Social Work in Health Care, 54:193–211, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 0098-1389 print/1541-034X online DOI: 10.1080/00981389.2014.990131

From Organizational Awareness to Organizational Competency in Health Care Social Work: The Importance of Formulating a “Profession-in-Environment” Fit WILLIAM SPITZER, PhD, DCSW Health Care/Social Service Consultant, Glen Allen, Virginia, USA

ED SILVERMAN, PhD, MBA Division of Social Work, Keuka College, Keuka Park, New York, USA

KAREN ALLEN, PhD, LMSW School of Social Work, Indiana University, Bloomington, Indiana, USA

Today’s health care environments require organizational competence as well as clinical skill. Economically driven business paradigms and the principles underlying the Patient Protection and Affordable Care Act of 2010 emphasize integrated, collaborative care delivered using transdisciplinary service models. Attention must be focused on achieving patient care goals while demonstrating an appreciation for the mission, priorities and operational constraints of the provider organization. The educational challenge is to cultivate the ability to negotiate “ideology” or ideal practice with the practical realities of health care provider environments without compromising professional ethics. Competently exercising such ability promotes a sound “profession-in-environment” fit and enhances the recognition of social work as a crucial patient care component. KEYWORDS organizational awareness, profession–environment fit, leadership, hospital social work

Received June 16, 2014; accepted November 17, 2014. Address correspondence to William Spitzer, Health Care/Social Service Consultant, 12208 Chadsworth Court, Glen Allen, VA 23059. E-mail: [email protected] 193

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INTRODUCTION While social work programs have long emphasized the combination of focused field and classroom experiences as requisite in the preparation of health care social workers, debate has long raged on the perceived disconnects between campus-acquired knowledge and its subsequent usefulness in professional social work practice (Carlton, 1989a, 1989b; Caroff, 1977; Christ, 1996; Silverman, 2012; Spitzer & Nash, 1996). Many scholars cringe when students and practitioners are unable to identify a practice theory or professional model that serves as the underpinning to their practice. Yet many students enter the first day of their field practicum only hoping that their field instructor and others in the placement setting will help them blend social work roles, knowledge, skills, and values into the beginnings of competent professional practice for effective work with clients. They often fail to appreciate how organizational characteristics and conditions directly impact their work with clients as well as their own satisfaction and morale. This is particularly difficulty in highly structured, rapidly changing, and complex organizations such as health care systems. While micro-level mastery is often enhanced through practice and ongoing professional development, even experienced social workers struggle with the more subtle aspects of macro- practice and leadership proficiency. For social workers, the ability to understand external influences on practice and propose creative patient care initiatives is crucial in today’s rapidly evolving health care environments. The emergence of transdisciplinary care and the mandate for integrated physical and behavioral health care requires keen sensitivity at both the individual patient care (micro-) and organizational/community (macro-) level. It is not sufficient to be merely clinically competent; one must be aware of organizational issues influencing and driving clinical practice in order to provide services that positively impact patients and organizations, foresee need, and propose and initiate viable change. To do so requires an initial sense of “organizational awareness” that evolves toward full professional competency. The Council on Social Work Education’s 2008 Educational Policy and Accreditation Standards (EPAS) identifies 10 core practice competencies that span the boundaries of micro-, mezzo-, and macro-level systems (http:// www.cswe.org, n.d.). While these are clearly productive steps toward defining professional practice, they cannot explicitly capture and address the extent of the knowledge gap experienced by novice professionals when transitioning from classroom to organizational settings. The behavior needed to assess one’s capacity to function effectively within organizations remains vague. At the same time we question the ability of the average graduate to become organizationally aware and competent by trying to apply to organizations those engagement, assessment, intervention, and evaluation skills learned in clinical programs.

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The ability to understand and adapt to the conditions of one’s organization, balance tensions between the mission of social work and that of the agency, and assess risks for initiating change can significantly impact the quality of the work experience and factor into retention decisions. This article explores the concept of macro-level “organizational awareness” in health care settings, specifically those contextual issues and organizational dynamics that a generalist or clinically oriented social work education may not sufficiently address. These include recognizing current challenges and state of the health care environment, emerging federal policies and mandates, the importance of differentiating competency and ideology and, importantly, understanding organizational culture so that a sound “profession-in-environment fit” can be achieved.

FACTORS AFFECTING AN ENVIRONMENTAL PERSPECTIVE FOR HEALTH CARE SOCIAL WORK A number of factors have combined to affect how social workers perceive their environment and their practice roles. These include the divisions in practice that historically evolved in the 1940s between psychiatric and medical social work. Each of these areas regarded patient concerns, interventions and professional roles from different perspectives, to the point that many hospitals maintained separate social work units. Shifts in reimbursement and the introduction of managed care and product line management contributed to declines in the prevalence of centralized social work departments and availability of intra-professional supervision and training. Social workers increasingly found themselves thrust into environments where refining professional identity was clearly subverted to completing those tasks necessary to expediently transition patients with a minimum of incurred costs to the health systems. Currently, however, a new opportunity presents itself for social workers to renegotiate and reestablish their presence, purpose, and role in health care systems. More than any piece of legislation in recent history, the Patient Protection and Affordable Care Act of 2010 (PPACA) will facilitate both an evolving role and new practice challenges by changing the environmental field (health care organization) of social work practice (Spitzer & Davidson, 2013; Allen & Spitzer, 2015). The PPACA seeks to curtail escalating health care expenditures while improving population health, patient care access and outcomes. It places a fundamental focus on efficient service delivery by integrating physical and behavioral health care along a continuum of settings orchestrated by new private and public Accountable Care Organizations (ACOs). Of these ACOs, 428 were operating in 49 states by January 2013, most typically sponsored by hospital systems, physician groups, insurers,

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and community-based organizations (Muhlestein, 2013). The ACOs expect cooperation and collaboration among health care practitioners and their reimbursement is influenced by the documentable delivery of outcomedriven services. Integrated care is key, creating opportunities for social work practitioners and educators to collaborate in redefining both micro- and macro-practice approaches to care. Competency in the PPACA environment is defined by demonstrating positive outcomes for both patients (micro) and provider systems (macro). Organizations will no doubt develop a host of strategies for responding to this mandate and these may or may not require the involvement of social work. To illustrate, primary care physicians, who write most prescriptions for anti-depressants, can continue and increase this practice. They may or may not have the capacity, however, to demonstrate required positive outcomes. To truly integrate behavioral and physical care, it is critical that care systems include individuals trained in behavioral health. Social work leaders, practitioners and educators must collaboratively advocate for social work as a qualified and cost-effective discipline in responding to this challenge. While practitioners understandably rely on their unique technical competencies, increasingly they must employ those competencies in service delivery models based on “transdisciplinary” care. To succeed in integrating care, social workers must contribute in developing shared patient care outcome goals and understanding the methodologies used to attain them. Transdisciplinary team models engage all needed disciplines and afford them an equal voice in formulating shared treatment plans (Little, 2011). Coordinated by a physician, these teams work collaboratively to competently provide care, access and communication, care coordination and integration, and care quality and safety (American College of Physicians, n.d.). Being cognizant of the physical, environmental, and psychological factors influencing both patients’ conditions and their response to treatment is crucial for effective functioning on transdisciplinary teams that address the physical and behavioral health needs of the “whole patient” (Gilbert, Trachtenberg, Davidson, O’Donnell, & Perone, 2011). As evidence, the “AccountabilityBased Primary Care Workforce Model” promoted by the American Hospital Association (AHA, 2013) presumes role clarity, role training, and team communication achieved by active collaboration on patient care. That model specifically identifies social work as an integral team component with responsibilities for case management that addresses the behavioral and psychosocial needs of patients and that is different from the type of medical case management performed by nurses. With the requirements of the PPACA and the workforce model endorsed by the AHA, social workers should be identified and included as essential members of the transdisciplinary team. Social work education can take a proactive role by establishing practice behaviors for organizational competence in these integrated health care systems, including competency in

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working effectively in transdisciplinary care teams. Social workers will also require acculturation to negotiating these increasingly complex, “matrixed” host organizations. The accountability for such preparation must be jointly assumed in the classroom and field. Included in that preparation is the specific need for a macro-related knowledge base designed to allow social work practitioners more impact and influence within the host organization (Silverman, 2015). Rothman and Mizrahi (2014) recently underscored this paradigm with a call that included increasing the numbers of both macro-oriented faculty and recruitment of macro-focused students.

DIFFERENTIATING COMPETENCY FROM IDEOLOGY The first challenge for students and new practitioners entering the health care environment is to recognize and reconcile the gap between professional competence and ideology. All professions have a culture and brand; social work is no exception. What becomes an issue is how the individual professional aligns their ethical values and practice competencies with a fluid health care environment—an environment in which both the needs of organizational providers and patients are ever-changing and driven by a myriad of factors. This distinction between competency and ideology is critical as it forces us to examine how we communicate and market “social work.” Perhaps too often we instinctively promote ourselves through the persistent maintenance of profession-based values and ideology at the expense of a more strategic marketing approach that could emphasize talent, competency, and knowledge-base (Silverman, 2008). It is at this point that health care social workers must recall that they are practicing in what has always been known as a “host setting.” In a host setting, social work and the social needs of patients are not the primary domain of attention. Dating back to the very origin of health care as a social work field of practice, Ida M. Cannon demonstrated sensitivity to the balance of her professional values/perspective and the operational realities of her employer—Massachusetts General Hospital. Cannon is credited with establishing the first organized hospital social work department, defining the role of medical social work in outpatient and inpatient settings, and negotiating the fine line for social workers serving in a “host,” and at times hostile, setting. Rather than taking a radical position that challenged the medical model and the primacy of the physician in health care, she instead attempted to accommodate social work within the prevailing hospital culture. The approach of advocating for patients and promoting organizational change while respecting the primary medical role of dealing with physical disease and the centrality of the physician on the health care team remains relevant for contemporary social work health care practice (Allen & Spitzer, 2015).

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Like Cannon, contemporary health care social workers reside in an ecosystem that does not naturally support social work life. The operational mission of health systems is to improve the health and functional status of the patient. Health care systems try to achieve this by efficiently and economically maximizing the use of available and appropriate resources, including diverse professions. Social workers contribute to this mission by addressing the patients’ psychosocial needs and the barriers that impede achieving this goal. They focus on personal strengths and accessing needed resources in the environment. How a component, in this case social work, is sanctioned to act within a provider organization is determined by its perceived worth. In the course of such effort, fundamental questions are posed. What value does the component bring to overall operations? What competence does the component offer that impacts on the status of both patients and the organization? Does it address patient need, promote positive patient clinical outcomes, reduce operating expenses, add revenue or efficiency, enhance organizational stature and community relations, and/or benefit risk management? The health care social worker must distinguish what knowledge, skills and abilities they bring to the organization and then conscientiously work in such a manner that these contributions become apparent. While the practitioner is anticipated to embrace the values, ethics, and standards espoused by their profession, their value to the organization ultimately surfaces in the effort made to blend those elements into the culture and operating systems of the provider organization. Demonstrating and effectively communicating the extent to which our services add value to the organization determines our continued presence within the system. Failing to do this has negative consequences. For example, Berger, Robbins, Lewis, Mizrahi, and Feit (2003) note that nursing and other health care professionals direct and lead an increasing number of health care social workers. The loss of social work leadership and supervision can and does have a compelling effect on not only the patient–practitioner but supervisory relationships and establishes parameters of practice unique to particular settings (Neuman, 2000, 2003). The ability to negotiate “ideology” or ideal practice with practical realities without compromising professional ethics is a fundamental skill for social workers in host settings like health care. Competency may thus be defined as encompassing the behaviors, skills and talents that one must possess to practice ethically while working within the constraints, resources, and expectations of the organization. Conflict management, interpersonal communication skills, and team facilitation are often competencies identified in leadership development models and can be operationally defined and measured as behaviors and proficiency. By comparison, an ideology is a belief or philosophy one aspires to and that is, by definition, ideal rather than reality based. For example, one may believe that teamwork is a noble or necessary endeavor, but that does not necessarily translate into team facilitation competence.

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With that said, we do not believe that health care social workers should be encouraged to dismiss or diminish the ideological and philosophic pillars that ground our profession. Social work has a long, distinguished history of both effectively advocating on behalf of those in need and delivering sensitively competent intervention. What is recommended is that social workers in health care (and other practice fields) assume a strategic, skill-based social marketing approach that is both collaborative and recognizes the needs of all system stakeholders. In other words, it is crucial to lead with social work competence rather than ideology. Diamond and Markowitz (1995) underscoring Dublin (1989) stressed that if social work leaders wish to transform and mold service, they need to study, examine and adjust all aspects of their operations. Those operations must be in harmony with the strategic plans and goals of the organization (p. 40). Failing to take into account the priorities, mission, strengths, and limitations of the organizational context in which one is practicing is to invite being regarded as making incomplete and inaccurate assessments and ultimately, faulty interventions. On the other hand, those who can envision future change and adeptly align their competencies with organizational goals most often create the prospect of an expanded marketplace for their professional services. Colone (1993) has specifically stressed the need for social workers to develop a practice perspective that is inclusive of effectiveness and efficiency as well as true to the ideals, values and ethics of the profession. These dimensions are not mutually exclusive and are in fact essential to organizationally competent practice in a host or complex system. It requires individuals to move beyond their professional ideology, identity, and instincts and think “organization too.” For the social worker to gain broader system recognition of their philosophic position on service delivery, they must first recognize the determinants of their organization’s mission, service priorities, and preferred operational modalities. Next they must assess what elements may be shared in common with the social work posture on an issue or care situation, what is unique to the organization versus the profession and then, modeling Cannon, what tact can be pursued to orchestrate a change that embraces a desired social work value or issue position. By effectively understanding organizational realities as well as abstractions such as culture, language, perception, symbols, social workers can join processes and activities to attain organizational power and influence that assures the continued provision of psychosocial care to patients.

FUNCTIONS AND STANDARDS FOR SOCIAL WORK PRACTICE IN HEALTH CARE NASW (2011) identifies four general and primary functions of health care social work as:

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1. Encouraging behavior contributing to physical and emotional health, while preventing disease; 2. Addressing psychosocial conditions that negatively impact on health/well being; 3. Intervening to assure patients receive necessary care and services required to improve and/or maintain health and quality of life as they transition through service levels; and 4. Helping individuals affected by health concerns to emotionally adjust and manage their condition in order to achieve maximum social functioning. To be able to advocate and assure that individuals receive needed care and services requires the practitioner to be organizationally competent. Guidance is not provided, however, as to what this might entail. The NASW Standards for Social Work Practice in Health Care (2005) identify 20 standards that include at least three that implicitly require organizational awareness and competency to carry out: Standard 9— Empowerment and Advocacy; Standard 11—Teamwork and Collaboration; and Standard 20— Leadership. Neither the functions nor standards specifically describe the skills or capacities related to successfully understanding and negotiating the organizational environment, yet it becomes impossible to meet these standards without such foundation. Standard 20—Leadership states that social work leaders “typically” demonstrate knowledge, skills, and abilities in the following areas: Management/administration, which includes supervision, consultation, negotiation and monitoring; specialized knowledge of how to function within care teams in which various disciplines are involved; research and education; legal, ethical, and professional standards applicable to health social work practice including standards of documentation (paper and computer) and quality improvement activities; ability to prioritize needs for social work services and to recommend adjustments to staffing levels accordingly based on current literature and industry standard; social work qualifications, productivity, and continuing education; policies and regulations that affect social work practice, and patient and family care; information on access to health care for the underserved and marginalized populations; consultation to social workers and allied health professionals on relative health social work practice issues; and development of and adherence to organizational policies, procedures, and regulations by staff. (p. 34)

Functions and standards, however, are not competencies. The Council for Higher Education Accreditation, which oversees accrediting organizations for many professions including CSWE, requires a competency-based approach to professional education. In 2008 CSWE articulated competencies for generalist social work practice (the BSW and foundation MSW curriculums). Graduate

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programs are required to develop individualized, advanced-level competencies and practice behaviors appropriate to the specializations offered. Competency based education requires two elements: (1) identification and articulation of the competency in clear, measurable terms with established benchmarks for judging competency and (2) systematic evaluation of the skills required to practice (Hackett, 2001). CSWE has developed suggested advanced competencies for mental health, trauma care, gerontology, and in 2012, launched a pilot project to train MSW students in integrated behavioral health care. Over 30 schools have begun to offer courses in integrated behavioral health care and the first cohort of students were funded for placements. This is promising; however, we believe that neglecting to identify specific organizational competencies and practice behaviors is a serious deficit that potentially inhibits the inclusion of social workers in this emerging area of practice and places them at risk when they are employed in evolving, complex host settings such as integrative care organizations.

ORGANIZATIONAL AWARENESS: THE MISSING SOCIAL WORK COMPETENCE The notion that health care social workers need to infuse a broader, organizationally pragmatic perspective into their practice is not new. There has long been a perceived gap between historical practice readiness and current knowledge useful in understanding evolving environments. Rosenberg (1983), citing an earlier observation by Bracht (1974), lamented that our profession short-changed itself in having a role in managing, coordinating, and planning the functions of the emerging health care system by maintaining a focus only on what we perceived to be the manner of conducting one-on-one clinical work. Nearly two decades ago, Volland (1996) observed that “social work in health care has increasingly been defined by events and boundaries set by the health care delivery system in which practice occurs” (p. 37). At that same time, Spitzer and Nash (1996) vigorously lobbied that social work fuse its empathy and passion for patient care with knowledge and appreciation for organizational priorities, limitations, cost containment and efficiency. They perceived it as crucial that practitioners and leaders have current knowledge of their organization, mission, and management philosophy. Jansson and Dodd (2002) stress it is important that students understand and appreciate factors shaping these environments and the skills relevant for effective institutional change. Gilbert et al. (2011) emphasize that it is not enough that social workers have clinical practice competence; they must be cognizant of the factors driving practice. While one may debate what to call it, there is clearly a missing competency in formal social work education. While the academic arm of the profession refers to micro, mezzo, and macro targets of intervention, new

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graduates are largely focused on client systems, or perhaps, community organization. Few graduates enter their field practices or first professional employment with an “organizational awareness” competency. Furthermore, social work like other practice-based professions tends to promote their best clinicians into supervision and management positions, thereby creating the prospect of furthered misalignment of needed leadership competencies. That prospect has far reaching implications as the actions of those individuals in management affect both the present and future practice within an organization. Having a professional vision that embraces both patient and provider organization need and being able to then creatively pose practice opportunities in perpetually changing, financially driven environments is repeatedly cited by health care social work administrators as a requisite skill (Rosenberg & Weissman, 1995; Spitzer, 2004).

FROM ORGANIZATIONAL AWARENESS TO COMPETENCY In order to be provided with and maintain the opportunity to perform the essential functions of health care social work, practitioners must be move beyond organizational awareness to organizational competence. Cultural competency is regarded as “having the capacity to function within the context of culturally integrated patterns of human behavior defined by the group” (NASW Standards for Cultural Competence in Social Work Practice). We modify this slightly and define organizational competence as “the capacity to function within the context of culturally integrated patterns of human behavior and performance as defined by and expected by the organization.” We briefly review characteristics of basic organizational theory so that specific competencies for organizational behavior can then be derived. Organizations are social systems that are deliberately structured and coordinated in order to serve a purpose and achieve goals. They have internal and external boundaries and exchanges and interactions occur between the organization and its external environment. Organizational structure describes the framework or skeleton of the organization, how units are arranged, defined, and supervised; and determines how tasks and responsibilities are assigned and overseen. It typically reflects or is a product of how power and authority are distributed and thus determines decision-making and communication patterns. Dimensions of organizational structure include the number and types of “layers”; complexity; span of control or ratio of workers to supervisor; degree of centralization versus decentralization; and degree of specialization and coordination within units (Tolbert & Hall, 2009, pp. 33–45). Organizations are goal directed, or “mission driven”; deliberately structured and arranged to coordinate activities and processes necessary to achieving goals; and linked to the external environment and broader social

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context. Organizations are also characterized by structure, processes, and outcomes. Organizations have their own culture, defined as the set of values, norms, guiding beliefs, and understandings that are shared by members of an organization and taught to new members as the correct way to think, feel, and behave (Daft as cited by Kirst-Ashman and Hull, 2015). This culture includes expectations for many tangible and objective behaviors such as expectations for dress and communication, but also involves many symbolic dimensions as well. Organizational climate describes the general atmosphere of the workplace, including stress, energy, and intensity levels as well as general morale and affect. Stern and Barley (1996) argue that organizational theories and research underestimate the importance of organizational structure and often fail to appreciate the organic nature of organizations as social systems. Health care organizations tend to be formal, complex systems with a high degree of specialization within units and to be hierarchical and multilayered. For social workers to thrive in health care organizations, they must develop skills to interpret and negotiate these structures effectively. We acknowledge that there are challenges for social workers in “host” settings where the primary mission of these organizations is not the provision of social services. Social workers are integrated into these organizations because they assist and remove obstacles to enable the organization to achieve its mission. This often creates ethical tensions with the practice of social work inhibited by the organizational constraints of host settings. Secondly, as social workers, we are ethically obligated to advocate for socially just policies, practices, and services and educators teach our students to be organizational change agents. The realities of today’s workplace, the right to work movement, and the dissolution of worker’s rights and union protections significantly increase the risks to social workers (and others) who seek to challenge organizational policies and practices. This unspoken reality demands further research and advocacy by our profession. However, we believe that the organizationally competent practitioner can find an appropriate balance that incrementally promotes change and positively influences their organization while preserving their employment security. Figure 1 depicts factors that can be regarded as influencing the determination of health care social work services. In decision making, the environment is complex enough, but one must additionally be cognizant of current and forecasted societal, economic, and political forces that can affect health care delivery and, consequently, social work services. The ongoing successful integration of social work into the organization (its “operational fit”) is dependent on the profession being able to anticipate and not just respond to these forces. Shockley-Zalabak (2006) presents a model that we modify slightly to describe levels and types of organizational awareness. The first dimension involves the social worker’s ability to understand and interpret the

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INPUT

Organizational: culture, mission, policies, priorities, strengths, constraints, resources, goals Patients/Community: current care needs, forecasted changes in population needs and volumes

PROCESS

Clinical knowledge and practice skills Professional ethics/cultural awareness

OUTCOME

Continuously modified practice reflecting professional values and business acumen Efficient, economical service Optimal patient care outcomes based on organizational context

New technologies and interventions

FIGURE 1 Synthesis of health care social work practice guided by organizational awareness.

organizational environment including its structure, politics and distribution of formal and informal power. The second dimension is sensitivity competence. This describes the ability to sense shared organizational meanings and understandings including organizational identity; relationships; culture and climate; and explicit and implicit expectations. The next dimension is a values competency and requires commitment and dedication to the organization and the internalization and valuing of its mission and purpose. Shockley-Zalabak’s final dimension involves the worker’s ability to successfully integrate all aspects of his or her organizational awareness and understanding to correctly interpret situations and problems and to negotiate them successfully. In what follows, a general model is offered consisting of three components that serve as a bridge between awareness and competency: ● ● ●

Understanding organizational leadership and counseling opportunities; Understanding organizational systems and culture; Understanding professional and environmental alignment opportunities

Counseling the organization is a behavioral and skill-based activity that requires the capacity to function effectively within an organizational context. The ability to do this is predicated upon leadership knowledge and the remaining above components, which involve organizational awareness and understanding. Thus awareness is a prerequisite condition that forms the basis for the development of skills and competencies. The skills of counseling are familiar to any social worker however the client system is now the organization. Counseling the organization therefore becomes a bridge between micro- and macro-practice. The following section outlines each of the components in the model above and suggests specific competencies that may emerge.

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LEADERSHIP AND COUNSELING THE ORGANIZATION The organization reasonably presumes that the professional possesses the updated knowledge, skills, and abilities necessary to competently practice. At the same time, it is the essential responsibility of the individual social worker to continuously advise their health care colleagues, both clinicians and administrators as to the optimal manner and circumstances in which to engage our practice. This educative function takes into consideration the social worker’s knowledge of the psychosocial dimensions of a patient population, the disease entities or health conditions associated with that population, the professional interventions found effective in addressing identified care needs and the organization’s mission and capacity. The contemporary emphasis on recognizing the impacts of social determinants on one’s health status affords a particularly valuable basis on which to promote social work intervention. Organizational counseling is a natural extension of interpersonal practice as well as systems thinking which is prominent in the social work knowledge base. Competency in this arena is demonstrated by being able to take a “30,000 foot view” of how the entity of social work can be effectively applied in a complex “host” health care setting featuring a broad array of interdependent departments, professions, technologies and procedural operations. For example, an understanding of general resistance and the ability to engage and continually assess an organization in the context of its ever-changing landscape facilitates an optimal professional–environment fit. As with an individual patient, to effectively counsel one must have made an accurate assessment of the organization, its current needs and potentialities. Rosenberg (1995) has long emphasized that social work leaders in particular must “be able to accurately read the environment of your community and of your health care system” (p. 115). An organizational assessment must include gaining knowledge of its structure, culture, activities, and components as well as an understanding of the organizational leadership, including its goals, priorities, and style. While the ability to understand and provide counsel to a health care entity relies on traditional assessment and intervention competencies, it can be argued that the process is more leadership-based than clinical. The literature is clear about the defining importance of vision as a basis for leadership (Rosenberg, 1995). Vision arises from perspective. Perspective in turn is influenced by the combination of experience, education, and values. Slavin (2010) regards a number of leadership characteristics as highly consistent with social work values and skills. These include the desire to make a difference, create change, sustain what works, act on difficult choices with infinite resources, and mobilize/motivate others.

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The emphasis on integrated, collaborative care and transdisciplinary teams requires patient care planning based on understanding and appreciating others’ professional perspectives and skills. Leadership reflected in successfully implementing ideas and programs is a product of moving beyond one’s own professional ideology, identity, and instincts to a point of envisioning the applications of social work in the larger organizational context. In so doing one does not acquiesce to authority, but rather seeks to understand, and then join, processes and activities infusing organizational power and influence. It is through this process that the social worker acts to provide counsel to the organization. The opportunities for social work to contribute in service planning and delivery are expanding as patient care volumes and needs are exceeding the numbers of available health care providers and professional roles are correspondingly changing. Social work administrators and practitioners demonstrating organizational competence will be able to identify those opportunities and effectively promote the profession.

UNDERSTANDING ORGANIZATIONAL SYSTEMS AND CULTURE Organizations strive to establish their own unique presence and manner of conducting business. Organizational culture is reflected in the norms, values, customs, and behaviors with which employees are expected to comply. Members of organizations are also expected to observe and follow the ways that others typically act. Organizational climate describes the general atmosphere of an organization that includes expectations of employee morale and attitude. Organizational cultures and climates can differ widely, depending on factors such as ownership, mission, staff composition, and geographic locale (Allen & Spitzer, 2015). Organizational culture is directly related to stakeholders. They create, maintain, and, at times, transform a culture. All organizations have certain values and norms that tend to drive, or at least influence, how people behave. As a graphic but sad example of this dynamic, a spate of aircraft crashes by Korean Air was blamed on the hierarchical culture of the company. In more than one instance a co-pilot was aware of approaching danger but felt culturally obligated to defer to the captain’s opinion and failed to effectively communicate his concerns (Gladwell, 2008). The safety and power relations of this illustration are often exhibited in hospital cultures. Again equating the organization as a client, it becomes important that the social worker be aware of cultural nuances. These may range from the basis for organizational power and the style of decision making to how personnel are treated and resources allocated. To succeed in promoting ideas, one needs to be sensitive to: where the power is located; why it is so endowed; the experience the decision maker(s) may have with the issue or involved

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parties; and the decision maker(s) interests, values, scope of influence, constraints and resources. Organizations with extensive hierarchies, complex multifaceted operations and high degrees of regulation may move more slowly in decision making and potentially stifle creativity. Contemporary health care provider environments more than ever expect documentable results that include optimal patient care outcomes, constructive community relations and importantly, revenue contributions and/or minimized expense achieved through operational efficiency.

ASSESSING AND ENHANCING PROFESSIONAL AND ENVIRONMENTAL FIT: ALIGNING THE ORGANIZATION By understanding the organization’s system, culture, and leadership, one can assess professional and environmental “fit.” Once the fit of a profession or discipline is determined, it becomes easier to define the actual and potential “fit” of the individual practitioner—including his or her own sphere of influence and opportunity. Fit is principally influenced by the entity’s worth or the perceived value of their contribution to the organization. That value may arise from technical competence; that is, the individual may bring knowledge, skills, and/or abilities that facilitate desired processes and achieved desired outcomes. Perceived value to the organization may also arise from the entity’s access to needed resources (i.e., financial and/or human capital), or the influence (power) they wield in the organizational decision-making structure. It is here that the notion of “host environment” becomes relevant, as health care provider organizations may not readily extend themselves to accommodate a social welfare orientation. The challenge is to achieve “organizational alignment” by developing support within the framework of the organization. As an illustration, policy and the law protect patients from absolute medical abandonment. If a patient arrives at an emergency room in need of care, they will be treated. If their condition requires and meets criteria for admission, they will have access to a bed. Therefore, suppose a patient is admitted with a minor cerebral vascular accident (stroke). They stabilize quickly and have minor residual deficits that can be easily rehabilitated with two weeks of home physical therapy. The social worker is faced with a dilemma. Although a hospital is required to admit a patient suffering a stroke, a home health care company has no such requirement. In many ways social workers are challenged by the fact that parts of the emergent health care system are “socialized” in terms of open access, while others are restricted by ability to pay. When a patient has no insurance and no longer meets acute criteria, hospital administration will rationally expect the patient to be discharged as soon as possible. The nurses will want an available bed for the next patient still waiting in the emergency

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department. The admitting physician will likely be ambivalent, but willing to discharge so long as the patient receives the therapy somewhere. Not one among these stakeholders is wrong; however, this only escalates the pressure on the social worker. If the social worker takes a social action-like advocacy approach for the patient to remain hospitalized to receive physical therapy he/she may be correct from a social justice perspective, but totally misaligned from an organizational one. However, to advocate that the hospital subsidize the home therapy from a cost-effective perspective (versus charitable) might work. In fact, many social work leaders have successfully received costcenters to execute similar discharge plans—the rationale being one of cost-effectiveness, patient safety, and decreased chance of readmission. Organizational alignment specifically refers to the establishment of a clear understanding and path toward institutional goal attainment. Purpose, mission, values, strategies, policies, staffing, and resource allocation should be logic and consistent. Senge (1994) writes that without alignment organizations and teams waste much time and energy; stakeholders have no understanding or ability to complement each other. Often alignment is fluid and it is incumbent on social work to evolve and align its skills and talents with the changing face of the host organization (Silverman, 2008). This level of organizational awareness facilitates full engagement with one’s organization. Constructive working relationships evolve through collaboration that acknowledges all parties’ positions on issues and ultimately strives for shared perspectives. Generating support becomes easier when it can be factually demonstrated that a certain course of action will yield desired outcomes. These may range from optimized patient health to enhanced financial margins and/or more efficient and collegial patient care interaction. For this reason, competency rather than ideologically based strategies become more appropriate to move ideas forward to action. Keeping perspective on the needs and benefits of the entire organization rather than those of an individual or profession facilitates engaging in what may be termed “collaborative visioning” (Spitzer & Baker, 1997). This perspective is particularly germane in contemporary environments emphasizing professional interaction across the continuum of care.

CONCLUSION Social work has long revered the principles of situational assessment, “person-in-environment,” collaboration, and advocacy. What has been less appreciated is the significance of remembering that many fields of practice, notably health care, operate within “host” environments that do not necessarily embrace the same ideologies, perspectives, and priorities of social work. Failure to recognize that reality along with being preoccupied with

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our own micro-level ideologies has had far-reaching negative implications, significantly including missed opportunities to participate in planning and coordinating care at the system level. Given the emphasis of recent legislation and the dominant business acumen of health care, it is crucial that social work practice be predicated on organizational awareness. The proud heritage of health care social work provides a strong basis on which to negotiate future patient care services utilizing documented competency and ideology tempered with the reality of practicing in “host” environments. The first organized hospitalbased social department evolved in large part by virtue of Ida M. Cannon practicing careful restraint in how she promoted the virtues of the profession in the face of competing ideologies (Allen & Spitzer, 2015). The success of her organizational awareness and tact should serve as the benchmark model in educating our contemporary social work practitioners and administrators.

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