Task 1 – Defining Cultural Excellence

(As-is Cultural Norms and Instilling the Changes)

Deliverable 1a: Cultural Assessment

Deliverable 1b: Change Strategy

Prepared for the

Oregon Health Authority / Oregon State Hospital

Salem, Oregon

in satisfaction of Contract #133459,

Oregon State Hospital Excellence Project

Prepared by:

14 January 2011
 Table of Contents

A. Executive Summary………………………………………………………………………………………………..….. 1

B. Background and Purpose…………………………………………………………………………................... 3

C. Situational Assessment………………………………………………………………………………………….…… 3

Introduction to Tools and Techniques……..…………………………………………………………….….. 3

1. Organizational Alignment and Effectiveness Survey (OAES)……………………….… 4

2. Focus Interviews…………………………………………………………………………………..……….. 7

3. Functional Mapping……………………………………………………………………………………….. 16

4. Online Surveys………………………………………………………………………………….…………... 25

5. Workplace Interviews………………………………………………………………………………….… 26

Current Cultural Norms………………..………………………………………………….……………………..…. 26

D. Cultural Changes to be Instilled……………………………………………………………….…………………. 27

E. Strategy for Bringing About Cultural Change…………….…………..…………….…………………….. 28

 A. Executive Summary

Introduction: This document is comprised of two merged Task 1 deliverables, 1a and 1b, satisfying the
State of Oregon’s Professional Services Contract Number 133549 for the Oregon State Hospital (OSH)
Excellence Project as follows:

• Deliverable 1a is a written report on current cultural norms, cultural changes needed and
identification of cultural norms necessary to be instilled in management, staff and patients, and

• Deliverable 1b is a written strategy for bringing about the recommended cultural change

The findings and recommendations cited in this document are employed to develop a practical approach
to instill behaviors that serve to improve organizational culture at all levels throughout OSH operations.

Overview: Mindful of the modern new facility that hospital patients and staff would soon occupy, and,
following sober consideration of the Quality and Compliance External Review Report, Oregon State
Hospital’s (OSH) top administration directed sweeping efforts to improve hospital performance through
the Oregon State Hospital Excellence Project. In its nine tasks conveyed in twelve deliverables over
seven months (Figure 1), the project focuses on making OSH a first class psychiatric facility where
effective patient treatment and recovery is the anticipated norm.

Figure 1 – OSH Excellence Project Tasks. Early deliverables include Task 1’s Cultural Assessment and
Change Strategy. Task 1 work was designed to unambiguously profile OSH’s current-state cultural norms
and then define an effective strategy to improve upon them in order to best focus resources to achieve
rapid and sustainable performance transformation. This document summarizes Task 1’s first two
deliverables (dark shading above). The companion deliverable, 1c, completes in June 2011. It focuses on
technical implementation support for adopted changes as supported and led by the OSH Cabinet.

Cultural Assessment: Task 1 used select data discovery and analysis techniques sourced from Kaufman
Global’s proven Culture and Climate Tool Suite. These included Organizational Alignment and
Effectiveness Survey (OAES), Focus Interview, Functional Mapping, Online Opinion Surveys, and
Workplace Interviews. These methods were chosen as they could be applied with speed, the needed

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breadth and depth, and, yield accurate strategy recommendations. While any individual tool might have
proved revealing on its own, such techniques applied in composite helped to boost fidelity of the
findings. Moreover, with these tools we could “touch” many hundreds of stakeholders, broadly
validating the hospital’s overall cultural norms.

Not surprisingly, such discovery techniques demand a great deal of stakeholder involvement from the
entire hospital ecosphere – patients, families, front-line staff, management and leadership – brought
into focus through the lens of their daily experiences. Such involvement isn’t only essential to ensure
accurate assessment findings, but, it also serves to build broad organizational buy-in for the cultural
change strategy.

Change Strategy: From an informed foundation of the completed cultural assessment, defining a change
strategy with practical recommendations was both simplified and put on track. Recommendations boil
down to two principal factors: (a) those cultural elements that should be recognized and enhanced; and,
(b) those cultural elements which must be overcome in order to foster an ongoing atmosphere of
excellence to deliver first class patient care and to manage hospital operations. Thus, from this
comprehensively informed platform subsequent culture change recommendations and urgently needed
follow-on implementation actions tend to be broadly supported, successful and sustainable.

Conclusions: This work was in part intended to build upon the Quality and Compliance External Review
Report taking awareness many levels deeper to clearly get at thorny problems, catalyze a path to lasting
solutions, and, build upon positive developments already underway. Such progress to-date includes: a
potent transition to treatment malls with a recovery model, hiring proven new leadership and qualified
staff at all levels, sweeping facility upgrades that promote safety and patient care, and scores of ongoing
improvement projects such as the Behavioral Health Integration Project (BHIP) all aimed at top
performance, securing beneficial changes, and, helping the cultural transformation endure.

That said, at a summary-level there remain many concerns that hamstring operations today. Throughout
the hospital there is pervasively:

• A general lack of accountability • Gaps in robust policies, procedures and

• No shared vision for the future or “what
good looks like”
• A lack of trust and fear of retribution for
one’s actions
• Ambiguity with respect to roles and
responsibilities
• Inconsistent adherence to applicable
policies and procedures
training
• Weak and / or unpredictable internal
communication protocols with many
conflicting agendas
• Little understanding of why to measure
things, what to measure, how to make it
a routine part of the work and how to go
about establishing meaningful metrics at
the workgroup level

While the hospital’s cultural challenges to-date have been serious and have gone on a long time, with a
clear understanding about the problems, and, a thoughtful, resourced and fact-based plan to improve
upon them, none of these problems are infinite, insurmountable nor irreversible. With an investment in

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the progress initiatives noted above, developing employees and leadership, a commitment to
continuous improvement, and, reconfiguring the way daily work is performed so that measurable
engagement, involvement and communications are the only outcome possible, there’s in fact little
doubt that a lasting cultural improvement is just upon the horizon.

B. Background and Purpose

Organizational culture is best described as the collective personality of an organization. It’s a complex
tapestry woven from the underlying assumptions, attitudes, values, beliefs, shared memories and
customs of the workforce. Some of its elements are readily visible while some may be so tightly
interleaved that they are both difficult to both see and differentiate. It’s upon these learned and shared
assumptions that individuals base their daily behaviors that become habitual, patterned and integrated
into work performance and service delivery.

The ongoing transition to recovery-focused treatment programs affects every aspect of OSH’s daily
work. OSH recognizes that such a significant transformation from the past approach to patient care must
align not only systems and processes, but also the underlying organizational culture in order to become
a first class state psychiatric hospital. Kaufman Global believes the three core elements that sustain such
a beneficial cultural shift are:
I. Leadership commitment with visible, measurable support
II. A shared vision, mission and values
III. Staff involvement and ownership at all levels
This cultural analysis was conducted in order to determine which factors and forces currently at work
are most apt to oppose these core elements. It’s upon this basis that ensuing recommendations for a
culture change strategy are made.

C. Situational Assessment

Introduction to Tools and Techniques: There’s no single perfect tool for measuring cultural norms in an
organization as large and diverse as OSH. Yet, a suite of culture and climate tools in their composite yield
an effective organizational profile upon which decisions can be made and actions catalyzed.

Within that tool box private focus interviews can provide a safe environment for honest and candid
feedback. Yet, they are labor intensive and time consuming thereby limiting the amount of interviews
and feedback available. But, in the end they offer rich, narrative context and information as well as data
so must be performed in some way.

When reaching out to a larger and diverse audience such as OSH stakeholders, other analysis methods
are often employed. For example, online and written surveys allow for rapid data collection and
characterizations. Yet, for best results these must pose the right questions in the right ways, i.e. with a
keen awareness of the history, language and cultural nuances that influence an entire organization. Even
with those consideration addressed, it isn’t always possible or practical to get to everyone, everywhere
this way. As well, survey-fatigue sometimes sets in where participants suspect or have experienced a
lack of results and follow-through with prior discovery efforts. Worse yet, they may anticipate
retribution concerning their views. This can “check-out” of the process and must be managed.

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Finally, it’s natural for many members of an organization to see the most immediate aspects of their
jobs and organizational involvements most clearly
clearly. Ass factors about the organization become more
removed from their immediate responsibilities, personal experience tends to pale in comparison to the
effect of rumors, cultural beliefs and other less accurate factors. These inputs must be recognized and
balanced.

Figure 2 - OSH’s Cultural

Assessment Toolbox.
1.
Work was completed
using a suite of five OAES
discovery tools. Answers
offered insights into
creating the architecture
for the hospital’s effective 5. 2.
and sustainable cultural Workplace Focus
change, all part of Interviews Interview
OSH Cutural
becoming a first class state
Assessment
psychiatric facility.
Toolbox

4. 3.
Online Functional
Surveys Mapping

For these reasons, as well as available time within the allocated project scope, Kaufman Global selected
instruments, as shown in Figure 2, to capture the cultural
a series of diverse yet compact data collection instruments
norms in play at OSH. Those were, the Organizational Alignment and Effectiveness Survey, Focus
Interviews, Functional Mapping,
apping, On
On-line Surveys, and follow-on Workplace Interviews
nterviews. Explanations of
each method and their results follow.

1. Organizational Alignment and Effectiveness Survey (OAES): The OAES offers insights on
organizational positions, roles and authorities to identify areas of misalignment and differences in
perception between the senior leadership and the workforce. Kaufman Global performs the OAES
through written surveys administered
red to a statistically significant sample of employees. Results are then
analyzed and correlated to determine potential barriers to effective cultural change. It ranks the
organization’s strengths and weaknesses relative to managing changechange. It’ss used to prescribe
pr strategies,
interventions and communications tto overcome those weaknesses.. It allows for the subsequent tasks of
developing objectives and measures for defining transformation success, change management planning, plan
continuous improvement Project Char Charters,
ters, the communication plans and talent management /
development needs.

At OSH, 432 employees or approximately 25% of the workforce completed the OAES surveys. It focused
on characteristics such as perceptions about work relationships with peers and supervisors, perceptions
about the work environment and work structure, as well as the amount of innovation and change
readiness that the organization appears to support. Precise se categories of inquiry include worker

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involvement, peer cohesion, supervisor support, worker autonomy, task orientation levels, work
pressure, task clarity, worker control, factors that foster innovation, and, overall organizational change
readiness. Figure 3 - OSH OAES Analysis on the following page displays the summary results of those
surveys. The areas in green are favorable. The areas in white indicate some concerns. The pink areas
indicate greater concerns. The areas in red are undesirable. There seems to be relative alignment
between the largest groups sampled: Administration, Clinical, Nursing and Support Services. Groups that
didn’t participate in significant numbers were combined with the closest match for their identified
group.

Oregon State Hospital

OAES - All Groups
80
70
Percentile Rank

60
50
40
30
20
10
0
NV PC SS AU TO WP CL CT NN CR

Scale

Administration Clinical Nursing Support Services

Figure 3 - OSH OAES Analysis. Table 1 - OAES Interpretation, below, describes the general rules to apply
in reading the portrayed graphic.
Table 1 - OAES Interpretation
Factor Discussion
Involvement (NV) High scores are better
Peer Cohesion (PC) High scores are better
Supervisor Support (SS) High scores are better
Autonomy (AU) High scores are better if TO and CL are at least average
Task Orientation (TO) High scores are better
Moderate level of 35th to 60th percentile rank is desirable. If
Work Pressure (WP)
WP score is high, usually the CL and TO scores are low
Clarity (CL) High scores are better
Moderate level of 35th to 60th percentile rank is healthy.
Control (CT)
Over 60th percentile shows too much management control.
Innovation (NN) High scores are better
Change Readiness (CR) High scores are better

Further OAES Analysis: Generally, if most scores are low (as these are), employees believe they have
very little structure, unclear roles, little support from management and their peers, and, little

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acceptance to change due to unstable work environment. The OAES findings all support the overall
cultural assessment cited later in this document.

Relationships between scores are also important. The low results in every dimension, except for Work
Pressure (WP) should be cause for concern. Very low scores on Involvement (NV), Autonomy (AU), Task
Orientation (TO), Clarity (CL), Innovation (NV) and Change Readiness (CR), coupled with low scores on
Peer Cohesion (PC) and Staff Support (SS), indicate a group that feels generally disconnected, dispirited
and, in some areas more than others, beset with hopelessness. Such indicators are often displayed by
groups whose major accomplishments are a tribute to individual perseverance and work ethic.

Task Orientation is in the poor range for OSH. This generally indicates that employees struggle to
complete work done amidst some level of day-to-day chaos. It wouldn’t be surprising to find that many
employees spend considerable time responding to emergencies and problems rather than addressing
critical long-term issues.

Low Task Orientation and Low Clarity can cause Work Pressure to be high. Currently, Work Pressure is in
the “good” range but very close to being too high. Without higher Clarity and Task Orientation, there
needs to be a great deal of structure, lots of rules and enforced procedures to ensure that work gets
done. In other words, in such cases rules and enforced procedures can actually assure that work gets
done. As is shown later in this document, other data suggests that separate power centers, aside from
the top leadership may be enforcing their own priorities. This causes a great deal of the workforce’s
talent and effort to be poorly utilized, unfocused or squandered. The most prevalent causes of low
perceived Task Orientation and the percentages of employees sharing that perception in each
represented group are displayed below in Table 2 - Sources of Low Perceived Task Orientation.

Table 2 - Sources of Low Perceived Task Orientation

% Support
Reason % Admin % Clinical % Nursing
Services
Wasted time due to inefficiencies 87% 80% 78% 72%
Inefficient, low effort workplace 73% 89% 79% 72%

The most prevalent causes of perceived low Clarity and the percentages of employees who feel Clarity is
low are displayed below in Table 3 - Sources of Low Perceived Clarity.

Table 3 - Sources of Low Perceived Clarity

% Support
Reason % Admin % Clinical % Nursing
Services
Things are disorganized 67% 86% 89% 81%
Rules and policies are constantly changing 80% 66% 80% 62%

Another scale to be concerned about is the Administration group’s perception of Control. The low score
indicates little structure to keep them on track. Coupled with the low Task Orientation, there is apt to be
a good degree of emotional detachment.

Every group scored low on Change Readiness. This is customarily an indicator of high resistance to
change and / or uncertainty. Results from the Online Survey and the Focus Interviews reveal that most
are ready for change. Yet, they feel stifled by their immediate or second level supervision from doing so.
Despite the willingness to change, there’s also a level of apprehension due to the lack of stability.

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There should be some concern, particularly where the scores are lowest, that the four major group
profiles are not completely aligned. Some difference can be attributable to survey error or other factors.
However, it can also indicate four different organizations having disjointed perceptions about workplace
realities, and, more importantly, what should be done about them. This tends to suggest that a shared
vision with a common set of goals and standard processes have not penetrated through these groups. In
the absence of these essentials, factions within the organization have adopted their own unofficial sets
of priorities.

Clearly these issues must be addressed in order to compel a positive cultural change throughout OSH.
Later in this document, the results of the following cultural measurement instruments suggest further
recommendations and prescribed methodologies to move forward.

3. Focus Interviews: The richest source of in-depth cultural information was the collection of Focus
interviews. They were conducted with a total of 51 people, both staff and patients, representing several
disciplines and wards throughout both the Salem and Portland campuses. Newer employees, with less
than 6 months seniority, and, more senior employees with 30 years of experience were included. The
average length of seniority was 9.1 years. The interviews averaged 90 minutes in length. Held behind
closed doors, they were completely confidential and intended to identify organizational concerns and
barriers to effective implementation across several portions of the organization. Combined with the
other methods of data collection, these were used to develop and refine responsive strategies,
interventions, countermeasures and communications.

A total of seventeen questions were designed to learn more about the existing culture and better
understand and validate the Quality and Compliance External Review Report prepared in 2010. A card
sorting exercise was performed to help prioritize improvement categories. Cards containing issues that
normally influence Management and Staff interaction and similar issues that concern Patients were
sorted by respondents.

Management and Staff Issues raised were: Patient Issues raised included:
• Training • Training
• Communication • Communication
• Vision and Strategy • Safety
• Leadership Involvement • Rules for Privileges
• Teamwork and Cooperation • Staffing Levels
• Accountability • Planning and Scheduling
• Organizational Structure • Input to Treatment Plans
• Employee Recognition (Program) • Grievance Process
• Defined Roles and Responsibilities
• Management Support Note: a) Bold text = similar concerns.
Tabular results of the Management and Staff card sorting exercise follow in Figure 4 - Card Sort
Prioritization by Management / Staff. Similarly, tabular results of the Patient card sorting exercise
follow in Figure 5 - Card Sort Prioritization by Patients.

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 Figure 4 - Card Sort Prioritization by Management / Staff

Figure 5 - Card Sort Prioritization by Patients

Weighted averages were developed based upon priorities to get a general sense of the issues most
preventing OSH from becoming a first class state psychiatric institution. The key issues identified were:

Priority #1 Priority #2 Priority #3 WT. Avg.

Lack of Vision / Strategy 41.38 % 3.85 % 7.14 % 52.37 %
Lack of Accountability 20.69 % 15.38 % 10.71 % 46.79 %
Poor Communication 13.79 % 15.38 % 3.57 % 32.75 %
Lack of Training 0.00 % 15.38 % 17.86 % 33.24 %

Coupled with the results of the OAES, a pattern of needs began to emerge. Yet, perhaps more telling
than these figures are the following transcripts of the specific responses by those interviewed. These
touch upon critical areas of concern as identified in meetings with the senior management and are in no
particular order. These comments and findings offer opportunities to make valuable and needed
changes to OSH culture.

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The good news is that many of the staff and management seem ready and willing to implement these
changes in a positive light provided the “key findings” are addres
addressed.
sed. The bad news is that several staff
members are looking for employment elsewhere because they have become upset with the amount of
time it has taken to get this far, or,, a perceived lack of willingness to tackle change. Here are the major
impediments to o positive change expressed by the interviewees
interviewees.

I. Accountability

VII. Human II. Shared

Lack of these seven Resources Vision and
Empahsis Strategy
characteristics in the
OSH workplace
significantly constrains
potential for consistent VII Adequate III. Trust and
Training Retribution
top service delivery and
performance results.
V. Effective IV. Defined Roles
Communication / Responsibilities

Figure 6 - Focus Interview Discussion Detail. Participants said that these characteristics are the
predominant obstacles to overcome when crafting a cultural strategy moving forward.. While it’s difficult
to snap the fingers and create “trust”
“trust”, others such as role definition, training and creating effective
communicationss become early wins in a new path forward as the deeper problems are tackled.
tackled The
good news about all of these categories is that there are finite problems with reasonable
countermeasures to resolve them and all have been solved in other workplace environments.
environments

I. Lack of Accountability

Lack of Accountability represents one of the greatest opportunities for improvement at OSH. Also
identified in the Quality and Compliance External Review Report,, there are a variety of indicators that
show a lack of accountability at all levels. These range from rom a lack of consistent performance
management reviews with staff to ignored policies and procedures. According
ccording to the online survey, only
32% of staff has had a performance evaluation ““often” or “very often”” with their Supervisor. One
employee, who has worked for the hospital for over 25 years, reported having had only ten performance
evaluations. Another staff member has had only had two in nine years.

Along with lack of defined roles and responsibi

responsibilities, another key finding, lack of accountability is an
enabler for problematic employees. Where work standards exist, it’s very difficult for Supervisors to
enforce them if they are not clearly identified and performance is not measured periodically. As one
employee put it, [there is] “far
ar too much inconsistency
inconsistency; there are people who don’t know policies so they
don’t follow them.” Another staff member stated that, “therethere are 22 wards and 22 different ways of
doing things.”

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Although patient and employee safety can be put at risk, lack of accountability appears to happen at all
levels of the organization, including at the patient level. When patients act out or cause injury, there’s
often no retribution or accountability. This creates staff resentment, and possibly, harsher future
treatment. Conversely, some wards, such as 50E, clearly explain patient expectations and the reward
levels that are possible if good behavior is exercised.

Staff members referenced a lack of accountability at the top, reportedly sending requests to
Administration but never hearing back from them on a potentially dangerous situation. Staff feels that
they are: “rarely asked for input” and that Administration “doesn’t come to their unit and is not clinically
in touch.” “Rounding” by the Superintendent seems to be helping, although more engagement by
Administration is what’s truly missing, not just showing up on ward but actually getting involved in
patient care.

Interestingly enough in this slurry of observations, frontline staff consistently expressed that they seek
to be held accountable and expect it of their colleagues, as well. They noted that people typically do a
“sub-par job when they are not held accountable.” It has been said that, “often the media and
newspapers are there to hold us accountable.” A patient felt that “line staff needs to treat patients
consistently, [yet] there can be different treatment depending on the staff member. It’s difficult being
spoken down to.” One staff member made it very clear in saying, “I used to work in a restaurant and was
held more accountable as a waitress.”

II. Lack of Shared Vision and Strategy

Most respondents were not familiar with the Mission, Vision and Values for the hospital. It was
identified by over 41% of focus interview respondents as the number one priority to achieving
significant performance improvement. Clearly, the majority of staff is interested in seeing a positive
change at OSH and desire success for the new Superintendent. However, in the absence of a clearly
articulated strategy, most are confused about how they can help. Data from the OAES showed 62% of
clinical staff and 65% of nursing staff “are often confused about exactly what they are supposed to do.”

There are several different approaches that can lead to deployment of a much needed strategic
objectives and measurable goals. Just as leadership involvement is a big part of creating an engaged
workforce and developing trust, listening and involving your staff in goal creation is an important path to
ownership and commitment. Staff commented that they liked that the Administration was “crossing the
road” to get more involved in patient care. In fact, one idea that a staff member proposed (which
Kaufman Global has actually implemented with other clients) is a “Bring Your Manager to Work Day.”

Rounding, practiced by the Superintendent, is having routine upper level management presence on the
wards. Staff says it’s essential. Staff would like other leadership to “feel their pain”, as well, and
experience what they do every day on their wards. They referred to it as “visibility of Cabinet members
on the wards, [with] more involvement in delivery of care.” This may involve signing up for some actual
work hours on the ward, possibly a rotation. (Such leadership standard work is now common in almost
every enlightened workplace.) Staff believes it would help top management better understand why staff
is asking for change, “Walk the talk”, they say, “Demonstrate the culture and beliefs that you are trying
to get the rest of the hospital to adopt.”

Employees and patients need to know that there is a plan and how they can positively impact it. The
mission, vision and goals are “needed badly” according to one respondent. Most Staff feel it’s just as
important that top leadership identify the strategy with input from them. Goals and objectives must be
clearly communicated to all disciplines and at all levels. They feel in the absence of a shared vision and

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strategy that, “every discipline creates their own vision.” It’s believed that some of the lack of
cooperation between disciplines partially results from staff not knowing what they are supposed to do,
and, how they can beneficially link their work together. This isn’t because they don’t want to, but rather,
no one has ever taught them. As one interviewee stated, “Traditionally, our education teaches us to be
the best nurses we can be or the best psychiatrist we can be, not necessarily to be part of the best team
we can be.”

A staff member commented that, “The culture here at OSH has always been “get ready, get set……… No
one ever says ’go.’” Again, a clear vision with actionable, measurable goals would compel this to change.
Without it there continues to be a lack of continuity. The message can change from meeting to meeting
depending on what the focus or agenda is for that particular meeting. A senior manager commented
that “If I don’t know at my level, I feel that others have no clue.”

In order to know where you’re going, there needs to be a meaningful strategy behind it. The recovery
model is a case in point. Most people could describe quite thoroughly the characteristics of the recovery
model and the expected outcomes of its successful implementation. Although the recovery model has
been identified by the Superintendent as the direction for OSH, there’s still some apprehension on how
it fits into the existing culture of the units. Generally, clinical and medical staff had a much better
understanding of what patient centered care was designed to do, which is to give control of a patient’s
treatment to the patient themselves, whenever possible. Conversely, most support people, although
somewhat familiar with the term, had no clear understanding, allegedly having no formal training in the
recovery model since being employed at OSH. Some had received training as part of their formal
education.

Interviewees were asked if changes were successfully prioritized and implemented, what would the
chances be of implementing the recovery model of care – from “don’t know” or “poor”, all the way up
to “good” or even “excellent.” Seventy-nine percent of focus interview respondents felt that the hospital
had at least a good chance of implementing the recovery model. At the same time, one staff member
stated that they’ve been in lots of meetings where people don’t really even know what “recovery”
means.

Some respondents felt that there were conflicting messages in the amount of training on patient control
and the additional hiring of security staff versus the single day spent on recovery model training. Many
believe the hospital is currently a very prison-based system. There are still some wards that struggle to
implement this model due to both staff beliefs and the behaviors of some forensic patients. Some staff
come from a corrections background and have become accustomed to treating patients like prisoners,
so a major paradigm shift is needed. Building 50 seems to lead the way with some of these concerns.

Some programs are very goal oriented which makes implementing the recovery model much easier, as
in 35A for example, a transition ward. Their comments and recommendations touch on issues that will
greatly impact the success of the recovery mode at OSH. One staff member stated, “Get rid of punitive
staff that is against the recovery model - telling patients that you are going to throw away their food
[and] sack.”, is not productive. Another stated, “Several staff used to be corrections officers and they
need help to create mindset change. Punitive staff.” It was also offered up, several times to, “Increase
buy-in from MD’s for recovery model, not all is on board. Provide additional training.”

A shared vision would greatly benefit the Treatment Mall and Treatment Care Planning, as well. There’s
a wide range of implementation levels for treatment malls. Portland has had the treatment malls in
place for almost four years and they are working pretty effectively, although, content based on

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treatment care planning could be improved just as in Salem. Thirty-four percent of focus interview
respondents feel that treatment malls are good. But, another 44% feel that improvements need to be
made. Although treatment malls have been effective in getting a large percentage of the patient
population off the wards, there are still some who don’t fit in well with group activities. Most patients
that were interviewed stated they liked the concept and had some ideas on how they could be
improved. Class selection and content are areas that were identified. Also, a patient’s treatment mall
classes aren’t always tied to their treatment care plans.

Some clinical staff members noted a gap between treatment care planning and what the patient is
learning on the mall. This and safety seem to be their biggest concerns. Many patients want to do more.
Unfortunately, some only get accepted into about 10% of the courses for which they apply causing some
patients to lose interest. There are several benefits that have been realized with the malls, such as
expanding social skills, learning new information and interacting with different clinicians. Continuous
improvement should be applied to make the most of the treatment malls as they expand at the new
facilities. Many thought there needed to be a way to communicate the progress of the patient at the
mall back to his ward so that his treatment plan can be updated or adjusted as necessary.

Malls get patients out of their wards and into more social environments. It helps their recovery and
treatment in most cases. Because there’s such a wide range of “functioning levels” among patients on
the mall, it can be difficult to set course content that meets everyone’s needs. Patients stated there was
a lot of repetition, which can be a good in order to learn and test your skills in the next session, but,
annoying if you have already taken that class. There needs to be more subject variety in class
availability. Perhaps some of these changes will be made in Harbors. PAR distributed a survey asking for
improvement opportunities and all of these were mentioned, but to date, there has been no feedback.
Consumer groups were thankful for the training that Therapists had given them on the mall, and are
anxiously awaiting future sessions on the treatment malls. Patients feel they can and should do more.
Sometimes staffing levels on the ward impact a patient’s ability to attend some activities which is
upsetting. Hope is a key factor in successful recovery; to that point, the new hospital represents hope
for some of the patients. Less overcrowding and newer facilities cause most patients to eagerly
anticipate the move.

III. Lack of Trust and Fear of Retribution

The staff seems to be especially untrusting of the Administration level. The new Superintendent is highly
regarded almost everywhere, but, many identify barriers that exist amongst the old guard at the
hospital. There is a belief that the, “Old culture is designed to protect itself.” Online, anonymous surveys
still had references to “traced keystrokes” and fear of Administration determining who they were. In
order for a true culture change to occur, there must be a stronger environment of trust. Staff members
must feel they have credible input into decisions that affect their work. They relayed examples of
incidents where valuable information was withheld from them strictly out of a lack of trust. Some staff
members, who are strong advocates for patient well-being, find it difficult to work with those that are
more controlling of patients. Based on many comments, there’s not a lot of cooperation between
disciplines. Power struggles occur. There is a strong and shared doubt that the Administration level of
the Salem facility is ready to adopt and promote an environment of change.

Lack of trust is being demonstrated in a variety of other ways. Staff members described their fear of
retribution if they were to speak up and ask questions. Yet, they do seek more input into decisions. At
the same time, there’s some fear that the new Superintendent may listen only to “his Cabinet” and not
to the rest of the staff. There’s also a reluctance to believe that the “barriers of the past” will be

Kaufman Global 12
effectively addressed by the new Superintendent. It has been said that, “People at the bottom want
change but they can’t make it happen.” Many respondents felt that hospital politics are the most
horrific. They see people being promoted outside of their skill base. Both lack of trust and fear of
retribution must be addressed now so that true culture change can begin.

Patient Grievance and Patient Care are extremely important to patients and consumer groups. With the
exception of the PSRB, it’s near the top of their list for improvement. During the card sort exercise, it
received the most first place votes as a priority for significant performance improvement at the hospital.
It was stated that when the patient grievance process isn’t used on a ward it can lead to aggression and
acting out by a patient. Unfortunately, wards do not appear to promote the patient grievance process.
One indicator as to whether grievance procedures are used is to simply ask a patient where the forms
are when visiting a ward. Although some staff members don’t seem to believe in allowing the patient to
have access to the grievance procedure, patients and patient consumer groups disagree. They feel that
grievances are a patient right and possibly might be a mechanism to keep them alive. Many staff
members aren’t against patient grievances as a voice for airing their concerns. However, the unwritten
law on the ward often dictates that the staff acts uniformly, even where it opposes patient concerns.

Patients acknowledge there are many wonderful staff members who are compassionate and interested
in patient recovery. Unfortunately, clinical-to-patient ratios are much too high to be fully effective,
leading to “burn out” of social workers. The feeling today among several staff members is that, with
more social workers and lower case loads, there would be fewer emergencies and less crisis
management, especially if case loads could drop to a more “reasonable 1:20” from the “current 1:46.”

Sound vision, strategy deployment, and disciplinary functions must be aligned to prevent current
functional silos. One respondent was quoted as saying, “doctors, not being part of a group, pull rank
[they feel they] “can change whatever I want. They don’t trust lower job functions.” (Note: Decision
making models, similar to those taught by Kaufman Global at the DHS Leadership Academy are targeted
at these types of attitudes and skill deficits.)

IV. Lack of Defined Roles and Responsibilities

Most focus interview respondents recognized that there have been a variety of role changes over the
past several years, significantly impacting everyone’s job function. Only forty-six percent of online
survey respondents stated that their roles and responsibilities were “very clear.” This means that over
half of those completing the survey didn’t have a strong understanding of what they were supposed to
be doing. Focus interviewees recognized “defined roles and responsibilities” as the third most important
management issue to address during the card sort exercise.

Some respondents mentioned that their Managers did meet weekly with teams, typically about
problems, successes and what’s going on. Kaufman Global has advocated in previous DHS /OHA
development that daily shift startup meetings, called “Huddles”, are imperative to improve processes.
Such frequent, open and honest communication is needed to foster accountability. As one employee put
it, “The hospital needs to get back to basics with common sense – do your job or expect consequences if
you aren’t willing to do your job.”

To be a well respected mental health care provider, defined roles and responsibilities must be
established immediately, or de-facto substitutes shall continue to rule. Staff noted that constantly
varying roles and responsibilities result in a lot of judgment calls. Some managers are very clear in their
roles and responsibilities, and, are trying to put action plans in place to bring their teams up to speed on

Kaufman Global 13
same. Many are lacking the training to clearly understand their roles. “No one ever told me is a catch all
excuse for staff not doing their jobs.” There are no written job descriptions for many positions, adding
to “loose” job responsibility interpretations. Roles and responsibilities need to be in writing and we need
to be able to measure job performance.

V. Poor Communication
Staff members receive their information from a variety of sources. Some are more effective than others
and include:

• Email
• Meetings
• Hospital Newsletter – “Recovery Times”
• Ward Newsletters
• Local Newspaper
• Word of Mouth

As in most large institutions, communication is a major concern. Email is the predominant avenue for
communicating and it’s fairly ineffective principally since so many people say they have no time to get
their email. Respondents feel that, (real) “communication never makes it back down from
Administration level” continuing that there needs to be some structure, more accountability and more
transparency with information transfer. An example cited in more than one channel during the cultural
assessment is the apparent communication breakdown with the treatment malls. Often, what happens
with a patient on the mall doesn’t get communicated back to the patient’s ward. As a result, ward staff
isn’t familiar with the patient’s progress. It was a concern of several staff members that, “we need to
figure out how to communicate back to the wards what happened that day.” Ward staff members really
don’t know what patients have learned, or, if they are struggling and need to be retrieved. The reality of
this communication process and disconnect would be exacerbated by virtually any of the previously
cited cultural norms in play.

For the recovery model to be successful, communication has to be improved -- with the patient’s family
as well. Information isn’t reliably being relayed to the Communication Center in building 35 which can
limit the information that’s supposed to be given to family members. Often, a family member has
granted permission by the patient to receive certain information but Security doesn’t always share it
with them. A big part of patient directed planning is improved communication with family. There must
be more family oriented education because we all need a support system. An example of how poor
communication affects the patients is when Security states that no one gets to take a walk, when clearly
some patients are allowed as part of their risk review and privilege level. When it comes to medical
information, Security may ask “who am I allowed to give information to?” When they don’t know, they
don’t provide, even if patients want to give family access to information.”

Staff relies heavily on electronic media to get a message out to the masses due to its ease and simplicity.
Although there are currently few other such timely distribution avenues, there’s some information that
could be distributed better. Many people prefer face-to-face communication from the source so they
can ask questions if necessary. Minutes from a meeting or even material posted on area bulletin boards
also may be appropriate. All levels expressed seeking a clear and concise message from their superiors.
Ideally, information needs to be more transparent and “we need to share information more clearly.”
Both staff and patients commented – “don’t know what rules I am breaking – need to make rules more
visible.”

Kaufman Global 14
It’s imperative that the ward staff communicate clear and concise expectations for each patient in each
ward. Patients feel that it’s sometimes hard to get in touch with their Interdisciplinary Treatment team
(IDT) and would like to have more clarification from the Psychiatric Security Review Board (PSRB). When
talking with some of the Consumer Groups they feel that the PSRB gives “totally inaccurate
information.”

In Portland, staff mentioned that there was a communication gap when it comes to their current
campus and whether it was going to remain open for much longer. A new facility in Junction City is
scheduled to be built by 2015 so that the Portland campus can transition out of their current campus.
There hasn’t been any update. Staff feels that in the absence of information that it’s not going to
happen. When these types of communication gaps exist, they’re sometimes filled with rumors, or
misinformation. Much of the communication that patients and staff members receive about the hospital
is reportedly received from state and local newspapers.

VI. Lack of Training

The OAES Survey, Functional Mapping exercise and the Online Surveys also identified interest from both
staff and patient to improve knowledge and skills training. With several new employees, some having
little to no mental health awareness training, it‘s imperative that more skills based, hands-on training be
provided. Many Managers became managers through internal promotion for performance in their
previous positions at the hospital. The hospital hasn’t been as diligent to provide the necessary training
for some of the new Managers in order that they might be effective and succeed in their new roles.
Twenty-seven percent of Managers interviewed stated that “training for Managers in hospital is really
lacking.”

Conversely, there are some competent Managers who are very well respected by their direct reports.
When asking the various respondents what made their Managers so effective, there were common
themes. They were involved in patient care and assisting staff, and, they were good communicators,
clear in their expectations and vision for the ward. Under their leadership, respondents felt that their
voice was being heard. However, it’s clear from some of the other data that there’s an opportunity to
provide more mentoring and modeling of desired behaviors. Kaufman Global believes such training is a
necessary investment in a much valued group at OSH, the caregiver staff. There has been some effective
knowledge based training provided for hospital staff by EDD, but normally, due to coverage issues
colleagues are unable to take the training together. This leads to staff members returning to their work
area with some new found beliefs and techniques to utilize, but without any acceptance from their
peers.

Training is generally offered during only day shift. This causes issues with staff members on both swing
and night shifts who would like to have access. They tend to opt out in order to neither lose pay nor
work two shifts in order to fit in training. Moreover, reportedly not all disciplines are provided the same
access to training due to availability. For example, Treatment Planning Specialists get good training while
Nurses are sometimes left “out of the loop” according to some respondents.

DHS staff has participated in the Leadership Academy training for leaders and managers with excellent
feedback and results. It is recommended that key OSH staff participate in similar training together with
the new Superintendent in order to help them align their beliefs and to create some unity across
disciplines.

Kaufman Global 15
 VII. Lack of Human Resources Emphasis
The hospital doesn’t have its own human resources management office. Instead, DHS / OHA Human
Resources (HR) support is located on site. There seems to be a disconnect between what OSH Managers
expect in the way of HR support and that for which Human Resources actually feels responsible. This
topic resulted in substantial commentary, particularly among OSH Managers. One manager noted, “HR
is a barrier, not a help. I’m not abdicating my responsibility to train and supervise, but, HR isn’t helping to
get rid of bad apples, not taking a stand.” Traditionally, HR has monitored the performance
management process and helps to document poor performance. Several Managers cited incidents
where they had done everything that they were supposed to do to profile poor performance; still, the
underperforming employee was never dismissed. They feel that when poor performers are allowed to
stay in their jobs it undermines accountability.

Relationships with the Unions surfaced while discussing problem employees. Many managers feel that
the relationship between them and the Union is adversarial and they feel that every effort is made to
“avoid any arbitration.” Managers feel that the hospital needs to gain HR support to disposition staff
that exercise abusive behaviors. They want HR to be more integrated and functional. Perhaps contesting
the findings of the Quality and Compliance External Review Report, they say that they in fact do want to
manage their people. The feeling is that it’s not always easy to get information from HR. When
information is provided, it’s sometimes not provided in a timely manner. The comment, “can be waiting
for months”, was thought to be because decision making seems tied to a single delegated HR person.
Such slow decision making seems to promote stress, poor morale and sense of frustration.

3. Functional Mapping - Often, it’s very difficult for large numbers of employees and stakeholders to
express their concerns and attitudes about an organization in a focused, yet global, fashion without
having a roadmap to follow. Many lack an accurate view of the complexities of an organization outside
of their immediate work area. Others aren’t accustomed be being asked for their input. Similarly, some
find it difficult to offer constructive criticism several layers away without a sense of the limitations
others also face in doing their own work. For these reasons, Functional Mapping work was performed
with more than 450 stakeholders at more than two dozen sessions and in three locations; two in Salem
and one in Portland.

The response to the Functional Mapping exercises was overwhelming in its popularity, energy levels,
and engaged participation (Figure 7). Most appeared thoughtful and passionate about it, sharing similar
concerns regardless of work area or experience level. While Functional Mapping was conceived as an
inclusive and open process, some participants expressed concerns about workers and supervision being
“up at the wall” at the same time. Inability to effectively suppress that anonymity concern issue no
doubt accounts for as many as 10% of the contributors returning later to add information at some
locations. Finally, sessions with the Cabinet and Physicians were conducted primarily to identify
differences in perspective between line staff and more senior levels.

Kaufman Global 16
 Figure 7 - Function Mapping at Portland OSH

The Function Map created a comprehensive and inclusive "big picture" current-state view of OSH
business processes. These do not necessarily line up along the lines of an organizational chart but,
instead, follow perceptions of the rank-and-file advisors we had at OSH. These business processes
consisted of:

• Business and Strategy • Patient Services

• People and Training • Professional Services
• Health, Safety, and Environment • Professional Services – Nursing
• Health Information Group • Professional Services – Clinical
• Operations

Participants offered their insights on nine large functional map sheets as appropriate. They placed a red
dot for process problems, or, a blue dot for a communications issue. Sticky notes were used to explain
or elaborate upon the issue cited. Participants generated over 2,600 comments, many of those
reinforced by multiple participants. All of the participant inputs were later placed in one of seventeen
comment classifications. We then ranked groups by the amount of comments each function generated.

Figure 8 - Comments by Workforce, and, Figure 9 - Comments by Cabinet respectively are Pareto
diagrams for the workforce and the Cabinet according to the number of comments generated. Holding
separate mapping sessions with the workforce and the Cabinet highlights differences in perception
between the workforce and upper management.

Kaufman Global 17
 Total Comments Per Function Group
Workforce
500
450
400
350
300
250
200
150
100
50
0

Figure 8: Comments by Workforce

Total Comments Per Function Group

CABINET
45
40
35
30
25
20
15
10
5
0

Figure 9: Comments by Cabinet

“People and Training” and “Patient Services” are the top two priorities, on both of the charts, by sheer
percentage of inputs. People and Training had high concentrations of the seventeen comment areas, in
the Human Resources group, relating to:

• Accountabilities and Responsibilities

• Disciplinary Actions
• Performance Management
• Employee Communications

Kaufman Global 18
As evidenced below, in Figure 10 - Snapshot of “Accountability and Responsibility” on Salem Function
Map, there
here were high concentrations of comments in all areas on Education and Development.
Obviously, that’ss an area of concern.

Figure 10 - Snapshot of “Accountability and Responsibility” on Salem Function Map

The inputs were then preserved and gathered electronically. Where numerous like comments occurred,
the dots were counted and displayed along with the comments as shown below in the example, Figure
11 - Seven Comments with Many People Reinforcing Them. In this particular figure, Patient Services
drew the next most inputs with Forensics Psychiatric Services opportunities and specifically with Staff /
Patient Interactions.

Figure 11 - Seven Comments with Many People Reinforcing Them

The first big gap between senior leadership and workforce views was surfaced with “Professional
“
Services – Nursing” and “Professional
Professional Services – Clinical”. Line and staff reported many more problems
and opportunities on the nursing side. The workforce viewed Professional Services – Nursing as lacking
in accountability and defined policies and procedures. The Cabinet saw the largest need in Nursing as

Kaufman Global 19
more standardized work processes. Arguably, these can be two sides of the same coin depending upon
perspectives and proximity to the daily challenges, yet, they also provide clarity for some of the
comments received during the Focus Interviews.

Among the other areas of major concern with the leadership were the “Health Information Group
(HIG)”, “Operations”, and “Profession Services – Nursing.” Predominant comments from the workforce
showed a lack of understanding of the output produced by HIG. Most comments indicted that people
didn’t know how the data was obtained and it provided no value to them. This doesn’t mean the HIG
data is non-value added, but, it probably shows a lack of communication and partnership in obtaining
and analyzing the data.

In Operations, there was a lot of workforce energy and commentary focused at Food Services. It’s
believed this is due to the workforce being at the source (patients) to hear the comments about quality,
type and amount of food served. Operations were at the bottom of the Pareto for the Cabinet. This
would hint at upper management not having the pulse of Operations.

Based on content, each comment was identified as being most symptomatic of one of the seventeen
major types listed below. These categories are no doubt to be pursued during this task's deliverable 1c,
technical support, in order to help implement the necessary OSH cultural changes. They also are
provided to the Cabinet to deploy for action throughout their organizations and for their own engaged
follow-up.

The type classifications and predominantly expressed key points are listed below:

1. Accountability
a. Tasks not being completed
b. Wasteful practices
c. Roles and responsibilities not being followed
d. Corrective actions for employees consistently late or missing, do not follow hospital policies

2. Administration
a. Unclear administrative business practices
b. Requesting clothing allowance, meal subsidy, etc.
c. Change in work hours, days off, etc.

3. Behaviors and Culture

a. Derogatory remarks about another group
b. Old practices which can’t be changed
c. Perception of hospital
d. References such as “this isn’t our problem”

4. Communications
a. Not knowing OSH vision and direction
b. Ineffective verbal, written, or electronic communication
c. Not knowing current status of OSH changes
d. Failed submitted ideas and missing follow-up

Kaufman Global 20
 5. Facilities
a. Size of rooms, people per room, etc.
b. Need for equipment, furniture, etc.
c. Maintenance of property
d. Property, buildings or equipment being unsafe

6. Organization / Structure
a. Anything concerning adding or deleting positions
b. Combining groups or moving groups to another part of the organization
c. Need for certain groups, such as committees, cabinet members or functional groups
d. Reporting structure and “chain of command”

7. Patient Care
a. Quality of life for patient
b. Neglect or abuse of patient
c. Monitoring patient improvements
d. Needs: medical, psychological, treatment mall, dietary, etc.

8. Planning and Strategy

a. Comments on wanting to be involved in planning
b. Not knowing what the future (usually 5 years) looks like
c. Questions on how Planning and Strategy take place

9. Policies, Procedures, and Documentation

a. Not knowing what the policies or procedures are
b. Need for updating policies and procedures
c. Not having the correct documentation
d. Questioning the need for certain documentation
e. Use of documentation (i.e., required by law, used for improvements or fixes, or, it isn’t used)

10. Process / Standard Work

a. Questioning if there is a process for a certain function
b. Requesting processes to be developed
c. Call for consistency in performing processes
d. References to standardization being necessary on certain functions

11. Quality
a. Quality of deliverable on any function
b. Patient care
c. Quality of what is offered to the patient in treatment malls
d. Daily patient hygiene, diet, room and building cleanliness, etc.)
e. Care of the employee (right equipment, safe environment, acceptable work environment, etc.)

Kaufman Global 21
 12. Roles / Responsibilities
a. Not knowing what a person’s duties / tasks are
b. Tasks not being done because it was unclear who should do it
c. New hires having to learn their job by “tribal knowledge”
d. Claims that someone else should have done a task

13. Salary and Payroll

a. Complaints about pay structure
b. References that one person gets paid more than another
c. Problems with getting paid (no comments were found on this)
d. Mandated OT may be here depending on context of comment. Most mandated OT comments
were placed in “Accountability” or “Planning” depending on the reason for the OT.

14. Security / Safety

a. Security concerning building access, badges, helping to secure a patient, transportation, etc.
b. All references to physical threats or actions to employees
c. All references to unsafe conditions due to building maintenance problems, broken or wore out
equipment, night lighting in parking lots, contact by patients (physical, verbal, or email
messages), lack of help to defend against patient aggression

15. Skills and Training

a. Amount of training (lack of or too much)
b. Quality of training
c. Needing a specific skill or training
d. Training delivery (classroom, web-based, self-paced, etc.)
e. Skill sets or training needed by patients to prepare them outside of OSH

16. Support (Agency, Community, etc.)

a. Individuals or groups outside of OSH who help patients
b. Involving the patients in community based programs
c. Family members being involved in the treatment plan of the patient

17. Technology / IT
a. New technology to streamline or improve hospital practices
b. Software applications for different functions
c. Needing computers, printers, copiers, etc.

At the conclusion of the Kaufman Global analysis of the Functional Mapping exercises, the trends of the
previous analyses were both reinforced and made increasingly clear. As was expected there were some
differences in perception between where workers had experienced severe issues and where senior
leadership saw areas for improvement. This is apparent below in Figure 12 - Comments by Workforce,
and Figure 13 - Comments by Cabinet, respectively. Kaufman Global believes that most of these
differences are attributable to readily solvable problems with communications.

Disturbingly, and as validation of some other findings, some participants in the mapping exercises
expressed a fear of stating their true opinion with supervisors in the room. More than half of those

Kaufman Global 22
expressing this fear returned at a later time to post their concerns. This indicator of the level of fear
among subordinates indicates a destructive cultural norm beyond what’s normally encountered by
Kaufman Global. It may also be a further indicator of a lingering fear of retribution, and sub-optimization
that have resulted from a past, prolonged environment of blame as cited in the focus interviews and in
interviews on the wards.

Also in what appears to be a related set of events, Kaufman Global experienced efforts by some
functional areas to avoid on-site interviews, attempts to control the dialogue, or both. These simply may
have been attempts to avoid additional painful scrutiny, or, may reinforce a belief in the cultural findings
cited later in this document.

Total Comments Per Classification

Workforce
350

300

250

200

150

100

50

Figure 12 - Comments by Workforce

Kaufman Global 23
 Total Comments Per Classification
CABINET
50
45
40
35
30
25
20
15
10
5
0

Figure 13 – Comments by Cabinet

Interestingly, among the first eight priorities cited by comment type and not functional area, Workforce
and Cabinet share the same concerns with only minor changes in their ranking position. Table 4 -
Differences in Frequency of Comments by Category, Workforce vs. Cabinet (below) shows a side-by-
side comparison of the categories and their ranking with minor out-of-sequence ranking highlighted.

Table 4 - Differences in Frequency of Comments by Category, Workforce vs. Cabinet

Workforce Ranking Classification Cabinet Ranking
1 Policies, Procedures, and Documentation 1
2 Accountability 2
3 Skills and Training 5
4 Behaviors and Culture 4
5 Communications 3
6 Organization / Structure 6
7 Roles / Responsibilities 7
8 Processes / Standard Work 8

Kaufman Global 24
4. Online Surveys – Two on-line surveys were posted, one for the workforce and one for the Cabinet.
The survey questions were identical, but less demographic information was solicited from a small intact
cabinet organization. 648 people completed the workforce survey and 13 Cabinet member surveys were
completed. They were electronically tabulated with results and demographics for respondents.

The online survey questions and responses are depicted below in Figure 14 - How much knowledge do
you have about the OSH Excellence Project, and the changes being made?, and, Figure 15 - Your
defined roles and responsibilities are . . .

These are two more examples of differences between workforce and senior leadership perspectives.
Again, solvable communications issues and ensuring a keenly understood sense of roles and
responsibilities is suggested for future implementation actions.

60%

50%

40%

30%
Workforce
20% Cabinet
10%

0%
None Very Little Fair Quite a A lot Don't
Amount bit Know

Figure 14 - How much knowledge do you have about the OSH Excellence Project, and the changes
being made?

80%
70%
60%
50%
40%
30%
Workforce
20%
10%
Cabinet
0%

Figure 15 - Your defined roles and responsibilities are . . . .

Kaufman Global 25
Just as the OAES survey indicated that “Clarity” was lower at OSH than any other factor, the Online
Survey provides us another indicator of a situation validating that employees aren’t sure of their roles
and responsibilities. The Cabinet seems to feel they are aware of their roles and responsibilities much
better, but, still aren’t completely clear. As they should have the greatest access to information,
initiatives and direction, this speaks to a decided opportunity to formalize and effectively communicate
an organizational strategy. That would surely be the first step in eradicating misunderstood policies and
procedures as well as a decided organizational dependence upon unofficial (and sometimes inaccurate)
lines of communication.

The last question of the online survey gave each participant a chance to make comments and be
completely candid. The surveys had no names or I.D. numbers assigned to them, so, the information was
strictly confidential. This helped ensure a sense of complete candor. 248 unsolicited remarks were
posted by the workforce. Many of them indicated dissatisfaction with the current culture and reinforced
the findings cited later in this document. The general tone and content of these were briefed to
leadership. With fully 38% of the surveys having such comments with a similar or common theme, the
issues of accountability, standard work, roles and responsibilities, communication, and training once
again came to the foreground. As demographic information didn’t appear on these comments, thereby
protecting the respondents, it’s believed that these comments were sincerely offered and perceived to
be true.

5. Workplace Interviews – As the hospital was quite open regarding access to the work areas, wards and
offices, we were able to capitalize on any time available to learn and refine recommendations sourced
though other channels. While there’s not a huge summary to be made concerning this method, it in fact
created opportunities to gather less structured opinion in an ad hoc fashion during the course of the
work. Moreover, it offered another important aspect of stakeholder involvement, particularly with
patients. It served to facilitate follow-up discussion where more topical clarity was needed from other
discovery tools. This learning has been incorporated in other sections of this document. Lastly and
importantly, it offered a chance to communicate about a brighter future with so many. The power of
these interactions moving forward cannot be underestimated.

Current Cultural Norms: Each of these instruments were used individually and collectively to evaluate
gaps between where the organization sees itself performing today versus where it aspires to be, and to
identify differences in perception between the different stakeholder populations involved. On the
positive side, the great majority of the workforce is here because they want to make a difference, care
deeply for the welfare of the patients, and, are committed to the welfare of their community.
Repeatedly, these traits were demonstrated as the Kaufman Global consultants and analysts went about
the task of collecting cultural data. These traits bode well for OSH becoming a center of excellence in
care and patient progress. Unfortunately, as has been pointed out, there are significant concerns as
well. Those factors can be separated into seven major categories, most of which are related and
therefore have similar or common causes and solutions.

Kaufman Global believes that, during prolonged periods of crisis management and change, sub-
organizations, including all levels of leadership as well as the workforce, can and often do tend to revert
to an attitude of self-protectionism. That is, since everything is constantly in flux, each area tends to
expend most of its resources -- whether informational, material, or people energy -- to ensuring that
particular area does not fail and lay itself open to even more pain and suffering, even if the rest of the
organization might.

Kaufman Global 26
This break in faith with the larger organization gives rise to separate agendas. Subsequently, the lines of
communication in practice, not necessarily the official communications channels, are sometimes used to
subvert what’s required and what is not. Therefore, accountability, communications, shared
organizational values and vision, and, defined roles and responsibilities suffer. At OSH, other factors
such as a prolonged past history of tightly controlled employees and a recent deep and sometimes
painful spike through external scrutiny have led to an imbedded culture of blame and protectionism in a
few functional areas. In those areas, individual desire to improve often competes with the need for
professional self-preservation.

D. Cultural Changes to be Instilled

Discovery in this document supports the assumption that the following cultural factors and
characteristics must be addressed. They’re what will most likely prevent OSH from becoming the mental
health excellence center it desires to be regardless of the quality of their facilities or level of resources.
Recapped, those cultural factors are:

1. A lack of accountability
2. Lack of a shared organizational vision and strategy
3. Lack of trust and fear of retribution
4. Lack of defined roles and responsibilities
5. Poor communication
6. Lack of training
7. Separate agendas at some levels and in some functional areas

Kaufman Global believes these are common ills for complex, diverse, highly visible organizations. Many
are inter-related. That means that improvements in one area may drive and yield improvements in
others. Yet, they deserve a comprehensive approach to ensure needed changes can take place. OSH is
fortunate to have a Superintendent and DHS / OHA top leadership team with the wisdom and resolve to
make the necessary changes. As it took a long time to get this way, it predictably won’t change
tomorrow. It requires time, effort and support over a long-term. Yet important wins can launch
immediately in terms of setting the vision and communicating progress. A re-alignment of the leadership
team accountabilities is indicated, and, depending upon the willingness of key players to adapt to a
shared organizational vision rather than their personal agenda, mid and upper-level leadership changes
may be required. But, to do so without substantive improvements in other areas of concern would be
purely cosmetic.

People must be held accountable to the senior leadership’s vision regardless of interim or opposing
loyalties. This isn’t a blanket indictment of past leadership or factional solutions; they had their reasons
to make the choices they did. Rather, it’s a systematic set of steps that must include informing everyone
of what is expected of them and holding them accountable. Related to this issue is a lack of a shared
organizational vision and strategy which has several independently moving parts. All must be addressed
as stated below. Poor communication need be addressed on many levels as must a lack of training.
Reversing issues around trust and fear of retribution requires action, evidence and above all the
leadership’s continued interest and attention.

Finally, overcoming a lack of defined roles and responsibilities must occur on many fronts as well.
Clearly, every nuance of a job cannot be etched in stone without sacrificing the agility OSH needs in this
changing environment. At the same time, it’s hardly too much to ask to document accurate position
descriptions as an important part of the solution. Perhaps the HR issues raised are simply related to

Kaufman Global 27
improved information being provided to the managers. Or, it may require a better, perhaps OSH-owned,
HR presence. That sorts out in the next steps. That is the power of a common shared vision.

E. Strategy for Bringing about Cultural Change

Introduction: As a result of these findings regarding as-is cultural norms, several next steps are
recommended, anticipated and planned as part of the strategy to transform both the hospital culture,
and in turn, hospital performance so that it meets and exceeds first class state psychiatric facility
standards.

In order to meaningfully and sustainably influence that culture, the leadership vision must be one, its
objectives and measures clear, and, the continuum of care refined and stated. Effective steering and
governance for change must be put in place and sustained. They must set the vision, remove obstacles
and barriers to change, and, reinforce and communicate continually about the good things that are
happening and how to tackle challenges.

From that fundamental platform of leadership excellence, people’s roles and responsibilities can be
captured and documented, then, unambiguously stated and imposed. A system of both recognition and
consequences against that very performance standard is then legitimately installed for all stakeholders.
Communications becomes integral and important. Positive work reconfigurations can be implemented
and sustained. Teams themselves work to establish meaningful metrics. People begin to see their work
add up to a common good.

Early Wins and Essential Quick Hits

Cabinet and Continuous Improvement Governance Structure – The key to so many of these changes is
a re-vitalization and re-alignment of the senior leadership and the continuous improvement governance
structure. To that end, Kaufman Global, in consultation with the senior leadership at OSH, has
recommended a new Cabinet structure and concepts surrounding its specific makeup to the
Superintendent. It includes a new position of Project Management Officer (PMO). The purpose of the
PMO would be to have a certified Project Management Professional to ensure all projects stay on or
ahead of schedule, on or under budget, and, enjoy appropriate risk, stakeholder, and communications
planning.

Robust Communications Framework and Protocols to Displace Current Channels – Kaufman Global is
slated to work with OSH to help expand and enhance the internal communications infrastructure. This
helps to fill the perceived void in information at OSH while reducing reliance upon third party and
unregulated sources. Doing so requires improving measurable communications accountability. That’s
likely best achieved by centralizing and endowing the Communications Office with oversight
responsibility for all ‘corporate’ communications. With help from Kaufman Global, OSH can better
leverage local communications initiatives while both simplifying and amplifying the message regarding
OSH Excellence with a strong identity. With an expanded, more functional communications
infrastructure alongside better sharing of critical functional information, OSH can celebrate successes
and progress – the many good things that are changing.

Performance Feedback – Several weeks ago at the prompting of Kaufman Global, a new performance
feedback system was initiated in OSH by HR personnel. In the majority of work centers, this change has
gone mostly unnoticed and has been poorly reacted to. This brings two additional factors to light that
must be addressed for accountability to improve. There must be a more robust system of official

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communications from the top down that transcendtranscends those areas where what
hat the senior leadership
desires is in conflict with the priorities of middle managers. The
he layers of management must be made
accountable to the senior leadership in ways that they haven’t experienced for many years. The
organizational power centers that are opposing the changes that the Superintendent desires to make
must change direction or lose that power.

Setting the Course – In order to secure top leadership engagement and involvement, an early February
2011 Strategy Development
elopment Rapid Process Improve
Improvement (RPI) workshop is planned for
fo the project roles
Figure 116):
forward from now as follows (Figure

Figure 16 – Rapid Process Improvement Workshop

Workshop. This chartered workshop brings together executive
steering / Cabinet to establish a credible foundation for continual improvement and hospital
performance. It meets the needs of the organization and the cultural transformation. It builds off task
work to-date
date and participant knowhow to create potent outcomes potentially refining deliverables
going forward.

Building off of Task 2, Objectives and Measures, tthis

his RPI workshop is essential to create buy-in
buy for
change and engage the right people in leading
leading, resourcing, monitoring
itoring and redirecting future
improvements. We’re thrilled to be conducting this timely and collaborative event that quickly brings
together needed facts, the right team and a lot of important knowhow to set the stage for an overall
OSH Improvement
ement Strategy. While performing this workshop and achieving its deliverables significantly

Kaufman Global 29
transcends a cultural assessment or a simple table of metrics, it also server to accelerate the pace of
change and produces a better outcome for the hospital and its stakeholders.

Anticipated Follow-on Implementation

Tasks to come are shown in Figure 16, above. There is an ample dosage of implementation and practical
skill transfer to come. Although all tasks to come remain priorities in our planning and delivery, Kaufman
Global intends to take an active role during Task 1’s deliverable 1c in order to:

1. Help strengthen accountability throughout OSH to ensure projects stay on schedule, on budget,
react well to risks and opportunities, stakeholder needs and communications plans. Kaufman
Global has a certified and experienced Project Management Professional on-site. Mentoring to
the superintendent and cabinet are available and are being offered.

2. Counter a lack of a shared organizational vision and strategy, better define both the roles and
responsibilities, and strengthen processes, through coaching and mentoring based upon vast
governmental experience.

3. Help re-vitalize and re-align the senior leadership at OSH to include an effective continuous
process improvement governance structure, add expertise and support to that transformation.

4. Take positive and proactive measures to help rebuild trust and eliminate acts of retribution, real
or perceived, through education, coaching and mentoring.

5. Providing much needed training in all of these concepts, especially in the areas of leadership
and management as has proved successful at the DHS Leadership Academy.

6. Teach ways to expose, make unnecessary, and eliminate any separate agendas in a blameless
environment design to foster continuous improvement.

7. Accessing proven Kaufman Global tools already in place throughout as a result of the DHS / OHA
Transformation including the full LDMS® with 20 Keys®. 20 Keys should prove exceptionally
important to put world class benchmarks and a linkage to the OSH Vision, Mission and Values at
everyone’s fingertips in every workgroup. With 15 joint keys in place, and five ready for OSH
customization, this proven tool makes improvement predictable.

Summary: Many improvement efforts often upset an uneasy equilibrium and seem to make things
worse in the short-term. It’s incumbent upon the senior leadership at DHS /OHA, the Addictions and
Mental Health Division, and, at OSH to stay-the-course, remain committed to resolve these issues, and,
make the lasting improvements the leadership, staff, workforce, patients, community and State of
Oregon deserve. Kaufman Global has overwhelmingly observed that both the OSH workforce and
leadership have demonstrated a very deep desire to make a difference for the better. Kaufman Global
finds this consistent with an almost universal regard for co-workers and the patients. Their honesty and
openness are at the same time impressive and inspirational. It’s now incumbent upon OSH leadership
and stakeholders to help ensure these steps are taken to become the first class organization that it can
be. To that end, Kaufman Global pledges its intent not only to reveal those cultural issues that must be
changed as it has here, but, to roll up our sleeves to help implement those changes. The forgoing culture
assessment and strategy has been only the first step.

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