Program Unity

It’s hard to overstate the importance of program unity. I have heard many times people ask program leaders and staff what they do. It’s a simple enough question, and yet, the answers can often be too vague or too convoluted. Having a program-wide, clear understanding of what the program does is a necessary foundation. Aside from mission statement development, I have observed that specific, inherent tensions consistently arise in facilities of all sizes, which can seriously impede department and team cohesion. Managing these tensions from the beginning can prevent many fires from even starting within the organization.

Inherent Tensions:

Time - Employees often feel pulled in too many directions, with never enough time to get everything done and do things well. This occurs when policies and requirements are implemented without conducting a thorough workflow analysis to assess their impact on each department's workload, or without speaking with staff in the departments to gain an “on the ground” understanding of how their workflows operate in practice.

I remember working with a Chief Operations Officer who was very numbers-driven. He calculated the number of clients at a given time and divided them by the number of therapists to get an idea of the number of FTE’s needed in clinical. This is logical, of course, but the team was struggling and felt incredibly invalidated when leadership said they shouldn’t be overwhelmed, given the numbers. I used a hiking analogy to explain this problem. Basically, the FTE formulas measure the DISTANCE of a hike, but they don’t always account for the INCLINE correctly. As anyone who has walked up a steep hill knows, one mile can feel very different and take much longer walking uphill than on flat ground. In this example, the “incline” included interdepartmental communication barriers, cumbersome and inefficient documentation requirements, and even something like the size and layout of a building can take up precious time.

Finances and Client Care - We all know that these two factors can be a source of tension in the treatment space. However, I have found that leadership teams and the “business” side of behavioral health stay compartmentalized from the treatment teams. While this is necessary and helpful to some extent, I believe there is also a benefit in acknowledging this tension to those on the other side, for the sake of transparency and understanding. Generally, I have seen mature clinical teams acknowledge this aspect of the work we do and even offer helpful solutions that non-clinical staff may not have considered. Likewise, sometimes the revenue side of the operation could use a reminder of the long-term benefit of building a good reputation, improving outcomes, and reducing staff turnover.

Differing views on client care. It’s often the case that therapy and medical teams have different and sometimes opposing views on client care, from diagnosis to expectations within the milieu, to consequence structures; the gap can be broad. Challenges with conflict and/or resentment between teams occur when each team is not educated on the fundamental principles of the other teams. For example, a nursing team is inherently more directive than a therapy team. This makes sense for their role. If these teams don’t understand one another, it’s tough to negotiate or ethically compromise on client care.

Hospitality and clinical - Hospitality usually covers admissions, community relations, and marketing teams. This tension can be seen as a subset of the inherent tension of finance. This tension arises when the treatment team’s recommendations, boundaries, ethics, or requirements are not well-received by individuals who are not part of these teams. I like to think of this in terms of the way these teams work. Essentially, hospitality is about pleasing a customer and saying, “yes”. While a clinical team is about challenging the client and saying, “no”. From this perspective, the tension becomes obvious, and we can see how easily conflict and frustration can arise.

Risk management and operations/client care/finance - For the most part, risk management and client care are aligned, with the tension more evident in operations and finance. However, we live in a highly litigious culture, which can lead to overwhelming demands to try to mitigate all possible risks. On the other hand, risk management itself can be costly and may be overlooked or cut, potentially putting clients and staff at risk of harm. Working with this inherent tension is crucial and nuanced.

These are a few of the tensions I have observed in facilities. There will likely be additional inherent tensions that are specific to each facility. In my experience, it works better to address them head-on rather than deny their reality or try to avoid them.