Archive for October 16, 2012

Adaptive Leadership Rises in Human Services

An autistic child must go to a residential treatment facility because his school cannot manage him — his mother, who is the only one who has the soothing touch her child responds to, is forced to give up custody. Thinking creatively, human services practitioners work with the school district to hire his mother, so she can be the one to give him the in-classroom support he needs. The boy stays in residential care for less than a month and the family moves forward together. This is the art of the possible in human services — and adaptive leaders are making it happen.

With budget cuts driving fewer resources and the economic downturn creating increased demand, human services leaders must continue to develop creative approaches to deliver programs with the resources they have. This pressure — and the media attention that covets headlines about tragedies over stories of triumph — can be overwhelming.

Yet there is optimism among human services leaders despite these challenges. Today’s environment is cultivating a new breed of adaptive leaders who favor possibility over pessimism, fearlessly go against the grain, and feel energized where others are paralyzed. As adaptive leaders break through traditional barriers to build capacity through outcome-oriented business models and family centered approaches, they are driving profound changes.

Adaptive leadership stands in stark contrast to the leadership style prevalent in human services of a decade ago that managed inputs and outputs in an institutional and bureaucratic environment where preserving the status quo was paramount. This transactional leadership model has become ineffective today. Clearly, as organizations traverse the human services value curve, there exists a need for transformational change — and transformational leadership.

Ron Heifetz, co-founder of the Center for Public Leadership at Harvard Kennedy School, has pioneered the concept of adaptive leadership with his book, Leadership on the Line — Staying Alive Through the Dangers of Leading, which he co-wrote with Marty Linsky.

According to Heifetz, moving an organization or system through transformational change requires identifying and resolving a mix of “technical” challenges (problems we can fix with current knowledge and abilities) and “adaptive” challenges (problems that require learning and the application of new competencies). People and stakeholders must internalize the changes, shedding old practices and loyalties, accepting new ones and developing new structures, systems and cultures. Adaptive leaders “exercise leadership” by guiding and pacing people through both the discomfort and opportunities of this adaptation.

This concept can be applied to the human services where “adaptive challenges” arise from driving change across two dimensions. The first is “technical innovation,” which involves typical changes that organizations and people experience when making incremental changes within existing structures. The second is “organizational innovation,” which is atypical change that requires new roles, capabilities and competencies within a new paradigm.

In human services organizations, those exercising adaptive leadership help staff, stakeholders and partners learn new practice models and new competencies — and pace the innovation at a rate that an organization and its people can sustain.

Adaptive leaders are making inroads in all sectors, but this leadership style especially aligns well with the social sector.

Human services leaders often cannot be as autonomous and authoritarian in their leadership styles as executives in the private sector and other state agencies are. Many must also manage through more complex stakeholder and partner dynamics and organizational structures.

Adaptive leadership is ideally suited to drive creative approaches in such a complex environment. Adaptive leaders are well positioned to create cultural norms, tangible plans and expectations in which continuous improvement and transformative change will occur.

Adaptive leaders set up and use systematic mechanisms for monitoring progress, impacts and lessons learned, creating a “learning organization” to drive outcomes. Adaptive leaders adhere to several fundamentals:

Know the organization. Traditional human services leaders view the organization as a singular entity, a monolith rich in sameness, common thinking and common doing. Adaptive leaders know their organizations as ecosystems bound together by a common purpose, but steeped in difference. They understand that their agencies include stakeholder groups that overlap, but that each group has its own unique characteristics. As such, moving people toward a common center means understanding existing competencies and attitudes.Forecast the future. Adaptive leaders get ahead of change before it happens because they take the long view of all impacts. This approach includes a willingness to consider longer-term strategies for change, despite the short political cycle, and an evolutionary versus a short-term results orientation. In this, short-term but unsustainable and potentially traumatic strategies of recent times are replaced by adaptive leaders’ measured understanding of “what it will take.”Break down barriers. Adaptive leaders are not turf oriented. They focus less on championing an organization’s place in the larger enterprise than on championing across the enterprise. This is important because human services is broadening to a community of interest that looks beyond contractual relationships, and is more about developing a collective of nontraditional public- and private-sector partners focused on sustaining whole community well-being.Be disruptive. Adaptive leaders privilege outcome-focused goals and principles above all else, even if they require major changes to organizational norms and sacred cows. This mindset is evident in approaches that were rare even five years ago, such as shared services, cross-jurisdiction collaboration and social media outreach. Disruption is also as much about building new competencies as it is about effectively letting go of old ones. Be agile to get to the end game. Adaptive leaders adjust mid-course if new information is revealed or if economic, technological or social changes occur that require a different approach. This spirit is couched in a realization that leaders must carefully calibrate an organization’s readiness for change and set the right pace accordingly.Empower the organization. Adaptive leaders focus on empowering and flattening the organization to deemphasize hierarchy and silos. They engage staff at all organizational levels in collaborative, cross-functional diagnoses of problems and solution identification. These leaders also foster other voices of leadership from all levels of the organization because they can seed change and motivate others. Sense and respond. Adaptive leaders hold true to their understanding of other people, and of themselves. They consider deeper impacts of gains and losses, and perform self-checks, realizing they may have their own barriers to work through to get to desired outcomes.

There are variations within the adaptive leadership style in human services. While leaders may lean more toward one, there is overlap and fluidity among them as leaders adapt to changing circumstances.

Silo smashers take the big picture view of the entire human services community of interest rather than having a myopic view of their own agency. They are open to new ideas because they are not mired in narrow context or subject-matter expertise. This relational mindset is vulnerable — in a good way — to the influence and interests of others.

Moreover, silo smashers are adept at driving outcomes that require cross-program and cross-system practices and services. These leaders can demonstrate a lack of pragmatism or systematic planning and execution if they are not well rounded or if they fail to surround themselves with necessary and complementary capabilities.

Lynn Johnson, executive director of the Jefferson County, Colo., Department of Human Services, is a model silo smasher. With a commitment to “do something different” to improve the agency’s program effectiveness and reputation, she has embarked on a transformation initiative to bring together historically siloed programs. To drive this change, Johnson is working across stakeholders — including 600 staff and 65 nonprofit and 350 faith-based groups — to drive a cultural shift.

Her approach is rooted in the philosophy that magic happens when there is no single leader and teams are allowed to focus on what they do best, making cross-program connections and taking risks along the way. It’s an outcomes-based focus made possible by cross-community engagement and whole-person, whole family solutions.

As Johnson explains:

“We started looking at the passion circles. We started saying, what are you passionate about? You know I have a huge agency, 13 different departments — 50 different programs. We all did our passion circles, and then we linked them because we didn’t want to be doing different things. We wanted to be driving in the same direction.”

First movers know that sustainability requires pioneering spirit that spurs renewal and embraces risks. They understand that trust requires being one’s own worst critic, which is counterintuitive for many leaders. These leaders are data and logically driven, and confident that moving the needle is strengths-based, instead of deficits-based.

These leaders make their own blueprints and know how to adjust midstream if outcomes are not forthcoming. They are likely to analyze root causes and underlying drivers of an effective practice as part of planning and execution.

The Washington Department of Social and Health Services moved from transactional management to transformational leadership because of former Secretary Susan Dreyfus’s passionate first mover approach.

Dreyfus recognized that driving outcomes in difficult times demanded “a different and dynamic organization.” She asked everyone to join her in leadership, and flattened the organization. She also set a unique precedent, finding unexpected value in ambiguity as only adaptive leaders can:

“… in bureaucracy as soon as something becomes ambiguous we want to shut it down, we want a technical solution, we want to get it under control because it’s in that space of ambiguity that bad stuff can happen from the political standpoint, and yet it’s that one space if we allow it to happen is where creativity occurs.”

Future drivers look to the horizon. They want to understand why things are the way they are and address problems at the root. These leaders are effective in driving outcomes requiring community capacity building and working from a low baseline current state. Weaknesses can arise if future drivers over-analyze and do not move quickly into execution mode.

With an eye to the future, the Hampton, Va., Department of Human Services — initiated by Walt Credle and now led by Director Wanda Rogers and Deputy Director Denise Gallop — used a legislative driver as a springboard to dramatic and lasting change. The department spearheaded the coordination and alignment of more than 30 programs over a 15-year period.

Creative and integrated service strategies ultimately led to positive outcomes. Hampton has not had one child placed in a residential treatment facility since 2007. The community has not placed a child in a group home since 2008. There has also been a greater than 85 percent reduction in foster care numbers. Part of this success comes from the future driving leadership vision to involve family perspectives in developing solutions. Rogers explains this “common sense” approach:

“We always, always, always start with a good assessment of what this family brings to the table and what this family wants, partnerships, public and private providers, recognizing that families are the experts about their families. When we begin to do that, we were able to really lock into moving from knowing to doing …”

While the results that these adaptive leaders have achieved are impressive, adaptive changes are only starting to take shape in human services, and most exist in pockets.

To make a lasting impact in human services, adaptive leadership must move beyond the top of the organization chart. Sustaining its value means “giving back the work” to everyone — embedding this spirit across the organization and addressing resistance by confronting its non-constructive forms with conviction. The adaptive model involves co-creating solutions and making it possible for stakeholders and partners to process change, add competencies and give up old ones in a protected environment.

Just as human services practitioners used a one-child-at-a-time approach to help an autistic boy stay in school, so must adaptive leadership be a one-leader-at-a-time approach where the art of the possible ultimately becomes a part of an organization’s DNA.

Republished from Policy & Practice, American Public Human Services Association. Antonio Oftelie is executive director of Leadership for a Networked World and fellow at the Technology and Entrepreneurship Center at Harvard University; Julie Booth is Accenture managing director for North American Human Services; Tracy Wareing is executive director of the American Public Human Services Association. The article reflects insights shared by human services leaders at the 2011 Human Services Summit, held at Harvard University in October 2011.

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Buzz Off! New Tech Tracks Pest Inspections in Virginia

Technology may never be able to fully eliminate bothersome pests such as mosquitoes, but it’s making it easier to spot and swat habitual insect breeding sites in Prince William County, Va.

Workers in the county’s Gypsy Moth & Mosquito Control program are using a custom-built, real-time data management system with a Web-based GPS-enabled map interface. Accessed via an iPad, the mobile field reporting tool has enabled field technicians to more efficiently find and mitigate insect sites, as well as record when the area was visited and what chemical or method was used for treatment.

Prior to the new system, workers would manually record site visits on paper forms and store them in a binder. They’d then head into the office to type the same information into a database, cutting short the amount of time they had in the field. That information would then be copied from one database to another as needed by county personnel.

Tim McGonegal, branch chief of the county’s Gypsy Moth & Mosquito Control program — a part of the Environmental Services Division within the Prince William County Department of Public Works — made the call to upgrade to a modernized reporting system a couple of years ago.

Field techs were spending up to seven hours a week on data entry, and anytime McGonegal had to run a report on their activities, he said it was like “pulling teeth” because the information was stored in multiple databases.

So instead of continuing a paper-based system, McGonegal came up with the application’s work flow and mocked up a set of electronic forms in Microsoft PowerPoint. After getting approval for the concept and selecting The Timmons Group of Richmond, Va., to design the system, the initial beta version was delivered in September 2011. The process to bring the system live took about a year.

The application features a variety of drop down menus and automated functionality, so very little typing and data entry work is required. McGonegal’s crew used the application for gypsy moth surveys through November 2011.

After the first trial run, some additional search parameters and reporting tweaks were made, and GPS tracking was added to the application so field technicians could more easily find existing breeding locations. The final version of the system went online in March, and the county purchased nine iPads for the crew and other personnel responsible for some field work. Total cost of the entire project was $40,000.

The department started using the technology for mosquito season and is up to 4,500 inspections so far this year — way up from past years, according to McGonegal, though he did not give specifics.

Adding the tracking functionality was a huge efficiency gain for McGonegal’s field crew. For example, in addition to plotting a more precise morning route, if field techs are in unfamiliar territory, they no longer have to rely on another crew member’s notes about the location to guide them to an existing breeding site.

“If they are in the middle of the woods with no real structures to orient themselves, they hit the tracking button, a blue blinking dot comes up and they can walk to the stand of trees accurately, without rely on an old description,” McGonegal said. “It’s really been a morale booster for the field crew; they all really like it.”

The system’s also been a winner back at the office. Instead of calling a technician’s cellphone to assign a site visit, McGonegal or his assistant can enter the information directly on the system, which will send it instantaneously to the person’s iPad out in the field. The change has helped improve response time to citizen requests.

In addition, the program makes pulling up detailed information and generating reports a lot easier for McGonegal. He said that at any time, a representative from the U.S. Department of Agriculture can make a visit and ask to see treatment records. In the past, the process of coming up with those records might have taken hours.

Now a report can be quickly created for each treatment area by map, including details on what technician was last at a site, the product used, and which type of breeding site it was. All of that information is available minutes after a tech completes a site visit. The data is also stored in the cloud, making retrieval more convenient.

Field technicians can also spend additional time checking out different types of potential breeding sites. In the past, because of the demand for data entry, technicians were just looking at storm water management ponds because there was no time to expand the program.

But now workers can take time to look and map places such as ditches, streams, swamps and other areas that could be trouble spots for pests. The department now has more than 1,800 breeding areas listed, which is double the amount they had prior to the new data management system coming online.

“Our volume of sites is getting larger and [the field crew] has time to do it because of the system,” McGonegal said. “As we grow, we may have to add another field tech, but for now, we’re handling it pretty well.”

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Eight States Awarded Health Insurance Exchange Grants

Eight states received funding to offer citizens and small businesses access to health insurance exchanges, the U.S. Department of Health and Human Services (HHS) announced Aug. 23. California, Hawaii, Iowa and New York were awarded Level One Exchange Establishment grants, which provide one year of funding to states that are in the starting stages of building an exchange. Connecticut, Maryland, Nevada and Vermont received Level Two grants, which are multiyear grants provided to states further along in the process of building an exchange.

Health insurance exchanges, which are one-stop marketplaces for comparing and selecting health insurance, are being created to support President Barack Obama’s recent law that requires every citizen to have health insurance. According to the HHS, access to these exchanges will be available in 2014, will provide access to “high-quality, affordable health insurance” and will provide citizens with “the same kinds of insurance choices as members of Congress.”

“We continue to support states as they move forward building an exchange that works for them,” HHS Secretary Kathleen Sebelius said. “Thanks to the health-care law, Americans will have more health insurance choices and the ability to compare insurance plans.”

A detailed breakdown of each grant and what each state plans to do with its exchange funding is available on

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Mining data for state CDC, Maine HIE pilot project aims for population analysis

The Maine HealthInfoNet is aggregating and analyzing health information exchange data at the population level, with the aim of finding trends and specific figures that currently evade most tools of epidemiology.

In a pilot project funded by the Centers for Disease Control and Prevention, HealthInfoNet, Maine’s statewide HIE, is collecting and assembling data for the Maine CDC, using the open source software popHealth. The project focuses on 13 Meaningful Use clinical quality measures using the ABCDS — aspirin therapy, blood pressure, cholesterol and diabetes control and smoking cessation.

It should let public health researchers find out, for instance, what percentage of Mainers with diabetes have sugar levels under control and what percentage of hypertension patients had their blood pressure checked during their last medical visit.

[Related: CDC to use Direct protocol for health safety network.]

These and other public health measurements, at least of large populations, have eluded researchers for a while, said Stephen Sears, MD, Maine’s state epidemiologist.

“If you want to know how many diabetics within a database there are within a certain age group,” Sear said, “that’s almost impossible to get right now unless you have a data set like the Maine HealthInfoNet registry.” Plus, you need the technology to sift through it all while staying HIPAA compliant.

Sears is cautiously optimistic that they’ll be able to find all of what they’re looking for in the various clinical areas. “What I’ve seen is that it suggests that for certain parameters it looks like its going to be able to work.”

The data basically runs from HealthInfoNet and its vendor, Agilex, to popHealth and then to the Maine CDC. The U.S. CDC’s role is mostly funding and support, through its program Demonstrating the Preventative Care Value of Health Information Exchanges.

The project and a lot of data collection started a little less than a year ago. Now HealthInfoNet and the Maine CDC are essentially testing their capabilities.

[See also: A look at how Maine’s HealthInfoNet is turning grant money into actionable outcomes data.]

“For every person, each month we’re producing different measures for people based on conditions,” said HealthInfoNet CEO Devore Culver. They’re able to make comparisons like how many diabetics who’ve had a hemoglobin lab test scored under 9, an indication of diabetes control.

“The state CDC expends a significant amount of energy and effort trying to gather and compile data that allows them to draw conclusion about trends of health in Maine,” Culver said. “Up until now, it’s been a fairly manual-intense process and the data is not always clear.”

Culver noted that the project is first of its kind and could be a boon to the Maine health department and CDC.

“It’s really a first foray into whether you can repurpose information, not violate patients privacy or expose providers, and use it for something of value and see how health is progressing in the state,” Culver said. “This is a very low cost, with a lot of value.”

If Maine can prove the analysis works, the goal is to eventually take the model to other states, said Dr. Taha Kass-Hout, Director of CDC’s Division of Informatics Solutions and Operations.

[Feature: A new age of biosurveillance is upon us.]

“We’re building a way for state health departments to use the data that’s circulating around their state health information systems,” Kass-Hout said. “The whole goal here for us is to be able to create shared services and platform for local and state health department to use this data.”

First, though, HIE organizations need to be able to meet certain technology and policy criteria that lets them navigate potentially rough waters, he said. HIPAA compliance is a major challenge, as is maintaining providers’ privacy.

“Maine Health InfoNet has the right governance, the right policies and it’s independent, non-for-profit — free of much political or industry influence,” Kass-Hout said.

The pilot project runs until the end of the year. Kass-Hout wouldn’t say if the CDC will renew funding for another year.

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CMS EHR incentive payments flirt with $7 billion

Medicare and Medicaid electronic health record payments are approaching $7 billion since its inception, with $6.9 billion paid out to 143,800 physicians and hospitals in total program estimates through the end of August.

Final figures will be available later this month as the Centers for Medicare and Medicaid captures more complete data.

In August, the agency paid about $500 million in incentives, with about $325 million going to Medicare providers and $175 million to Medicaid providers, “which will bring us knocking on the door of $7 billion in incentive payments issued as of the end of last month,” said Robert Anthony, a specialist in CMS’ Office of eHealth Standards and Services. 

He reported the latest EHR incentive program statistics at the Sept. 6 Health IT Policy Committee meeting

In July, the totals were $6.6 billion since the program’s start paid to 132,511 eligible providers.

As of July, nearly 1 out of every 5 Medicare eligible provider, or about 18 percent are meaningful users of EHRs., he said. Additionally, 1 out of every 4 Medicare and Medicaid eligible providers has made a financial commitment to an EHR, he said. And 55 percent of eligible hospitals have received an EHR incentive payment for meaningful use.

As of July, 271,105 Medicare and Medicaid physicians and hospitals have registered to participate in the incentive program, tracking at about 10,300 monthly, he said. Breaking down the total, that’s 180,513 Medicare physicians, 86,708 Medicaid clinicians and 3,884 hospitals.

[Survey analysis: Romneycare vs. Obamacare, do Americans care?]

Even as more physicians and hospitals participate in the incentive program, nothing has changed related to their level of performance in the attestation data, Anthony said.

“The longer we go saying that not much has changed, the more encouraging that trend actually is because it is an indication that more and more providers are coming in, yet everybody is performing at a statistically high level,” he said.

Providers tend to exceed the required threshold of performance for recording objectives for problem list, medications list or medication-allergy list. And there is little difference in performance among physicians and hospitals, Anthony said.

“As we move into August, we’re no longer looking at just the early adopters, we’re looking at people who may still be in their first year of meaningful use, but they’re not necessarily the people who are at the beginning of the curve. Yet we continue to see very high performance across the board on all the objectives,” he said.

“We will be better informed when we have people returning later in 2012, and we can do a comparison of meaningful use in a second full-year period vs. a 90-day period,” Anthony noted.

Besides the required measures, the most popular menu objectives to attest to are advance directives, drug formulary and clinical lab test results for hospitals; and drug formulary, immunization registry and patient lists for physicians. The least popular measure is the transitions of care summaries for both.

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