Organizational change for services integration in public human service organizations: experiences in seven counties.
This is a study of organizational change strategies employed in
seven county human service agencies to improve the coordination of
services through the structural integration of previously free standing
organizations or the development of voluntary interagency collaborative
service delivery systems. The central question involves the
identification of organizational change tactics which contributed to the
success of the organizational change initiatives. The literature on
organizational change is reviewed, with particular attention to a
framework developed by Fernandez and Rainey based on their extensive
review and synthesis of the research on successful change strategies in
the public and business sectors. Qualitative and quantitative data were
gathered from over 250 individuals and from agency documents. Findings
are compared with the success factors identified by Fernandez and
Rainey, and refinements to their propositions are suggested. More
precise methods for measuring successful and unsuccessful change
initiatives are suggested. Implications for practice and research are
Key Words: Organizational change, services integration, collaboration, human service organizations.
(Forecasts and trends)
Health care industry (Forecasts and trends)
Health care industry (International aspects)
Health care industry (Social aspects)
Public health administration (Research)
|Publication:||Name: Journal of Health and Human Services Administration Publisher: Southern Public Administration Education Foundation, Inc. Audience: Academic Format: Magazine/Journal Subject: Government; Health Copyright: COPYRIGHT 2012 Southern Public Administration Education Foundation, Inc. ISSN: 1079-3739|
|Issue:||Date: Spring, 2012 Source Volume: 34 Source Issue: 4|
|Topic:||Event Code: 010 Forecasts, trends, outlooks; 290 Public affairs; 310 Science & research Computer Subject: Health care industry; Market trend/market analysis|
|Product:||SIC Code: 8000 HEALTH SERVICES|
|Geographic:||Geographic Scope: United States Geographic Code: 1USA United States|
In recent years, human service organizations (HSOs) and other government organizations have come under increasing pressure from policy makers, funders, community members, and other stakeholders to improve the quality and cost effectiveness of services and the management systems which support them. One approach to these concerns has been extensive and persistent work to achieve more coherent and effective human service systems through services integration and coordination (Austin 1997; Jones, Crook, and Webb 2008). Goals have included finding ways to reduce fragmentation and service gaps to improve access and continuity of care, reducing duplication and redundancy in order to lower costs (time, energy, and inconvenience associated with accessing and receiving services) for clients, utilizing scarce resources more effectively, and achieving greater accountability. One common solution has been to structurally integrate programs serving common clients under one administrative umbrella. A more recent idea has been to develop collaborative systems or processes which autonomous programs can use to facilitate better service delivery.
To implement changes such as those related to services integration, the technologies of organizational change, many originating in the business sector, have been used and studied with increasing frequency in the health and human services sectors. In healthcare, for example, Rubino and French (2004) reported the challenges for large governmental organizations trying to create large-scale change with a case example of the Los Angeles County Department of Health Services. Regarding an attempt at restructuring through reengineering (Hammer and Champy, 1993), Rubino and French noted that a major barrier to reengineering is "getting the various departments inside as well as outside to work together" (2004, p. 62). They also listed several factors which needed to be managed to enhance prospects for success. These will be discussed below, related to findings in the study reported here. Additional themes in the research on services integration and collaboration have been summarized by Patti, Packard, Daly, Tucker-Tatlow, & Prosek (2003).
This growing literature on organizational change was recently reviewed and summarized by Fernandez and Rainey (2006), but many gaps in knowledge still exist.
In the study reported here, a team of researchers studied seven county human service organizations which had all engaged in significant organizational change in order to improve the coordination and efficiency of agency services through either structural integration of previously free-standing agencies or by developing voluntary interagency collaborative service delivery systems.
The paper has two main purposes. The first is to compare our findings with the propositions contained in the Fernandez and Rainey framework, with a view to refining their schema. This paper is also intended to advance the development of research methods for studying organizational change. Much of the literature in this field, in both the business and government sectors, is based on individual case studies or the authors' practice wisdom based on consulting or managerial experience. Fernandez and Rainey (2006) have suggested the use of more systematic methods. This study advances knowledge in this field by using a comparative case study method and both qualitative and quantitative data.
After a review of the literature, the setting and research methods will be described. Findings will then be presented, followed by lessons learned and study limitations. The paper will end with a discussion of implications for practice and research.
PRINCIPLES AND MODELS OF ORGANIZATIONAL CHANGE
Within the huge literature on organizational change, the focus here is on planned change implemented with managers as change agents or change leaders, using rational adaptation approaches which include contingency, resource dependency, and strategic choice theories. All of these suggest that managers can use various strategies and tactics to adapt to changing environmental conditions (Demers 2007).
Since many health and human service organizations are in the government sector, some of the unique challenges facing change leaders in public sector organizations warrant mentioning here. Rainey (2003, 12-15, 59-62) outlined unique challenges facing public sector managers, ranging from intense scrutiny and criticism from elected officials to the complexities of cross-sector relationships. Behn (1997) identified challenges related to innovation in government, including complex accountabilities, inappropriate paradigms, tradeoffs between analysis and action, and complex structures.
The reinventing government movement, and notably the National Performance Review (NPR) (Gore 1993), launched recent efforts to change public sector organizations. Kamensky (1996) provided an early summary of this work; and Ingraham, Thompson, Sanders, and others (1998) detailed the experiences of "reinvention laboratories" to implement NPR directives.
Kelman (2005) described the major reform of the Federal Government procurement system when he was its administrator. His focus was on change at the front line level, and on perspectives of workers at that level. He suggested (p. 6) two "paths for successful organizational change": "activating the discontented", in which top leadership creates conditions in which lower-level staff can begin implementing change that they seek, and "change feeding on itself", with positive results leading to subsequent positive results.
In a similar vein, Rossotti (2005) provided an extensive description of his efforts to reform the IRS when he was the commissioner. Change activities included formation of a steering committee and a project team, recruitment of executives as change leaders, extensive consultation with a wide variety of stakeholders including union leaders, and meetings with staff in field offices.
Abramson, Lawrence and others (2001) reported the results of "case studies of the most successful transformation initiatives of the 1990's in the federal government" (p. 2), summarized with eight lessons learned: select the right person; clarify the mission; get the structure right; seize the moment; communicate, communicate, and communicate; involve key players, engage employees; and persevere.
Light (2005), after a thorough review of RAND research on organizational change, with a strong emphasis on government organizations, identified six "lessons on managing change: 1. Create a sense of urgency, 2. Remove the barriers to success, 3. Recruit the champions, 4. Build internal momentum, 5. Prove that change works, 6. Keep experimenting" (p. 230).
Brudney, et al. (2009) and Liou and Korosec (2009) studied the impacts of various reform strategies in the states.
The largest and most prominent HSOs are in the public sector, but there are also many not-for-profit, and even some for-profit, human service organizations. Public HSOs, of course, have much in common with other public sector organizations, including, for purposes here, the dynamics of internal organizational functioning including organizational change.
Austin (2004) and others described over twenty cases of changing public human service agencies, with many based on the new expectations of the Federal welfare reform legislation of 1996. Schmid (2010) used four case studies to illustrate the relevance of leadership styles in organizational change theory. Jaskyte (2010) summarized the literature on innovation as organizational change and suggested implications for human service organizations.
In HSOs, seminal writing on organizational change began over thirty years ago (Resnick and Patti, 1980; Brager and Holloway, 1978; Patti and Resnick, 1985), and has been addressed sporadically in the human services literature. In recent years, it has received increasing attention (e.g., Schmid, 2010; Packard, 2008; Perlmutter, 2000; Perlmutter and Gummer, 1994). Galaskiewicz and Bielefeld (1998) studied change in charities in Minneapolis-St. Paul, and Hagedorn (1995) profiled change activities in public social services in Milwaukee. Eadie (2006) has outlined a model for change and innovation in not-for-profit organizations. In a special issue of Administration in Social Work, Bargal and Schmid (1992) summarized other work in this area.
In recent years, two models for organizational change designed for use specifically in human service organizations (Proehl 2001; Lewis, Packard and Lewis 2007) have been articulated. These two HSO models suggest steps to be taken in the process, while acknowledging that tactics and principles are applied at different points based on the uniquenesses of a situation. These "phase" models (Armenakis and Bedian 1999) include steps which should be of use in the application of propositions such as those suggested by Fernendez and Rainey.
There are still notable limitations in this literature, however, with much of it based on only authors' experiences as consultants or on profiles of allegedly successful change leaders, with little or no empirical support, and limited or nonexistent conceptual models. On the other hand, the academic literature often focuses on only a limited number of possible variables or on individual case studies. A commonly agreed upon phase model of organizational change has yet to emerge; and further research will be needed to build upon the work of Fernandez and Rainey.
Fernandez and Rainey (2006) advanced this field of study with their comprehensive review of the literature, which identified eight factors associated with organizational change in both business and government settings. Their framework will be used to organize and analyze the study data presented here because it draws upon the widest survey of the existing empirical research literature yet available. Their review identified major theoretical perspectives on organizational change and a framework of eight factors which can determine successful organizational change. Their findings, stated as propositions summarizing the literature, are consistent with the models proposed by Proehl (2001) and Lewis, et. al. (2007). Findings from the study reported here will be organized and analyzed using the eight factors they identify.
This study was part of a larger research project to assess the organizational change processes and results achieved through structural and services integration initiatives undertaken in seven public human service agencies in California in recent years (Patti, et al., 2003). The research was sponsored by a consortium of eight county human services agency directors and two universities serving as a forum for county directors to explore and exchange ideas and information on issues facing public human services and to develop strategies for addressing these issues. The purpose of the larger study was to produce information relevant to these county directors as they addressed issues of service integration. The study also shared county experiences and identified strategies that appear to be effective in moving public and private agencies into productive collaborations.
The study's research questions which focused on organizational change, the subject here, were: 1. For the structurally integrated counties, what strategies were used in each of the counties to develop new organizational cultures and build commitment to the new umbrella organization? To what extent were these strategies successful? 2. For the collaborative counties, what conditions and processes facilitated and sustained and/or impeded inter-agency collaborations?
The analysis described here addresses these questions by examining the change management processes used by leaders and other stakeholders to move these agencies into either integrated or collaborative systems of service delivery.
Because of the complexity of the subject, a comparative case study method was employed to look at the seven counties. The methods of this study are described below. Major findings clustered around several major themes (Patti, et al., 2003): factors in the political and policy environment which served as drivers of change, top officials as prime movers of the process, the role of leadership in articulating the vision for change, strategies for mobilizing the executive team to lead the change, marketing change goals, involving stakeholders, maintaining a long term vision while engaging in incremental change, services co-location and regionalization as useful integration strategies, and developing teamwork across professional and program cultures.
Because the study reported here focused on assessing specific prescriptions for organizational change (Fernandez and Rainey, 2006, described below), the relevant data from the larger study will be presented here based on the Fernandez and Rainey framework. Details on the larger study are available in Patti, et al. (2003).
Another aspect of the larger study was an initial survey of all counties in the state to identify those counties which had adopted a structurally integrated human services agency model, defined as an agency that includes under its jurisdiction two or more previously free-standing county agencies. Directors of those which, based on their title or other descriptors, appeared to be structurally integrated were sent a questionnaire to confirm that they were structurally integrated. Additional data were gathered from human service agencies in those counties through a questionnaire and secondary data sources including web sites and agency directories.
This phase of the study found that 26 counties had untaken structural change initiatives. From this group, four county agencies were chosen, representing a range of demographic and regional characteristics. The selection process used purposive sampling including the preliminary survey just described and reputational sampling based on input from expert informants from human service organizations in the state. These county directors and members of their executive and program staffs meet regularly to address policy and program issues. The directors are members of a statewide association of county welfare directors; and through these various contacts over the years they have become familiar with the major changes and functioning in each others' counties. Counties chosen were known for having implemented extensive structural or collaborative approaches to services integration. All these agencies were considered by other county directors familiar with their functioning to have successfully implemented, to varying degrees, major changes which led to demonstrable improvements in agency and program functioning.
In addition to this group of 4 integrated agencies, 3 other agencies were studied: three free-standing departments that had developed extensive collaborative networks with other county organizations in their counties. For structurally integrated agencies, a purposeful sample of four agencies was selected to represent two large urban counties with over one million residents and two smaller counties, both of which had populations of less than 500,000 at the time of the study. The three non-structurally integrated counties selected were ones in which the agency director and other knowledgeable informants believed that a high degree of service integration and collaboration had occurred between his/her department and two more other county departments. The populations of these counties ranged from nearly three million to under 150,000.
The differences between the two organization design solutions used in these counties-structurally integrating programs into one agency versus leaving program in separate administrative structures while enhancing coordinating mechanisms-could be seen as a confounding variable in this analysis. However, in fact, the change dynamics and processes used showed much consistency across these groups. The key exception was the notable collaboration of executives across free-standing departments in the agencies which did not structurally integrate. This possible limitation and others will be discussed below.
Several types of data were obtained for the seven counties in the study: agency archival documents such as organizational charts, budget information, strategic plans, historical information, newsletters, etc.; and interviews, focus groups, and a survey involving selected agency staff, county officials, and consumer representatives. Data collection was not structured based on a specific theory or change model, but rather was designed to give wide latitude to respondents and researchers to refer to any goals, driving forces, and change processes they had observed. In the section below, these findings will be analyzed with respect to the Fernandez and Rainey factors mentioned above.
Interviews were held with a vertical slice of key stakeholders in each county (executive staff, program directors/middle managers, supervisors, front line workers and consumer group representatives). Executive staff and consumer representatives were interviewed individually, while middle managers, supervisors and front line workers were interviewed in focus groups. In a few counties, individual interviews were conducted with members of the Board of Supervisors (elected officials) and/or the County Administrative Officer (CAO). Specific questions asked of different groups of respondents are in the Appendix.
All interviews were in-person, with notes taken by the researchers. Interviews ranged in duration from 30 to 90 minutes, typically averaging approximately 60 minutes. Details on interview and focus group subjects are in Table 1. The Ns represent individuals or, for focus groups, the number of focus groups. Also included in Table 1, in the far right column, are County scores on the extent of implementation of collaborative practices, which will be discussed later. The N there shows the number of respondents who completed the Collaborative Practices Questionnaire.
While qualitative data were primarily used for this analysis, some quantitative data were compiled. First, the content analysis of the interviews resulted in quantification of response frequencies within major themes. These themes included:
* Goals for Newly Integrated Agencies
* Prospects for Success when Integration Started
* Concerns not Attributed to any Particular Group
* Strategies for Addressing Concerns / Building Support
* Major Barriers to Implementation of Integrated Agency
* Processes Used to Promote Collaboration and
* Advice for Others Attempting Integration
* Environmental Factors Facilitating Collaboration
* Environmental Factors Hindering Collaboration
* Factors Contributing to Successful Collaboration
* Major Barriers to Collaboration
Aspects of these findings which are relevant to this study, which focuses specifically on dynamics of the change process, will be presented below as relevant. Complete results are available in Patti, et al. (2003).
The other quantitative data came from a Collaborative Practices Questionnaire, which was used to allow respondents to assess the extent to which 16 collaboration practices were seen as implemented. Program-level factors included co-location of services, case plans developed jointly by all service providers working with a client, a common understanding of workers' roles, and consumer ease of access to all services. Administrative factors included integrated information systems, routine sharing of resources, cross-program training to improve teamwork and coordination, and reduced redundancies and gaps in services and functions. The instrument was adapted slightly from an instrument developed by O'Looney (1997) who, based on his research with human service collaboratives, proposed a number of markers to gauge the extent to which collaboration and service integration have occurred. A pilot test of the questionnaire was conducted with executive staff from one of the county agencies, and changes were made to improve wording and eliminate redundancy.
Separate questionnaires were developed for structurally integrated and free standing agencies (questions are listed in the Appendix), each focusing on a different unit of analysis. For integrated counties, the unit of analysis was relationships among all elements of the agency. Items asked respondents to characterize the extent to which various kinds of collaborative practices were being implemented throughout the agency. The questionnaires were tested for internal consistency and were found to have high reliabilities with alphas ranging between .89 and .93.
The questionnaires were given to all individual interviewees and each member of the focus groups. The response rate for the integrated counties was 94%, with 144 of the 153 interview and focus group respondents completing the questionnaire. In non-integrated county agencies, by contrast, respondents were asked to select a significant collaboration with one (or more) other county public human service agencies and characterize the extent to which certain collaborative practices were implemented in that collaborative. Both instruments had common items, but each also included questions that were specific to the types of collaboration in that county (i. e., intra-agency vs. interagency). It is important to note these differences in the instruments because it would be misleading to compare results obtained in the two types of counties. In the nonintegrated counties, the response rate was 92 percent, with 95 (out of a total of 103) interview or focus group respondents completing the questionnaire.
In both cases respondents were asked to rate the extent to which each collaborative practice was being implemented on a five-point scale ranging from little or no implementation of a collaborative practice to full implementation of the practice. Mean scores for the global level of collaboration in each county are indicated in Table 1 above. Practices included co-location of services, training to improve teamwork, integrated information systems, and blended funding. Additional detail was not seen as essential for the current focus on organizational change processes, but these findings are available in Patti, et al. (2003).
As with the interview guides, the questionnaires for both types of counties were particularized for respondents at different levels of the organization and types of organizations to maximize the relevance of the items to respondents' experience and knowledge. (County supervisors and CAOs were not given questionnaires.) Thus, there were three variations of the questionnaire (executive, middle level/front line and consumer representative) in the integrated and non-integrated counties.
Each director or his/her designate was asked to select for interviews persons from an array of program areas in the department who had been in or related to the agency for at least five years. In each county, there were seven to ten interviews with executive level staff, county officials, and consumer group representatives and two to three focus groups representing middle level managers or front line supervisors and workers, with eight to twelve participants each. Interview questions addressed background information on respondents, agency integration/collaboration history, external factors, change goals, change strategies and tactics used, success factors, supports and barriers to integration, effects on programs and clients, and advice for others.
Four researchers conducted intensive interviews in one or two counties each and compiled findings into one case analysis for each county. The senior researcher, who had conducted similar research projects on collaboration (Ezell & Patti, 1990, Patti & Einbinder, 1997) analyzed all cases and identified common themes and differences. This summary analysis was reviewed by all researchers; and adjustments were made to ensure accuracy and completeness. Full instrumentation and case narratives are available from the senior author.
Across the four integrated counties, 41 interviews and 11 focus groups (with 113 total participants) were conducted. For the non-integrated counties, 21 interviews and 8 focus groups (with 82 total participants) were conducted. A total of 195 participants attended 19 focus groups, which had an average of 10 participants each. The findings presented in this report thus reflect the perspectives of 257 individuals in seven counties. It is important to note that for each of the focus groups, participants' responses were grouped and counted as one interview, reflecting the "group's" perspective, rather than the perspective of each individual in the group. As a result, data collected via individual interviews are more heavily weighted throughout the findings section of this report. Data analysis included tabulation of frequencies of responses to closed-ended questions and a content analysis by the researchers to identify themes, patterns, and connections among responses.
Findings will be presented as major themes, grouped according to the eight success factors identified by Fernandez and Rainey. Themes and examples were drawn post-hoc from this study's data and were connected to the appropriate success factor. Highlights which augment Fernandez and Rainey's sub-propositions are summarized in Table 2. Some of these findings suggest refinements to the model which will be discussed in the final section.
Ensure and Communicate the Need
While external support from executive and political leaders was almost always a key driving force for the changes undertaken in these agencies, it was equally true that if agency leaders were to obtain widespread commitment to change they needed to "craft a compelling vision of change" (Fernandez and Rainey 2006, 7). A key strategy used by leaders to persuasively communicate the need for change was to emphasize the importance of improving services through coordination and to project a vision for how that might happen. In each of the counties we studied, there was a small set of "prime movers," or persons who initially projected a vision and expectation of improved interagency or inter-program coordination. In the Integrated counties, 73% of respondents identified the County elected officials or county Chief Administrative Officer as prime movers, with 69% identifying department directors and 33% identifying other executive level staff as prime movers.
Their visions centered around a few central ideas, including easing access for clients, improving services through coordination, greater attention to consumer needs, performance enhancement and assessment, achieving savings through the reduction of duplication and economies of scale in administrative operations, and improving the extent and quality of partnerships with the community (e.g., community-based organizations).
The visions, usually stated as principles or guiding values, were often formally promulgated early on in the process of change and positioned prominently in Board resolutions, agency business or strategic plans, and newsletters and other media (see the section below on building support). Common examples of guiding values included efficient government, improved services for poor and vulnerable clients, and increased accountability to the community. These values served as mantras in most change projects, though the extent to which they were communicated did vary. In those cases where agencies made the greatest progress toward integration or collaboration, it appears that staff and the community resonated with these values, even though they might have had reservations about whether they could be achieved or concerns about their impact on particular programs or client groups. The importance of communication cannot be overstated. In one county, it was noted that department heads needed to send out regular messages regarding their expectations. According to one respondent, "people need to hear the leaders talk about this."
In several of the counties that were most successful in building collaboratives, the credibility of the goals articulated to staff and other agency directors seemed closely tied to the perception that the agency director was a trustworthy, knowledgeable, and effective leader.
In spite of all the communication from leaders regarding the change process, the most commonly mentioned advice in the structurally integrated counties, mentioned by 35% of respondents, was to have more information exchange up and down the line. This was also the third most common piece of advice, mentioned by 24% of respondents, from those in the non-integrated counties. Thirty four per cent (the second highest percentage) of all respondents in the collaborative counties recommended cross training between partners and development of a shared vision. Some respondents noted that if a person was not involved in an implementation group they were less likely to be knowledgeable of change activities. In one county, a less successful one, there were only three issues of a newsletter over a two-year change process.
Provide a Plan
While all counties had some form of a formal planning process to integrate services, many respondents, and particularly those at lower organizational levels who were not involved in the planning, noted that more planning would have helped. In the integrated counties, the second most common piece of advice, suggested by 21% of respondents, was that more planning was needed. Almost half (45 percent-the highest percentage) of respondents in the collaborative counties said more planning would have helped.
One county, which used a consulting firm, had a very elaborate implementation plan. Change project staff initially formed 15 work groups (with more added later) to undertake some 2 dozen-change projects over the next three years. The work groups or teams were composed of members of the core project staff, a group leader (usually from top management), volunteer staff from various parts of the new agency, and usually some community representatives. The work groups were given goals, tasks and time lines to guide their work. In each case, staff assisted in the management of the projects by organizing meetings, tracking progress, report writing and so on. Within the first year, 125 staff members and others had worked on these teams.
In another county, respondents suggested that staff that are actually "doing the work" need to be involved and provided the opportunity to share ideas and to learn what is going to occur. They added that lower level staff should be made clear as to what their role will be in the new organization and how their job will change, to help them to "buy-in" to the benefits of integration. A manager in another county asserted that "without buy-in at the front line, collaboration can't work."
One of the sub-propositions under Fernandez and Rainey's (2006, 7) proposition for planning is "The strategy should rest on sound causal theory for achieving the desired end state". Plans were generally clear and specific, partly because the overall goal was so clear; but we found only one example in which "sound causal theory" was explicitly used. This was in one county in which consultants used a theory of change known as the Technology of Participation (Spencer, 1989). The key weaknesses in planning may have been the limited ways in which plans for the change process were communicated to staff, and the limited involvement of middle- and lower-level staff in planning.
In the county which experienced the most challenges with integration, in spite of a clear articulation of overall goals for integration, and the fact that people had a general understanding of these, it was clear that a clear and compelling "case" for this massive change was never made. Staff were not convinced that the benefit would outweigh the threat. One deputy director suggested that it may have been better to start from the bottom, focusing on what works best for the client. Another manager recommended involving staff at all levels and communicating progress to staff, suggesting labor-management team meetings early as one way to initiate this.
Build Internal Support and Overcome Resistance
Important to success in these initiatives were efforts to aggressively involve community constituents and internal staff in planning for implementation. Staff and key community groups usually understood that reorganization or collaboration was a fait accompli, but their acceptance of the change and enthusiasm for implementation depended on their involvement in real time planning.
The counties that moved quickly toward integration and/or collaboration mobilized a wide variety of constituents in a number of workgroups, committees, task forces, "charter teams," and the like, to work on organization redesign technologies and processes to facilitate the change goals. As indicated in Table 3, which includes data from the structurally integrated counties (this question was not asked in the collaboration counties), 62% of respondents mentioned such task forces as helpful in building support and addressing concerns. For the most part, these work groups were charged with important responsibilities and were relied upon to find solutions that could be implemented.
In one county, several managers were of the view that collaboration at the program and service levels depended largely on the ability of staff to solve problems as they arose without having to continually refer to superiors. The freedom of subordinates to problem solve at this level must be done within parameters that the agency can live with, but unless a good deal of authority is delegated, staff will not take the initiative to solve the problems associated with interagency work. In some cases, these work groups were supported by a central staff that oversaw and facilitated the entire change project.
The work groups typically involved middle and front line staff and representatives of top management, and were seen as key success factors. In some instances, external consultants were available to assist work groups, but staff was not uniformly satisfied with the kind or quality of help they received. In two counties, where consultants were perceived as uninformed about the realties of public human services, their assistance was considered in some respects as detrimental to the change process. A common suggestion was to choose consultants who were better informed about the about the day-to-day realties of human services work. In two counties, early staff involvement included having staff develop the scope of work and request for proposals for consultants, and this was seen as helpful in building support for the project.
Researchers found that there had been resistance to change projects among middle management and front line workers in certain program areas such as mental health, child welfare, aging, and drugs and alcohol. The resistance to change was manifested in a variety of ways, such as fears that expertise would be diluted, that service standards would be compromised, that information shared with others would be used inappropriately, that workers in other programs with less professional preparation could not be entrusted to perform competently, and that general managers would not have expertise needed to effectively manage programs. These matters continued to serve as barriers in some counties, either slowing or preventing the full development of interagency cross-agency or cross-program coordination.
Success factors noted by respondents in the "collaboration" counties which helped to build support for the changes are listed in Table 4. In several counties, teamwork began to occur in facilities where staff from different programs were co-located and involved in joint planning and service activities. Co-location was enhanced through team building activities, executive staff modeling, staff development, regular meetings, and cross training where stereotypes and distrust could be addressed and relationships built. These supports were an integral part of the planning, with time and resources allocated. The researchers observed in several counties that, with improved communication skills, workers in different program areas often developed mutual respect and enthusiastically embraced the opportunities to utilize one another's expertise to further the interests of their common clients.
In one county, having people from different programs working together on projects was seen as moving integration beyond what team building activities accomplished: regular contact through joint work (e.g. team service planning) expedited staff getting comfortable working with each other. In one county, there was considerable agreement in the middle management group with the statement: "Team building activities did not take the integration effort as far as having people work together on projects." In several counties, pilot projects in selected geographic areas were useful in showing quick successes and examples of the ultimate vision.
In all the counties, it was generally agreed by middle and front line staff that while it was necessary for them to understand the values and vision of change, this was not sufficient. In most cases, staff at these levels continued to have professional and personal reservations about the change projects well after they were underway. Marketing efforts, information dissemination, and involvement in planning were important ways to address these concerns, but in the end "consideration"-the belief that the agency executive team understood that the additional responsibilities associated with the change effort were heaped upon ongoing responsibilities that did not abate while new policies, rules and procedures were being put in place-emerged as a central issue. Even in counties where change was more effectively implemented, many staff expressed initial resentment and even resistance to change proposals because of the perception that management did not appreciate the impact of these changes on them personally and professionally. Some thought their concerns were simply not heard; others felt that changes were sometimes implemented without a careful consideration of human costs such as confusion, conflict, and loss. In combination, these perceptions often created discontent, which in turn slowed or undermined the change project itself.
One way in which this concern was addressed was for change leaders to communicate concern for staff and an understanding of their day-to-day demands in staff meeting, newsletters and other venues. Such information dissemination, seen as helpful; by 56% of respondents, was useful in not only building support but also in communicating the need for change and reporting progress. The nearly universal advice from line staff was that changes should be introduced incrementally, at a pace that permitted staff to absorb new policies and practices into their work and with careful planning about how to deal with the staff reactions. A slower implementation plan, it was often recommended, should be balanced with need to maintain the momentum of the change project. Ongoing, frequent, and regular two-way communication between leaders and staff was seen as essential. Related to this, a common theme was that change leaders should aggressively involve agency constituencies and stakeholders throughout the process.
This proposition includes several dimensions, ranging from building support to addressing resistance, and may warrant refinement. Empowering employees has often been noted in the literature as useful for other reasons, separate from the notion of addressing resistance. This will be discussed more fully in the section on implications for further research.
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