within the workforce (Benge & Hickey, 1984). Heavy industry of the post-Civil War era dominated the United States economy for nearly a hundred years before the micro chip jettisoned the nation from industry- based, to information-based and service -oriented. The workplace has shifted largely, in the last few decades, from the factory to the service centered; and, the industrial workforce has changed to service personnel. The workplace of concern is community mental health services, and the workforce encompasses the employees responsible for delivering needed mental health services.
Of essence in mental health, as well as with any other service, is the quality of the service. Satisfactory interactions, on a one-to-one basis between the provider and receiver of services, requires high quality service from the giver to the receiver. The fact that high quality is so often lacking forms the backdrop of this article. It has been suggested that quality of service is greatly affected by employee morale (Senge, 1991).
In 1981, the Reagan Administration repealed comprehensive mental health legislation enacted by the Carter Administration (Williams, 1993). This marked the beginning of financial cutbacks and degovernmentalization, specifically, the privatization of government-operated mental health services throughout the United States (Dorwart & Epstein, 1993). Budget reductions in health and social services have accelerated the need to cut programs and to increase the purchase of mental health services from the private sector through managed care arrangements (Motenko et al., 1995). Such cutbacks, privatization, and managed care in California Mental Health Services have raised concerns about employee morale, because morale is considered critical to quality of care.
The most successful organizations in the future must be able to learn to adapt to environmental change. But, according to Senge (1990), increasing this capability is only the first step toward creating a learning organization. “Organizations must also focus on generative learning which is about coping” (p. 8). How to address the issue of morale is one of the most challenging questions with regard to coping. “The total quality management (TQM) movement has been the first wave in building learning organizations” (p. 8). Learning organizations are structured to address the needs of the employee. Benge and Hickey (1984) wrote, “The first step for increasing quality is to find out what is on the workers’ minds. If you can uncover workers’ opinions of their supervisors, working conditions, and their job, then you can take action that will improve quality” (p. 6).
The purpose of total quality management (TQM), herein used synonymously with continuous quality improvement (CQI), a term preferred by health-care practitioners in higher education (Marchese, 1993), is to improve the quality of organizational systems, processes, and services through customer satisfaction (Bemowski, 1992). Continuous quality improvement (CQI) is unique in that there are internal and external customers. The employee, the provider of services, is an internal customer. The patient, cargivers and community partners are the external customers.
Continuous quality improvement (CQI) may be operationally-defined by the outcomes an organization strives for and the major activities its people seek to create or enhance (Glazer, 1994, p. 15). In other words, outcomes in CQI can be whatever results that matter most to customers and the organization (Benveniste, 1994, Vermillion & Pffeiffer, 1993). One of the salient outcomes is employee satisfaction. McLeod (1991) and Glazer (1994) have written that the implementation of CQI improved morale in educational settings. In their article on TQM in mental health programs, Rago and Reid (1991) discuss specific strategies to empower workers. However, employee morale in community mental health was not addressed even though there are definitely problems with morale (Motenko et al., 1995).
One way to increase morale is to train and empower workers to recognize problems and to propose solutions. Manufacturers have made great strides in this area by implementing CQI, but service organizations are not moving fast enough (Oberle, 1990). The implementation of CQI can facilitate the assessment and the improvement of morale and other important customer outcomes (Senge, 1991). Moreover, since CQI encourages the worker to participate in the vision and the decisions of the organization, it can transform an organization into a learning entity which is able to adapt and to cope with the vicissitudes of a changing information and service-age environment (Morgan, 1986). My study in 1997, University of San Diego, specifically focuses on employee perceptions and concerns,and how specifically to implement CQI to assess, improve, and maintain morale in community mental health organizations. It is one of the few studies that conmtributes to a critical need for research on the implementation of CQI and on how, from the perspective of the worker, it addresses morale.
What the Literature Suggests
High morale among workers is viewed as crucial to quality of care in service organizations. The literature clearly documents the demoralizing effects of cutbacks, privatization, and managed care. Ironically, privatization has lately been viewed as addressing governmental bureaucracy problems (Osborne & Gabler, 1992). Yet, except under idea circumstances, private-sector organizations are seen to be no more responsive than publicly-operated organizations (Dorwart & Epstein, 1993).
The literature on organizational change theory suggests that the morale problem may lie in an out-dated view of organization itself. Consequently, learning organizations are needed, and can be created through the implementation of CQI.
Concerns about the Impact of Managed Care on Morale
By 1995, officials in many California Counties decided to contract virtually all county-operated mental health programs, and to convert its mental health system to managed care. A major concern about the decision for a managed care system is that quality of care may be adversely affected by job dissatisfaction associated with cutbacks, privatization, and managed care. According to Senge (1990), the issue of morale is critical to service organizations. “Quality [in service organizations] is determined in individual transactions between ‘servers’ and customers, occurring literally thousands of times each day in large organizations. . . . It depends on how happy the server is and on whether he or she experiences the job as satisfying (1990, p. 333).
Motenko and others (1995) examined the effects of managed care on the therapeutic milieu in a recent case study of client and workers’ impressions of privatization and cutbacks in the Massachusetts mental health system, they found that, “Services were cut so drastically, that the therapeutic milieu was lost” (p. 461). The association between managed care and dissatisfaction among physicians was specifically discussed by Williams & Torrens (1993). They found physicians were most disaffected by the fact that control over important treatment decisions was taken out of their hands by managed care. The study by Motenko and others (1995) also reported that employee morale was seriously impacted by managed care and that higher levels of burnout and job dissatisfaction were noted. “They were demoralized, but we did not expect the depth of demoralization we encountered. . . .Social workers are not just overworked by new agency policies; their work environments violate the basic tenets of professional ethics” (1995, p. 461).
The issue is widely discussed, but there is no stopping degovernmentalization, privatization, and managed care according to Dowart and Epstein (1993). Consequently, employee morale is one of management’s greatest challenges in creating and maintaining high quality in the twenty-first century service organization. Quality care in the service organization spans the continuum between how to cut costs and how to improve morale.
Organization Theory
Senge believes that increasing quality and lowering cost can go hand-in-hand in learning organizations. The use of metaphor can help us understand better what a learning organization is from a theoretical perspective, because the way we conceptualize and define reality is basically metaphorical (Lackoff & Johnson, 1980; Morgan, 1986).
Organizational theorist Garrett Morgan (1986), suggests that the metaphor of organization-as-machine characterizes today’s classic industrial era form of organization. Typically, its hierarchical, command-and-control-oriented management excludes employees from the organization’s decision and policy-making process (Senge, 1991).
Morgan observed that this mechanistic metaphor, epitomized by Fredrick Taylor’s scientific management, is so ingrained as to be second nature in our everyday way of thinking about organization. “The principle of separating the planning and design of work from its execution is often seen as the most pernicious and far reaching element of Taylor’s approach to management, for it effectively ‘splits’ the worker, advocating the separation of hand and brain” (Morgan, 1986, p. 32). The management system Taylor created tends to breed apathy, anger, and alienation among the workers at the bottom of the organizational hierarchy; thereby lowering productivity (Odiorne, 1991).
Part of the problem is that today’s service worker feel a sense of empowerment and entitlement to human rights, and they are not satisfied with just earning a pay check. They want to be prized, creative, fulfilled, and feel they are part of a community (Holden, 1990). The mechanistic manager does not agree with the current sense of entitlement. But, once managers accede to the workers’ need to get involved, it is posited, that increased morale and productivity follow (Harris, 1989).
The concept of a learning organization is best understood as a metaphor of organization-as-brain. Below, Morgan describes a particular learning organization.
- The whole ethos of plant operations is characterized by holographic integration.
- The work design was stimulated by the desire to create a holistic relationship between people and their work, so that employees would acquire a sense of identity with the firm and its products. . . . The results have been spectacularly successful, improving productivity, quality, innovation, and work life in almost every aspect. (1986, p. 104)
In the concluding chapter of this book on the brain metaphor, Senge summarized what theories of organizational learning and capacities for self-organizing suggest: “In particular, they suggest that innovative organizations must be designed as learning systems that place primary emphasis on being open to inquiry and self criticism” (p. 105).
The concept of learning organizations is not new. Osborne and Gabler (1992) recently argued for privatization of government programs in their book. Dorwart and Epstein (1993) found that historically the case for privatization has held that government is too rigid and inflexible and, therefore, lacks the learning capacity to meet the needs of the customer. The implication here is that private-sector organizations are learning organizations, inherently capable learning. Dorwart and Epstein (1993) conducted a national survey which refutes this belief.
Their survey examined the influence of government versus private-sector ownership on organizational responsiveness to the needs of a diverse mental health population. They found no evidence that private organizations are inherently more innovative or inherently more adaptable than are government agencies. They suggest that in noncompetitive circumstances, “government agencies will in fact be more innovative” (p. 89).
Senge (1991) suggests that one of the ways to create a learning organization is by implementing continuous quality improvement (CQI). Little agreement exists on the definition of CQI, and a wide variation exists in the content, scope, and formality of processes in existence today. Nevertheless, Crosby (1984), Deming (1984), Juran (1988), and Seymour (1993), all authorities on CQI, espouse certain common principles. One of the most important principles is the belief that the employee closest to the job has valuable experience and knowledge needed to develop the best solutions to job-related problems (Herman, 1989).