Where everyone leads

BY: CHRIS GREEN

NEARLY FIVE YEARS AGO, A COMMUNITY MENTAL HEALTH CENTER IN SOUTHEAST KANSAS EXPLORED OFFERING EMPLOYEES LEADERSHIP TRAINING AS A WAY OF PREPARING FOR AN ERA OF CHANGE. LITTLE DID THEY KNOW, THEY’D SOON BE FACING A TRIPLE WHAMMY OF DAUNTING CHALLENGES. ALL INDICATIONS ARE THAT FOUR COUNTY MENTAL HEALTH CENTER HAS COME OUT STRONGER, EVEN IF THE PROCESS OF BECOMING A PLACE WHERE EVERYONE LEADS REMAINS A WORK IN PROGRESS.

Facing just one big change can be enough to tax the leadership capacity of many organizations. But in 2020, Four County Mental Health Center found itself in the midst of what might be called a triple whammy.

Already transitioning in how it served patients and utilized electronic health records, the COVID-19 pandemic forced employees of the southeast Kansas provider to grapple with another major adaptive challenge.

If there was a bright spot, officials at Four County, one of 26 community mental health centers scattered across the state, knew years before the pandemic that big changes were coming their way. They were also aware that staff members would need to be well-prepared to respond to change as they continued to serve some 6,000 patients at nine different locations scattered across five counties. (Yes, the scope of the center’s work transcends even its name.)

Rewind to the summer of 2018, in the pandemic Before Times. Greg Hennen, the executive director, with a tenure at the center spanning three decades, began discussing with his team a strategy that might help the organization deal with change: leadership training.

Specifically, training at the Kansas Leadership Center through a grant program that would allow his employees to attend without paying tuition. The sessions would serve not just his employees, but would also enroll representatives of other organizations who had received similar grants.

Compared with other training opportunities, the KLC offerings were unique in that they taught participants to embrace leadership as an activity that anyone could do, and that employees could lead beyond their positional authority with a style that engages others in solving the toughest problems. (The Kansas Leadership Center also publishes The Journal, although this story was produced independently of other parts of the organization.)

Hennen had seen more than his fair share of changes in the mental health field over the years. He started out at Four County as a therapist in 1989 as the 26th employee on the roster. He rose to become the executive director in 2010, and now Four County employs close to 400 people.

A state policy shift in the 1990s toward providing mental health services at the community level, instead of at state hospitals, drove much of Four County’s growth. But the organization found itself in the midst of another of the field’s sea changes. Providers like Four County were shifting from being paid for the services they offered to the outcomes they produced for patients.

For patients, the changes offered the promise of longer, healthier lives. Individuals with severe and persistent mental illness, Hennen says, live on average 25 years less than the general population, dying in their 50s rather than their late 70s. Serving people with mental health challenges holistically meant helping them manage other aspects of their health, from ensuring regular visits to a primary care physician to managing high cholesterol or diabetes to seeing a dentist.

For a system that had long been rewarded for providing a narrower range of traditional mental health services – therapy, case management –the transition would require shifts in how the center operated.

Hennen knew Four County had to evolve. But he didn’t want to lose the core of what made Four County the place he had invested his career in.

“It’s a culture that I want to preserve,” Hennen says. “But at the same time … we were going to be going through a large transformation. I wanted to do something to help people kind of envision what the transformation was going to be and to help shape it. That way, they could be on board and not feel like we’re such a different organization.”

‘THE STORY IS THE TRANSFORMATION’

In the years that followed, 235 employees at Four County attended at least one leadership training experience through KLC, and at least 85 have attended multiple programs, according to Melissa Lunsford, Four County’s grant project manager and a member of the core team that oversees the center’s engagement with KLC and its curriculum.

As a result, Four County not only has had large numbers of its workforce trained, it’s reached a point where more workers have been trained than not, achieving a level of saturation with the training concepts that is rare among the organizations that KLC has worked with.

At times, you can hear the difference it has made. It’s increasingly common for employees to talk to each other differently, Lunsford says, with more utilizing the phrasing in what KLC calls its framework to discuss their work and the challenges they face.

“You’ll hear it in just a normal conversation in the hallway,” Lunsford says. “You’ll hear it in a meeting format. Not all the time. But it’s just those hints of, ‘OK, somebody’s looking at something a little differently than they were before.’”

Four County’s commitment to training so many people to exercise leadership makes it a particularly interesting testing ground for KLC’s ideas about leadership, which were recently spelled out in a national best-selling book called “When Everyone Leads: How Tough Challenges Get Seen and Solved.” Ed O’Malley, KLC’s founding executive who now heads its largest funder, the Kansas Health Foundation, and Julia Fabris McBride, KLC’s chief leadership development officer, authored the book.

If ever there was a proving ground for the idea that everyone in an organization can lead, it would be Four County. And the mental health center has, indeed, achieved key goals. Not only did it weather the pandemic, but it fully integrated the use of electronic health records and, with help from a federal expansion grant that sped up its rate of change, became the first center in Kansas to resemble a certified community behavioral health clinic.

After lawmakers passed sweeping legislation in 2021 aimed at transforming the community mental health system, Four County became one of the first six certified community behavioral clinics in Kansas, a designation signifying it as a state leader in the transition to a model aimed at providing higher quality, comprehensive services to patients.

“To me, the story is the transformation, and that the transformation happened in some really challenging times with so much happening,” says Steve Denny, Four County’s deputy director. “Everyone knows what COVID was like. But to think about (electronic health records), that grant, and all those things happened at once. We were able to emerge from that as a leader.”

At a time when just holding steady might have represented success for many organizations, Four County pivoted into embracing major changes, shifts that Denny says are helping the Kansas mental health system avoid plunging into a severe crisis.

“We’ll look back 10 years from now and be like, ‘Wow, that was a huge moment in the transformation of our mental health system.’”

Beyond Just Getting It Done

But despite those successes, the process of Four County becoming a place where everyone can lead remains a work in progress. For one thing, it’s unlikely there will ever be a day where every single employee has been trained in using leadership ideas.

Turnover remains a major challenge among mental health providers. Four County, for instance, brings on 60 to 75 new hires every year, Lunsford says. Even among the 235 employees that have received training, at least 25 of those have moved on. And when employees do get trained, participation has to be structured and staggered so that any absences get covered.

“Just for workflow, we can’t have 50 people gone at any given time for a three-day training,” Lunsford says. “That’s just not functional.”

Such dynamics raise questions about how organizations can manage the “hamster wheel,” as Lunsford terms it, and keep the leadership ideas front and center as the composition of their workforce changes.

Even embracing the idea of training large numbers of people raises questions about competing values between immediate responsibilities and building capacity for the future. As Lunsford puts it:

“I don’t know if this is true to every industry on the planet or not. But I have literally never held a job in my lifetime, especially within social services, where you didn’t have too much on your plate. That just sheer volume of workload keeps people out of that more creative mindset … Because they are just trying to get it done.”

And being able to get it done matters. Gena Kastler, a case manager based in Independence, works across five counties with individuals with mental or physical disabilities who are homeless or precariously housed and helps process disability claims. While her daily duties include interviews and paperwork, when her clients call for assistance, they become her priority.

“We see people in their environments,” Kastler says. “We see what their living room looks like. We see if they’ve bathed in the last few days. We see their facial expressions, probably once, twice, maybe three times a week. So, we are on the ground.”

Still, Kastler says participation in the training is strongly encouraged at Four County, so she signed up. She liked the introductory program, but she felt lost during a second, more intense program, which she felt like required more selfdirection. Despite that, she’s signed up for a third this summer.

“KLC is kind of like algebra,” Kastler says. “It’s a way of thinking. It’s a higher-level process. Most of it is pretty simple. I mean, it’s not anything new. But it’s a different way to put it. And a different way to think about things.”

However, she says she has found it helpful in her approach to client relationships. “On a lot of different levels, we help individuals learn how to regulate their emotions. When to say something. When not to say something. And how to take leadership of their lives.”

Yet there’s little doubt that even among the workers who do get trained, there are varying reactions to the training experiences and the content. While many if not most workers find immediate value in leadership training, others are a harder sell.

“We’ve really had the whole gamut,” Lunsford says. “We had a few people that were almost rolling their eyes like, ‘This is not new. This is not earth shattering. Thanks for wasting three days in my life.’

“Other people were so energized that when they came back, it was like a religious revival. They’re like, ‘OK, let’s do things differently. Let’s figure out how to be more interactive with everybody and listen to things in a different way,’ so they could make changes on the challenges they were enduring. And we had a bulk of people that were just kind of like, ‘OK, I can do that, if that’s what you want me to do.’ They can take it or leave it.”

Language That Brings People Together

Even small differences in the experiences of participants can prove polarizing, says Andrea Hinkle, an outpatient therapist at Four County’s Cowley County location. As part of their training experience, Four County employees spend part of their time learning in small groups with individuals from other organizations scattered across the state, and sometimes beyond it. Hinkle says she found such interactions energizing.

“For me, I enjoyed being able to interact with other people throughout the state but are in different roles,” Hinkle says. “It was interesting to get other people’s interpretations, to get other people’s ideas on some of the challenges that we have within our agency. They would kind of get up on that balcony and look at things a bit differently.”

But some of her co-workers didn’t have similarly great experiences with their groups, which can be conducted virtually or in-person, depending on the program.

“They had people that ate, didn’t show up, had their screens blacked out, and didn’t want to participate, things like that,” Hinkle says. “That left a bad taste in their mouths about the training.”

Still, Hinkle says, she’s encouraged those who did have bad experiences to try to move beyond them and to try to see the benefits of using the ideas at Four County. For her, the leadership concepts were empowering, especially in her interactions with management.

The framework gave her a way to more effectively communicate concerns about work schedule flexibility and benefits, which led to changes that felt like progress to her. In the past, the organization hadn’t seemed quite so responsive.

“It kind of sometimes felt like we were just a piece of the machine that’s moving,” Hinkle says. But the leadership framework gave the organization a way to talk about challenges in ways that people with different perspectives can understand. “It felt like we actually had a chance to have a voice and to speak up,” Hinkle says. “I felt like the executive team would really hear us out. And since then, we’ve had some incredible changes happen.”

The idea that everybody could and should lead made more people responsible for shaping the organization. Employees such as Hinkle knew they had to speak up if they wanted to see changes, and managers, having invited more people into the conversation, felt obligated to listen and respond. Because workers and managers shared a common leadership language, Hinkle says, “I felt like I could bring this up in a way that I wouldn’t get ignored.”

For managers, the framework has given them a method to communicate changes, which have been significant over the course of the shift to the certified community behavioral health clinic designation.

To provide care to patients under that model, Four County employees have had to expand the scope of their work to make sure that whatever the patient needs gets provided to them, even if it’s not a service that the center provides on its own.

For more than a quarter-century, Hennen says, Four County could operate with a more targeted approach: “We’re going to deliver behavioral health care, and if it doesn’t have to do with therapy and if it doesn’t have to do with case management, we don’t touch it.

“The transition that our organization needed to make is to say, ‘I’m not going to say we don’t do windows.’ We do everything. We’re going to do whatever the patient needs, and we may not be the service provider for it, but we’re going to coordinate it to make sure it happens on behalf of that patient.”

But as promising as that seems in theory, in practice it means employees have to operate in areas outside their comfort zones, whether it’s asking to measure a patient’s waist to calculate their body-mass index or assessing someone’s risk for diabetes.

“The struggle I can see us having is people taking on that much greater scope,” Hennen says. “It can feel like it’s a little bit intrusive as opposed to beneficial,” to patients and even employees.

Communicating changes related to the transitions can be challenging. Ian Cizerle-Brown, a Four County therapist based in Independence, is a part of a change management committee that has sought to carefully think through changes and how they’re talked about to keep them from becoming too stressful or disruptive.

“With Four County in the past, I’ve seen them implement big changes, or things have come and it’s just been like, ‘Deal with it,’” says Brown, who has worked for Four County for nearly 14 years. “This group has been a really good breath of fresh air. It’s being facilitated by a person (Eric Valle, director of Four County's transportation program and project development manager) who really uses these ideas.

“He’s asking, ‘What voices do we need to implement it?’ He’s constantly taking the temperature, trying to raise the heat on issues. If it’s a quiet meeting, he’ll point out, ‘Hey, I see we’re pretty low energy today. What’s going on? How can we fire up on these issues? Where do we need to focus?’ Things like that. It’s been a very huge change for the organization and that’s been a very powerful use of the leadership dimensions.”

A Work In Progress With Tangible Wins

Denny, the deputy director, says he sees the application of the leadership framework leading to transformations that are creating tangible progress. The center couldn’t have achieved its goal of serving significantly more veterans – 120 a quarter, a 27% increase from the previous year – without navigating the adaptive challenges of building partnerships with the local Veterans of Foreign Wars post and the Veteran Affairs system.

In hopes of better serving patients at their time of greatest need, the center worked collaboratively across three locations to change long-established procedures, a process that required engaging, listening and responding to voices across the system, Denny says.

87% of admissions now occur on the same day they are requested. 91% of admissions occur within 10 business days, with an average wait time of three business days. The number of clients being served went up 5% from the previous year.

Employee departures are on the wane, too, with the turnover rate dropping from nearly 21% in 2020 to just under 19% the past two years.

And the center’s services are making a difference in people’s lives. 82% of children and 85% of adults showed functional stabilization or improvement. Readmissions to inpatient psychiatric care within 90 days are at 2%, a drop from 7% the previous year. Higher risk patients are largely kept out of the state hospital system and avoid homelessness. 65% avoided incarceration incidents.

Despite the center’s achievements, changing an organization’s culture is not something that happens quickly, Hennen notes. Becoming a workplace where everyone can lead is a multiyear process. He mentions the concept of a flywheel, which is discussed in “Good to Great,” a management book by Jim Collins that describes how companies build momentum in a variety of areas over time, which leads to selfperpetuating success.

Hennen notes that at one point, a new employee was visibly anxious or nervous to speak with him. He suspects she had past experience in environments where those in authority retaliated against people who spoke out.

“I’m not an ominous guy. I don’t think I look that threatening. But the position that I hold was.”

But over the course of six to eight months, the employee – a member of the core team that interacts with KLC – reached a point where she could provide candid feedback to authority. It’s something that he hopes becomes widespread in the years to come.

“My fantasy is that every employee in our organization would feel as comfortable as she does to be able to say, ‘Hey, I’ve got a different idea.’ And ‘What is this?’ And, ‘Man, here’s what I’m hearing in the hallway. I think we really goofed that one up.’ My hope is that eventually we get to the point that people do that in a constructive and respectful manner. Then I’ll know we’ve got the momentum on that flywheel really moving.”

Discussion Guide

1. What are the key characteristics of an organization where everyone leads?

2. What barriers do you think prevent organizations from having leadership at more levels?