Too often, caregiving systems and the organizations that provide service to individuals with disabilities create incident-management systems that fail to account for distorted and, in some cases, dishonest communications. Certain policies will require staff members to report a wider range of incidents based on the notion that sometimes serious harm can be predicted by tracking the less serious episodes (i.e., the “accident waiting to happen”). In addition, we expect that providers will better use collected incident data to fashion solutions that treatment teams, program staff, and others will implement to the benefit of the individuals they serve. Every incident management policy includes provisions for the conduct of investigations. There is almost always a clause in that policy that requires all staff members to cooperate during the investigation. The clear implication of that clause is that if an investigator asks someone a question related to the care of an individual, that person will answer the question honestly.
Unfortunately, such rules are often grafted onto organizational cultures that do not support open and honest communications. To participate in effective incident management processes, organizations must develop a culture that is consistent with the values of such policies.
Departures From the Ideal
The most obvious result of any incident management policy is the accumulation of incident data that the organization can then analyze and use to better protect people from harm. In order to create a database that is a valid representation of reality, stakeholders must be willing to provide information based on what they saw or what had been reported to them. Individuals providing that information must be committed to writing without varnish based on friendships, self-interest, or a variety of other factors that might cause someone to avoid telling the truth. However, actual practice within the long-term care industry can vary substantially from the ideal:
I have experienced facilitated meetings with direct care staff in which rank-and-file employees were warned by managers not to disclose “dirty linen.”
I have been involved in interventions where reports from such facilitated experiences have been “confiscated” by facility management to avoid making public accusations of misconduct within programs.
In another case, psychiatric management “outsmarted” regulators by placing excess numbers of mental health patients on “buses to nowhere,” driving around the country-side until regulators had left the premises.
Older employees often create informal orientation to “train” new staff members what not to report and, basically, help them understand how things “really work,” notwithstanding anything learned in formal orientation classes.
Staff members frequently write incident reports in vague language (“staff member restrained the individual”) rather than concrete terms actually describing the interaction. Although some of the ambiguity that results is simply the product of poor writing skills, in other cases the ambiguity is a deliberate attempt to mask what actually occurred.
A common response to an investigator's question when examining allegations of abuse or neglect is, “I can't remember.” Although such responses are often justified by the fact that a witness really cannot remember certain events, many of these responses do not seem credible.
Organizational Structure: Ideal and Reality
Interestingly, it is doubtful that most of the actors in the foregoing vignettes thought of themselves as personally dishonest. In fact, in virtually every other part of their lives, they might be quite virtuous; their organizational behavior occurred in the context of written polices—both internally and externally promulgated—requiring that incidents be reported and investigated honestly and that anyone failing to behave consistent with that expectation would be subject to discipline. At the same time, the most common organizational structures in which they worked created pressures that made open and honest communications difficult.
First, bureaucracy itself creates the seeds of dishonest communication. It begins with the division of labor inherent in every organizational structure and is exacerbated by the discrete offices that emerge, connected by hierarchal lines of authority. As many writers have observed, organizational structure creates discrete offices. The members of each office will tend to focus on their day-to-day responsibilities rather than the organization's mission. In essence, they displace that mission with their parochial goals and objectives. As a consequence, they tend to compete with other offices for resources. In that context, information is itself a resource and managed very much as a public relations effort. Whatever tends to make the office and its interests “look good” is valued more than the factual truth.
Equally important is the concept of informal organization, the social context in which employees must operate. Notwithstanding the organizational chart, actual lines of communication are hardly so neat. The message from the top that all incidents must be reported is often modified by the staff members within programs to conform to what they believe is appropriate given their own experience; and those who are part of that group are likely to be influenced by the peer version of the responsibility as the formally created rule, if only to more successfully manage their interpersonal relations with their colleagues.
Know Your Job, Love Your Purpose: The Role of Organizational Culture
As a consequence, every organization must develop a comprehensive plan as opposed to simply assigning jobs on the basis of discrete parts. Administrators should create an organizational culture that will ultimately bind those jobs in a manner that will allow stakeholders to work together toward a common purpose, or mission. Such a responsibility is hardly unique to caregivers. In fact, one of the icons of 21st century America is the Disney Corporation, where creating a common culture has been critical to its success.
In October of 2002, the Disney Institute presented a seminar addressing what amounted to the “Disney Way” with respect to common issues related to human resource management. What was clear, however, was that the presentation was ultimately focused on how any specific Human Resource Management practice related to the problem of organizational culture: “(A) system of shared beliefs and values that develops within an organization and guides the behavior of its members.” Where could the problem be more demanding? Disney World, the Orlando version of Mickey Mouse and friends, employs approximately 50,000 people from around the globe. People, whether they be entertainers or young people wanting a job just to be close to the fantasy world they visited as young children, congregate at the “casting” office to seek work. There are thousands of retirees living in Central Florida who also apply for part-time work. In some cases they need the income; in others they work enough to receive merchandise and entertainment discounts that they can “spend” on their grandchildren. It would be hard to find a more diverse group of employees and, therefore, a more difficult problem of reconstructing their various roles, responsibilities, and life experiences with a common purpose.
What is the Disney culture, or as the presenters often stressed, the Disney purpose? It is to provide a “Magical Experience” for everyone who visits its venues. What does Disney mean when it says cast members must provide a magical experience for all their guests? The instructors provided the following example.
Suppose a parent bought an ice cream cone for a child; and, suppose the child dropped the cone. The chocolate first smears on the child's shirt and then lands on the sidewalk. Suppose further that a grounds person is nearby and notices the situation.
Of course, the grounds person's job is to clean the sidewalk. But his purpose is to provide a magical experience for the guests. Therefore, the Disney Way expects the grounds person to take the child and parents to the nearest ice cream stand and provide, free of charge, a “replacement cone.” But wait! That child has a chocolate covered shirt, and a parent who is focused not on enjoying the day, but fretting over the child's appearance. So the Disney expectation is that the grounds person will escort the family to the nearest Disney store and at no expense to the family provide the child with a new, clean shirt. But the day is not yet as magical as it might be. The grounds person is expected to send that dirty shirt to the Disney laundry facility to be cleaned and placed in the family's hotel room, waiting for the family as it returns from the day's festivities. Put simply, Disney expects every employee to know the job, but also to love the purpose for which Disney exists.
Changing Organizational Culture
Much like Disney, any organization providing services to individuals with disabilities must create a whole out of disparate parts. One of the underlying values stakeholders must exhibit is open and honest communications, if only to better achieve the organization's mission. Merely writing policy and training staff members to perform their jobs competently will not suffice. How do we develop employees at every level who are different in so many ways and help them love the purpose for which the organization exists?
Establishing a Mission
We have read hundreds of long-term care mission statements. Some are the product of intense discussion and debate among all stakeholders. In other cases the CEO—or perhaps more likely, a designee of the CEO—composed the document working alone one long weekend. It is interesting, however, that virtually all of the statements can be reduced to the following: To provide excellent services in a safe, caring, and hospitable environment. The services themselves might vary. Some organizations serving the people with developmental disabilities, for example, might only provide case-management services. Others might only provide residential services. There are still others that will provide an array of services, particularly state-operated facilities and larger community-based organizations. In each case, however, the mission statement must require that those involved in that journey must construct the services in such a manner that customers would find them to be excellent; they must occur in an environment that is free from at least avoidable harm.
Operationalizing the Mission
Merely writing a clear mission statement is not sufficient. In order to provide clear guidance to those participating in the journey, author(s) of the statement must establish how the mission is to be operationalized. In recent years, managers have described this as the need to measure outcomes. Without a clearly understood measure of outcomes, it would be easy for individuals in discrete parts of the organization's structure to interpret “success” in a variety of ways, some of which might be quite at odds with how others interpret success. Generally, outcome measures associated with incident management include the number and severity of incidents, the nature of injuries individuals suffer, and the frequency with which abuse and neglect occur. (This latter measure, abuse and neglect, is commonly used, but it is not the most reliable or valid measure of the success of an incident management program.)
Creating Effective Structures and Processes to Support Open and Honest Communication
A mission statement, however, is only a point of departure. It expresses the values, but cannot by itself cause stakeholders to share those values nor learn to conduct themselves consistently with those values. Organizations must consider the broader influences on individual and group behavior that will actually nurture staff commitment to the mission.
Matrix Organizational Structures
One way to avoid Balkanizing stakeholders' understanding of how their discrete functions relate to the whole is to create matrix structures at various places within the more traditional hierarchy. A matrix structure is one in which employees report to more than one person. A common example within the caregiving sector is the interdisciplinary treatment team, groups that seek to harness the expertise of people in a variety of disciplines to help a particular individual. Any team member might report generally to the director of social work, for example, but for purposes of one's responsibility on the team itself, to the team's chairperson.
There are other opportunities for such structures as a means of focusing on the whole, not the organization's parochial parts. In some cases, organizations have replaced the traditional incident-reporting mechanisms with a frequent meeting protocol, an attempt to force both line and staff administrators to work together to address not just the serious incidents that occur, but even the accidents waiting to happen to which I previously referred. In addition to the sublimation of mission in addressing incidents, the frequent meeting protocol has a salutary effect on open and honest communication. Presently, most incident-reporting systems require someone to file a written incident report, which wends its way eventually to an incident management committee that meets once a month. Given the number of incidents that can occur, the committee can only address the most serious examples of harm as well as whatever trends and patterns that might emerge when including the larger number of less serious incidents. During that hiatus between meetings, the primary responsibility for addressing immediate needs of individuals receiving services will be lodged within the functional area responsible for the care. In situations where subcultures have developed that are inconsistent with the organization's mission, it is more difficult to perpetuate that inconsistency when stakeholders have to meet face-to-face with their peers about what did and did not occur during the past 24 hours in the programs for which they are responsible. It is easy to be dismissive of a series of “minor” occurrences if they are treated as discrete written reports, rather than personally presented to a group of colleagues who have also been charged with the responsibility of helping to find causes and solutions related to the incidence of harm.
Consistent with the overall theme of this commentary, if an organization's structure is modified to one that nurtures stakeholders' perception of mission, assurance is needed that other systems affecting the attainment of that purpose also are in place. For example, to be successful, the frequent meeting protocol must not become a star-chamber experience, where each program manager is subjected to an emotional beating as they air their program's “failures.” This protocol was designed to create open and honest discussion in order to help the organization find solutions to problems that undermine its achievement of its mission.
As a consequence, actual behaviors during these meetings must be consistent with the purpose of the meeting. The traditional method of using diverse elements to negotiate their interdependent needs is often destructive of open and honest communications. One need only think of car buying experiences to reflect on the degree to which bluffing and other insincere behaviors dominate our communication patterns.
On the other hand, cooperative decision-making strategies (e.g., win/win negotiations) sublimate transparency. It would never be appropriate to bluff. It would never be appropriate to hide information. Candor is truly valued. Cooperative strategies, however, are generally inconsistent with our culture and will only occur when organizations make self-conscious efforts to connect the strategy with the mission: All things being equal, human beings make better decisions when there is more rather than less relevant information available to the decision makers. Those who make better decisions are more likely to create excellent services in a caring and hospitable environment.
The Employee Selection Process
Notwithstanding organizational structure and decision-making processes, no organization can be successful in achieving its mission without recruiting and then selecting a competent workforce. In this context caregiving organizations have an extraordinarily complex task. Administrators must hire a large number of staff members who often work in remote locations with vulnerable individuals. In many cases these individuals can present quite challenging behaviors; however, all employees are expected to conduct themselves consistent with the mission of providing excellent services in a caring and hospitable environment. Further, as I noted earlier, to create that caring and hospitable environment, organizations need staff who will engage in open and honest communication. All of this must occur in an economic environment that provides relatively low wage rates as compensation.
Virtually every organization hiring staff will conduct interviews. Interestingly, most such interviews are unstructured. That is, the interviewer will meet with the employee and engage in dialogue. There may be certain issues that the interviewer will raise with all candidates, but the process is characterized by a wide-ranging discussion of issues addressed to some potential employees and not with others. The research literature has shown such interviews to be highly invalid predictors of actual performance at work.
A more valid predictor is the structured interview, one in which all candidates are asked the same questions, in some instances based on case studies to which they must respond. Such a method allows for the organization's interviewer to present situations illustrating a person's tendency to value candor and other elements of the organization's mission. It is much more effective in seeking to change culture to hire someone already committed to open and honest communication than to hire a person who sees it only as an alternative.
There are other variables that are not directly related to the issue of open and honest communications that contribute to the success of incident management processes beyond those noted in this commentary. For example, the manner in which we conduct education, or the performance appraisal processes we implement, or the rewards systems we create, or the interpersonal communications we model and tolerate all represent iterations of the organization's culture. All must be founded on a similar set of values to help stakeholders achieve the mission.
To the extent that executives of organizations can begin to conceive of incident management in a more systemic way, they will address these additional issues as others are resolved. The most important point is that merely publishing a policy, posting it, and explaining it may be necessary, but certainly insufficient if incident management is to actually protect people from harm. Every organizational resource available must be used to create a culture that actually supports our mission.
Author: Antone Aboud, PhD, President, Antone Aboud Associates, Inc. Correspondence should be sent to 3 Cayuga Ct., Albany, NY 12208. Aaboud@aol.com