Using Strategy to Promote Knowledge Utilization and Change in Community Mental Health Systems Paul D. Peterson, Ph.D. Lyle Quasim, M.A. Washington State Mental Health Division Abstract The Washington community mental health system illustrates three examples of knowledge utilization: a long range strategy to improve the accountability of the service system and finances, the formulation and implementation of a strategy to expand minority services in provider agencies, and a process to expand the application of community support concepts for adults and children in local service systems. The management information system (MIS) implementation applies the Davis A VICTORY model
Background Washington State's community mental health structure is composed of 39 contracted counties and 75 provider agencies. Sixteen counties, generally small in size, provide services directly while the remainder subcontract with private nonprofit agencies. These multiple levels of administrative control with their differing missions, allegiances and concerns make the task of state leadership to introduce new knowledge and facilitate change either challenging or problematic depending on one's level of optimism.
Accountability In the mid 1970s, the Bureau of Mental Health (BMH) was at a clear disadvantage in arguing positions before the legislature regarding community mental health because of inadequate data on client and fiscal activity. The legislature threatened to stall any further budget increases until an improvement occurred. A management information system (MIS) with relatively sophisticated content had been developed, but, because of several major flaws, produced questionable reports. Many agencies dropped out of the system. Financial management was present in only a few agencies and most utilized inadequate accounting procedures. No standardized accounting practices existed. Paul D. Peterson, Ph.D. is chief, systems planning
and evaluation, Washington State Mental Health Divi-
sion, and clinical associate professor, Departmentsof Psychiatryand BehavioralSciencesand Nursing, University of Washington. Lyle Quasim, M.A. is director of communityservices, Washington State Division of Juvenile Rehabilitation and clinical associate professor of nursing, Universityof Washington.
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At this point, the BMH executive staff selected a strategy to address and remedy deficiencies in accountability given available resources and current readiness for change. State, county and agency representatives serving as a steering group to guide overall system development concluded that information system improvements were essential for future progress and that the development of a new management information system including standard accounting procedures should be staged over time to avoid unnecessary stress on the system.
New MIS The first step was the development and implementation of a new management information system to be used by agencies. After reviewing a number of available systems and the possibility of developing a new system, a novel strategy was chosen. The system designed by Attkisson and his colleagues at the University of California at San Francisco, 1 unlike most of the systems evaluated, had varied managerial levels accepting, using, and supporting the system. While significant modifications would be required, the human engineering principles underlying the system were sound. Next was the adoption of an incremental, evolutionary approach to modifying the system as well as to the strategy of implementation. The implementation team was selected carefully to improve acceptance. The majority of the team were clinicians with managerial experience, were under contract to the division and were viewed as brokers between the state system and the agencies. A test agency was solicited, and the initial modifications were developed and tested. Features of the developmental project included: 9 9 9 9 9 9 9 9 9 9 9
assessment by a broad advisory committee; continuous assessment of usefulness by the test agency; compensation for extra staff time required to participate in development; invitations to examine the system; use of test agency staff to market the system to other sites; invitations to other agencies to enter into the system; no formal mandate requiring the use of the system until it was largely in place; careful integration of the system with agency process and staff; active pursuit at promoting involvement and system acceptance; process evaluation of the implementation process; 2 time taken to allow and to build acceptance.
The output of the system began to be incorporated into the ongoing management of the community system by state and county administrators further reinforcing the value of the information and use of the system.
Standard Accounting System The second stage of the accountability process involved the development and implementation of a standard accounting system for all contract agencies. A small group of key fiscal managers from community mental health agencies was initially convened by the Mental Health Division (MHD) to develop consensus around the need for the accounting system. Although the need had been identified by the original broader-based steering group, the most effective strategy was to gain acceptance from the leadership of the fiscal managers who would be the principal users. For many years, Title XIX rates paid to the service provider agencies had lagged behind actual cost. If rates were to more clearly reflect cost, the agencies must adopt uniform cost finding and rate setting procedures. Fiscal managers lobbied their bosses in the association of community mental health providers, the Washington State Community Mental Health Council, to form an official subcommittee composed of these same key fiscal managers to work with the MHD in developing the system. A consultant was hired to act, as with the MIS implementation team, as a broker between division and agency. The consultant compiled a system
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based on generally accepted accounting principles (GAAP) accepted by the Division and Council. Implementation was achieved through a series of training workshops followed by on-site technical assistance sponsored by the Division but carried out by the fiscal managers committee of the Council. Following implementation in 1982, the state legislature mandated a standard accounting system across agencies in the new Community Mental Health Services Act. Thus, as with the information system, most of the development and implementation occurred prior to any mandate. When the mandate arrived, it was readily accepted and served to validate and fix the processes in place. As each rate setting exercise was carried out, the quality of the product increased. Integration of accounting and management was initiated with a productivity workshop by Sorensen and Hanbery sponsored by the MHD and the Western Interstate Commission on Higher Education (WICHE). 3 Subsequently, a number of agencies generated useful approaches to data integration into routine managerial functions.
Services to Minorities In 1976 the MHD instituted administrative policy to encourage the expansion of services for ethnic/cultural minorities in community mental health programs. Little progress resulted. When opportunities were available to expand programming, minority groups would disagree among themselves over the allocation of these scarce resources and the disagreement would be used as an excuse to delay action. Little progress was made in expanding services or in acquainting community mental health staff with the sensitivities and skills necessary to serve ethnic/cultural minorities.
Ethnic Minority Consortium To address this stalemate, the MHD initiated a strategy to assist ethnic minorities to organize in order to improve their ability to influence the allocation of service dollars and to serve as the focus for training of community personnel. The result of this effort was the Ethnic Minority Mental Health Consortium which has come to be a strong asset in providing services to ethnic minorities. The Consortium is a coalition of persons from a wide range of ethnic backgrounds who have specific concerns, interests, or experience in the mental health service system in relation to minority communities. Charter members of the Consortium saw the value in joining forces to advocate for services to minorities rather than remaining separate interest groups. Consortium members advocate at the state and local levels for services to diverse minority populations, participate on boards and committees, and provide training and consultation to the mental health system. The Consortium provides a continuing link between the mental health system and minority communities that allows for long-term strategies for change to be developed and not just the crisis management which often characterized the relationship between service agencies and angry consumer advocates.
Training Materials In collaboration with the Consortium, the MHD training experience led to materials useful for training in services to minorities. While these materials were initially more costly in materials cost and staff time, the potential payoff is much larger. Three publications are available:
. Annotated Bibliography of Training Resources; 4 9 Mental Health Services for Ethnic Minorities (Training Manual and Video tape); 5 and 9 Mental Health Services for Minority Children and Youth (Training Manual and Video tape). 6 The Community Mental Health Services Act in Washington State requires that services to minority clients be "provided by, under the supervision of, or with consultation from a minority mental health specialist." A minority mental health specialist is one who has specialized
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training and supervised experience with the specific minority group being served. This provision of law is important because mental health agencies must have an ongoing relationship with an expert in serving minority clients. The Ethnic Minority Mental Health Consortium has provided excellent assistance in helping agencies to identify these consultants. Since clinicians are required to contact the consultant with every new minority client at least once, there is a rich opportunity for client-specific education of clinicians.
Summary The expansion of the knowledge and skills to support service delivery to ethnic minorities was the result of a process which combined policy, advocacy and human resource development in a coordinated way. The outcome of these activities in some parts of the state is a clear expansion in the quality and quantity of service provided. 7 In other areas of the state, where advocate pressure has not been maintained, progress has been limited severely.
County Plan Development Process The Washington State Community Mental Health System has been evolving toward serving more severely disabled persons. Prior to 1982, this movement was initiated administratively. In 1982, the Washington legislature passed a new Community Mental Health Services Act in which accountability for system development and the priorities of the system were clearly specified. Particularly, the key role of county government in local planning and coordination was re-emphasized, having been defined in the previous governing legislation, and client priorities for service were defined as acutely and chronically mentally ill and seriously disturbed people. Within these priorities, the special needs of underserved populations to be addressed were minorities, the elderly, children, disabled and low income people. Community support services were identified for the first time in law as one of six required services. Until recently, community support has been treated as just an additional service to be provided rather than as a central guiding focus. Amendments to this legislation in 1986 emphasized further the need for coordination of services across service systems for children.
County Plan Each county is required to develop a biennial plan as a basis for the establishment of the contract between the state and county. Staff of the System Planning and Evaluation Unit (SPEU) of the MHD were assigned responsibility for the county planning process. SPEU contains both general planning staff and the federally funded CSP and CASSP projects. Since the goals of these projects overlap with the state-defined priority groups, a strategy was developed to integrate the resources of these projects with those of the state's community mental health system using the philosophy and principles of community support service as a foundation. The state's county planning guidelines were modified to include a statement of philosophy reflecting a community support orientation and offering a vision of those consumer outcomes desired by the state. The statement of philosophy is tied to goals for each service modality allowing each county to assess the degree to which their service system approximates each goal, to identify the need for modifications and select those most amenable to change during the next grant period. Strategic planning with an emphasis on action based on a careful selection of critical and feasible areas of change has been incorporated into the county planning guidelines.
Outside Expertise To assist the counties in developing these new plans, the MHD contracted with the Mental Health Center of Dane County, Wisconsin to conduct three three-day training workshops each one month apart. 8 Each county was invited to send a county planner, a family advocate and a third person of their choice, typically a service provider. The first workshop emphasized
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community support services to chronically mentally ill adults, while the second, using staff from the two CASSP Research and Training Centers at the Florida Mental Health Institute of the University of South Florida, and Portland State University, emphasized community-based services for severely mentally ill children. Each of these first two workshops contained a segment on strategic planning, culminating in the emphasis in the third workshop on technical assistance and consultation on draft county plans. Training is intertwined with the planning process to encourage analysis, provide new or broader visions of service potential and encourage the use of strategic planning techniques throughout. Involvement of family advocates broadened the base of understanding of community support concepts and provided each county with greater support for its system' change. The intent of this strategy is to develop a higher level of collafioration and sense of common mission between the state, counties, providers and advocates with plans, and eventually contracts, reflecting a shift toward a stronger orientation to community support philosophy as a guide to service delivery.
Influences on Strategies The strategies discussed in this paper were influenced by the Davis 9 A VICTORY model, the writings of Larsen, 1~ strategic planning concepts of Goodrick, H and the conflict manager model of Yates. 12 Each suggests the need to understand clearly the environmental context in which a new concept, business method or management tool is introduced. Once the context is known, the need for acceptance must be established and potential avenues for change assessed for openings or resistance. A strategy is then devised to encourage and reinforce the acceptance of skills, attitudes and behaviors necessary to incorporate the new ideas and/or accomplish desired change.
MIS Implementation Implementation of the MIS can be examined against the A VICTORY framework. 9 The A VICTORY acronym stems from the first letters of eight factors considered necessary for organizational change: ability, values, information, circumstances, timing, obligation, resistances and yield. In analyzing our approach to the introduction of the MIS, these eight factors are discussed in the suggested order for use in the implementation process. Obligation relates to establishing the perception of the need for change. In our illustration, the need for change was highlighted by establishing consensus among the key factors in the face of legislative thrust to retard funding and their own awareness of the limited management potential within the system without such change. Information, the selection of knowledge or a pattern of action likely to lead to a reduction of need, was developed in a number of ways. Initially, the review of available systems provided understanding of the possible dimensions of a new system. The decision to adopt a successful system, attested to by its users, coupled with the reputation of its originator in evaluation circles lent greater credence to the effort. Implementation utilized consultants who understood system and clinical issues and who were able to use the learning of the initial test agency and each subsequent agency added to the system to expand acceptance of the system as solution to the felt need for change. The consonance between the chosen pattern of action and the beliefs and styles of the organization, its values, was actively addressed through open communication between the implementers and the staff of each agency. The system was tailored as much as possible to the organizational structure and the system was explained in ways which demonstrated its usefulness to management and other staff. Implementation was delayed at times until it appeared that adequate information had been diffused throughout the organization to foster acceptance. A critical step was the ability of the organization, through its deployment of resources, to carry out the implementation. Within each agency, the implementation team attempted to assure that enough of the appropriate and essential personnel who understood and were committed to the system were assigned to carry out the implementation process. Once designated, the state staff promoted and supported these internal personnel.
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The next of Davis' eight factors is circumstances, the assessment of aspects of the environment that pertain to the appropriateness of the intended action. Here the ability of our consultants to assess, work with and/or modify the organizational characteristics of each individual agency worked to expand the potential for acceptance. Next was timing, or the anticipation of events that could influence the success of the process. Here again, consultants would delay or speed up the implementation schedule across agencies when each agency was most ready to accept the system. Resistances were many and varied. One frequent perception was the new system would increase the agency's workload and information costs. A study 13 to identify the current and often hidden costs associated with the present style of information management demonstrated that the new system could replace the current activities and greatly expand the quality and accessibility of information and at no increased cost to the agency. The study proved helpful by reducing resistance in midsize to large agencies that were subject to continuing information requests. The last factor is yield, the establishment of meaningful rewards for participating in change. In many ways this was the most difficult to implement. For line staff, the impact of better information on subsequent legislative budget increases is far removed from their daily work. A number of agencies were able to adjust workload or obtain new funding for valued programs through utilization of their new information source. For those agencies, most staff were quickly converted to the need for good information and were reinforced with reduced workload or satisfaction in addressing a seriously felt service need. Follow-up activities were designed to address potential yield by identifying agencies that had used the system profitably and by using them as examples in continuing management training in system use. Use of the A VICTORY schema aided in understanding the knowledge utilization and change process and in developing processes to promote success;
Features of Strategic Planning Strategic planning is both an aspect of the strategy to instill community support concepts throughout the Washington community mental health system and a framework for analyzing that strategy. The initial step in strategic planning is to scan and understand the environment in which one intends to introduce new concepts. Yates ~2 and Davis 9 emphasize the need to grasp fully the context of action. In the initial stages of project design, DMH identified the opportunities and threats and how DMH could capitalize on DMH strengths and avoid the weaknesses. Two dissatisfactions were identified: poor absorption of community support principles in spite of numerous educational efforts at the agency and clinician level and, second, a county planning process which produced compliance documents rather than forward-looking initiatives. If a more action-oriented approach, applying community support concepts to county plan development, was imbedded in DMH management approaches, DMH could address the dissatisfactions. However, knowledge of the principles of community support principles for adults and children was unequally distributed within the DMH administrative structure. The strategy selected was designed to integrate the concepts into the DMH management system while developing a broad-based coalition in support of the utilization of community support concepts. A clear-cut statement of philosophy in the county plan guidelines guided the general direction of knowledge utilization (change). The strategic planning segment of the county plan was a vehicle for initiating change and lead to a coalition of administrators, providers and advocates to foster acceptance and utilization of the technologies associated with the community support philosophy. The SOCA-cycle (scan-orient-commit-act) of strategic planning was extremely useful in selecting the strategy with greatest potential.
Impact on Future Performance Perhaps the most useful aspect of strategic planning models is the emphasis on the particular strategy or set of strategies which will have the most impact on future performance. This contrasts with a frequently used approach to planning in which a series of targets, some critical, others not so critical, are selected. 34
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Everyone gets their favorite project on the "wish list," and even though these lists may be prioritized, there is no disciplined attempt to identify those elements most conducive to knowledge acquisition and long-term modification of individual or organizational behavior. Support of the Ethnic Minority Mental Health Consortium is an example of a carefully selected and focused strategy which has had far-reaching consequences. This single, critical action, albeit with continuing support, has had a significant impact on knowledge acquisition, utilization and service delivery. Other strategies without this essential element would have been far less successful.
Interlocking Demands The more entities orchestrated to request change in an integrated manner, the more likely the possibility of change. In the case of improving services to minorities, for example, policy, human resource development, peer and community pressure were coordinated to expand the capacity of the community system to serve this population. In the areas of the state where one of these elements was not sustained, little progress was made.
Timing and Critical Mass For diffusion of new knowledge to occur throughout a system, an effective number of proponents must be convinced of the usefulness of the new idea. Without this number, which may vary greatly depending on the issue, progress will not be made. This critical mass must be assembled before effective change can occur.
Repetition Knowledge is seldom acquired by an organization of any complexity with a single exposure. Without sufficient repetition, the critical mass necessary to instigate and maintain acceptance of new ideas is not generated. Virtually all of the successful DMH efforts to expand knowledge utilization have required ongoing and repeated reinforcement.
Common Vision Shared goals are essential to the acceptance of any new ideas. These shared visions should be directions rather than maps. Trying to get everyone singing off the same sheet of music may be an ideal, but an appreciation of jazz suggests the best music arises from improvisation on the basic theme. Knowledge utilization, while preserving the basic structure, must support the need to improvise around the basic structure. As Yates le notes, in the area of process, a sense of common mission is derived from the achievement and maintenance of equalpartnerships, real and perceived. A critical aspect of the county plan development process was the close, equal partnership between state and county administrators in the development of county guidelines and design of the training conferences.
Incremental Approach Incremental steps in knowledge utilization and change allow a change to be accepted and to occur which, if perceived in its totality, might be rejected as impractical or overwhelmingly difficult. An incremental approach allows for adjustments to be made as one gains knowledge of the fit between plans and the reality of implementation.
Broker and Surrogate Roles Being perceived as an impartial mediator is useful in gaining acceptance of concepts which would be rejected out-of-hand if promoted directly by the state authority. Conversely, the state level may be more responsive to the broker presenting grievances from agencies than if received
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directly. Similar to the role of the broker is a surrogate who can put forward an idea or concept for the state mental health authority. Such a person or organization can present ideas which are received in a somewhat more objective manner than if promoted directly by the authority.
Summary Utilization of new knowledge and the change associated with this acquisition is always difficult. There are many impediments to change in any organization: lack of ability to see beyond the next crisis; too much work with too few resources; lack of information; inertia; and anxiety (organizational and personnel). Any administration attempting to produce change must carefully evaluate the total context in which change is to occur. A strategy must be selected which focuses the efforts of as many participants as possible and will support their efforts as long as necessary. Lastly, any change effort must be consolidated through use and institutionalization into the routine processes of management.
References 1. State of Washington, Department of Social and Health Services. Contract with The University of California at San Francisco. Olympia, WA, 1977. 2. Crowell J: Implementing a Statewide Computerized Management Information System in Mental Health Centers: An Evaluative Study of Organizational Change. Seattle, WA: Unpublished Doctoral Dissertation, University of Washington, 1982. 3. Sorensen J, Hanbery G: Washington State Mental Health Productivity Workshop. Boulder, CO: Western Interstate Commission on Higher Education, 1984. 4. Annotated Bibliography of Training Resources. Olympia, WA: Washington State Mental Health Division, 1985. 5. Mental Health Services for Ethnic Minorities, Training Manual and Video Tapes. Olympia, WA: Washington State Mental Health Division, 1985. 6. Mental Health Services for Minority Children and Youth, Training Manual and Video Tapes. Olympia, WA: Washington State Mental Health Division, 1985. 7. O'Sullivan MJ, Peterson PD, Cox GB, et al: Ethnic Populations: Community Mental Health Services Ten Years Later. Unpublished manuscript, 1987. 8. Daniels L, Mohelnitzky B: System Development in Washington State: A Mental Health Strategic Planning Approach to Development of Community Support Programs for Seriously Mentally Ill Adults and Children (Final Report). Olympia, WA: Washington State Mental Health Division, 1987. 9. Davis HR: Change and Innovation. In: Feldman S (ed): The Administration of Mental Health Services. Springfield, IL: Charles C. Thomas Company, 1973. 10. Larsen JK: Knowledge Utilization. Knowledge: Creation, Diffusion, Utilization 1980; 1(3):421-442. 11. Goodrick D: Mental Health System Strategic Planning Guide. Washington, DC: Alpha Center, 1986. 12. Yates D: The Politics of Management. San Francisco, CA: Jossey-Bass, 1985. 13. Lacy D: Information Cost in Community Mental Health Centers in Washington State. Olympia, WA: Washington State Mental Health Division, 1978.
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