Factors influencing organizations' use of NIATx: Dr. Tom Hilton responds

July 23, 2015

Tom Hilton is a retired NIH science officer and NIDA program official now in private practice. Tom has over 40 years of experience studying and conducting large-scale organizational change initiatives in publically-traded corporations, DOD and other large federal agencies, as well as general-medical and addiction health service organizations. In this blog post, Dr. Hilton comments on a recent study published in the Journal of Behavioral Health Services Research that discussed the factors influencing use of NIATx. That study found that larger organizations with more administrative resources that treat more patients and participate in national associations and in NIDA’s Clinical Trials Network are more likely to use the NIATx model.
Organizations change in response to one of two things: being oriented towards continuous improvement, or crisis. Both are usually rooted in leadership.

Organizations in crisis suffer from emotional blindness caused by fear, panic, and role overload. As far as leaders of declining organizations can see, exploring changes in policies and practices is an impediment to immediate mission accomplishment. That lack of foresight too often leads to the organizational equivalent of a massive coronary that usually puts the organization out of business.
How does one overcome such thinking? The real challenge in change involves overcoming inertia. Usually that inertia emanates from the widely accepted values, beliefs, and practices that determine what and how work gets done (i.e., organizational culture). Some cultures facilitate productivity and quality outcomes. Other cultures unwittingly undermine it. So how can one determine if their culture is in need of peaks and tweaks or complete overhaul?

 I have always found an organization’s climate to be a ready indicator. When people are “burning out” and moving to another clinic or leaving the field altogether, it is usually a reaction to a toxic climate.

Both directors and clinic staff can contribute to a toxic climate by externalizing organizational problems. It is easy to blame overwork on insufficient community support, dwindling third-party reimbursements, and simply too many people seeking help. The resulting exhaustion derived from a toxic climate and culture enables that sort of rationalization. “I know how to swim, but I am still drowning here.”  That sort of thinking often blinds incumbents from noticing how simple changes can help to turn things around. In the swimming metaphor, it can be as simple as allowing yourself to drift into shallower waters.

In the field of addiction recovery, organizational inertia is especially common because so many provider organizations are small in size and resources, and many have a long history of struggling to find resources to support their work. The role overload that once was due to external factors gets mistaken for role overload now emanating from internal factors that are creating barriers to efficiency and effectiveness.

So, unless the organization perceives that it has some extra resources, it is unlikely to perceive that it has the “luxury” of exploring change, much less believe that it has the energy to engage in change. This is the same vicious circle as the revolving door metaphor for addiction relapse. Cruelly ironic is the likelihood that if you do not fix the organization, you are not likely to slow the addiction revolving door for clients either. So, I guess a big challenge for NIATx is finding a way to educate providers about the need for change.

As I mentioned, a fairly reliable barometer of organizational health is organizational climate. And a bellwether sign of a deteriorating climate is staff exhaustion. Being tired after a busy workday is normal. Feeling exhausted on most days signals organizational decline, a decline that risks taking staff and patients down with it.

Maybe offering a checklist of climate indicators of decline might stimulate interest in change. I have a million of ‘em, but these five seem most germane to addiction:

1. Staff members frequently complain of feeling exhausted.
2. Clients are dropping out in greater numbers than the past.
3. No-shows are becoming more common.
4. Employee turnover is diverting resources to recruiting and training.
5. Most of staff members feel that things would improve if only external factors like funding would improve.

Any one of these symptoms signals a need for continuous improvement troubleshooting. More than one symptom usually indicates the need to stop and assess the entire organization’s health. This is the sort of activity that NIATx was designed to help addiction health service providers accomplish.

How does your organization identify the need for change or the need to improve your processes and systems? Let us know in the comment section below.

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