FILE
BEGINS

_ pee #/2S

ene ANAGEMENT

 

 
10/26/70.

SUMMARY OF ADL-CSTI REPORT

é

The ADL contract has been extended for one month (to November 20)
without additional funds. This extension was made in order to allow
them to (1) more fully and adequately reflect in their final report
the extension comments, criticisms, and suggestions received from
those selected coordinators, RMPS staff, and others who reviewed
their draft report, and (2) prepare a summary of the larger report.

A short staff summary (8-10 pages) of the draft ADL-OSTI report will
be available at the time of the Council meeting. Copies of the final
report paper and a summary version of it will be sent to Council
members as soon as it has been received and reproduced in quantity.

Enclosed are copies of two papers that may be of interest to you,

(1) “Regional Medical Programs: Improving Health Care Through
Voluntary Regional Cooperative Programs," by Dr. Donham.
This brief paper not only draws upon the contract effect of
ADL-OSTI, but in a sense is a highly selective and incomplete
summary of that study.

(2) "An Approach to Evaluation for the Regional Medical Program,"
by Dr. Schon. This paper very nearly mirrors the substantive
evaluation chapter found in the draft ADL-OSTI report. It
also reflects some of the major themes, such as systems trans-
formation, of that larger report. ,

Enclosures

 

 

 
 

REGIONAL MEDICAL PROGRAMS

IMPROVING HEALTH CARE THROUGH VOLUNTARY
REGIONAL COOPERATIVE PROGRAMS

PHILIP DONHAM, D.C.S.

Arthur D. Little, Inc.
Cambridge, Massachusetts

Eastern Regional Conference on Science
and Technology for Public Programs
Boston, Massachusetts

April 2, 1970

Workshop Session I:
Case Reports
Section G: Health Services

 

 

 
 

REGIONAL MEDICAL PROGRAMS

IMPROVING HEALTH CARE THROUGH VOLUNTARY
REGIONAL COOPERATIVE PROGRAMS

*

EASTERN REGIONAL CONFERENCE ON SCIENCE AND
TECHNOLOGY FOR PUBLIC PROGRAMS

April 2, 1970

ARTHUR D. LITTLE, INC.

 

 
This paper is written for the Eastern Regional Conference on Science
and Technology for Public Programs. My assigned subject, "Regional Medical
Programs," is heavily weighted with science and technology; and it most
certainly is a public program.

Now it would be very satisfying to be in a position to show you how
advanced medical technology was expedited throughout the medical system
3 a result of a public program, but that is not what really happened. When
wedical discoveries of great import are made, they become widely known in
avery short time. And if they have significant potential for affecting
primary care, they spread through the system as if by magic: witness pen-
icitllin and the Salk vaccine. ,

Regional Medical Programs started as a vehicle for accelerating the
dissemination of the latest advances in technology to where they could reach
the patient. This paper tells why this turned out to be an inappropriate
target and what took its place when it did. I rather think that the new
target may turn out to have more significance to public officials in the
future than the original one would have had.

ee “

 

 

 
 

 

REGIONAL MEDICAL PROGRAMS

PHILIP DONHAM

ARTHUR D. LITTLE, INC.

Precis

Regional Medical Programs was one of several Federal programs that
were initiated in the eighty-ninth Congress in 1965 to respond to the
growing health problem in the United States. Its contribution was expect-
ed to be to unlock the vast storehouse of medical research that had accumv-
lated over a decade or more and make it available to victims of the killer
diseases: heart disease, cancer, stroke, and related diseases.

As the Congress finally passed the Law (P.L. 89-239) it conceived of
regional voluntary cooperative programs as the most effective vehicle for
facilitating the movement of advanced technology through the medical sys-
tem. When the Regions began to operate, several unexpected conditions
slowly emerged:

(1) To the extent that new technology had real applicability to
primary health care, it was already very widely known throughout
the system.

(2) Obstacles to the application of the latest technology to patients |
were either economic or institutional for the most part.

(3) When economic, they were usually beyond the anticipated financial
resources of RMP to deal with beyond a token level. (And other
agencies usually had a more direct responsibility for them, as
with renal disease.)

(4) RMP was ideally situated to work on the problem of institutional
barriers because of its charter to build on cooperative arrange-
‘~ments among ali those participating in or closely related to the
medical system.

Regional Medical Programs has found itself able to turn in the direc-
tion of facilitating closer relationships and improving communications
across institutional barriers without having to abandon the professional
orientation it started with.

Regional Medical Programs has thus become a significant practical ex-
ample of how a public program can learn and evolve as it develops, so that
it can be responsive to reality while pursuing its valid social objectives.

 

 

 

 
 

IE ORIGINAL GOAL: IMPROVED NATIONAL HEALTH CARE

As long ago as 1965, the Congress of the United States acted on the emerg-
ing awareness that the state of the Nation's health was unacceptably poor

even after billions had been spent on medical research. That was the year
that the Congress established Medicare and Medicaid to help old people and
poor people meet their medical bills.

In the same year, two laws designed to improve the capability of the
medical provider system were put on the statute books. (1) The Regional
Medical Programs (P.L. 89-239) dealt with improving health care for victims
of heart disease, cancer, stroke, and related diseases through voluntary
cooperative arrangements among those directly concerned with medicine. The’
other, Comprehensive Health Planning (P.L. 89-749), dealt with state and
area-wide planning of health resources to optimize their effective application.

Let us look for a moment at the condition of health in the Nation that
led to the concern of those in positions of public responsibility. As told
to an audience at Airlie House by Joseph T. English, M.D., administrator,
Health Services and Mental Health Administration, on September 28, 1969:

“We are 15th now among the nations of the world in infant mortality."

“We are 22nd among the nations of the world in life expectancy for
adult males."

and in another vein he said:

"In 1955 the total public-private expenditures for health care in the
United States was about $17.1 billion. In 1965 it had grown to $37.3
billion. Today, in 1969, it has grown to better than $60 billion. A
conservative projection of what that total will be in 1975 is that it
will approach $100 billion."

.In 1965, the relationship of these numbers was not already evident.
What was evident was that billions had been spent on health research with-
out a corresponding improvement in health statistics.

President Johnson, in 1964, established a Commission on Heart Disease,
Cancer and Stroke, the three leading killers, to investigate what might be
done to reduce morbidity and delay mortality from these diseases. The
DeBakey Commission, as it was named after its Chairman, Michael E. DeBakey,
M.D., of Baylor University, submitted its report in December, 1964. The re-
port, which became the basis for an Administration bill recommended a detailed
Federal blueprint for action. It proposed the building of a number of "re-
gional medical complexes" around the United States for research and training

and for demonstrations of patient care in the fields of heart disease, cancer,

TI meee

 

 

 

 
stroke, and other major diseases.
Implicit in the Report were two beliefs that have since undergone
careful scrutiny and, at least in some quarters, strong challenge:

(1) Effort spent directly on the leading killer diseases is the most
promising way to improve health statistics quickly, and

(2) Regionally organized medical complexes could force-~feed the en-
tire medical system with knowledge that had built up in the great
medical research centers. .

The administration bill had very hard Sledding in the Congress. There
was wide resentment in the profession at the suggestion that excellence and
the latest medical knowledge were attributes confined largely to research
centers. There was also widespread fear that this was a first step toward
a Federal medical system directed from Washington.

The Act as passed (P.L. 89-239) turned away from the idea of a detailed
Federal blueprint for action. Specifically, the network of "regional medical
complexes" was replaced by a concept of “regional cooperative arrangements"
among existing health resources. It recognized geographical and societal
diversities. It established a system of grants to enable representatives of
health resources to exercise initiative in identifying and meeting local needs
within the area of categorical diseases. "Other major diseases" became lim-
ited to "related diseases." How well local health resources can take the in-
itiative and work together to improve patient care for heart disease, cancer, ;

stroke, and related diseases became a measure of the degree to which the vari- i
ous RMP's would be perceived as meeting the objectives of the Act. I |
|

I

The Act was intended, as was the Administration bill, to provide. the means
for disseminating to medical institutions and professions the latest advances
in medical science for prevention, diagnosis, treatment, and rehabilitation of
certain categorical diseases. But the dissemination, instead of being directed
from regional centers, was to be implemented through grants which would be used
among other things to encourage cooperative arrangements.

RMP AS A VEHICLE FOR DISSEMINATING THE LATEST MEDICAL ADVANCES TO THE PATIENT

By the time the Regional Medical Programs came into being, its objectives
had been spelled out in the Law as follows:*

The program was expected to encourage research and training (including
continuing education) and related demonstrations of patient care in the »

 

* Condensed and paraphrased.

 

 
 

fields of heart disease, cancer, stroke, and related diseases.

the program was expected to afford the opportunity to the medical pro-
fession and medical institutions of making available to their patients
the latest advances in the diagnosis and treatment of these diseases.

The program was expected to improve generally the health manpower and
facilities available to the Nation.

RMP, it would seem, was given responsibility to seek out the latest
medical advances and find ways to disseminate them for the purpose, so far

as possible, of wiping out heart disease, cancer, stroke, and related diseases.

Regions were approved by the Surgeon General and issued planning grants
as follows:

1966 34
1967 19 -
1968 2

| 55

With approval of the 55, every part of the United States became included.

While each Region went about organizing and planning in its own way, they
all turned almost immediately to the medical schools for access to the latest
aedical technology that they were expected to help disseminate. The medical
schools, by and large, were ready and waiting.

Hopes and expectations ran high in some quarters. There had been, con-
siderable publicity given to the truly marvelous medical research being car-
ried out in medical schools and research centers across the country. This
brilliant research had resulted in exciting -- even dramatic -- advances in
dealing with what had previously been obscure or untreatable diseases.

As the Regional Medical Programs turned to these institutions for the
latest advances to be disseminated, the astonishing thing was that virtually
no new technology appeared in their grant proposals. Their ideas were al-
most universally confined to ways of using RMP funds to make already widely
known technology more readily available to local physicians and community
hospitals; e.g., coronary care units, audio-visual teaching tools, assistance
in multi-phasic screening, and a broad spectrum of continuing education pro-
grams, from conventional to creatively new. But the expectation that there
was a storehouse of unrecognized advancés in medical technology, ready to be
applied by the medical profession as fast as they could be made aware of them,
proved to be a myth.

There could be no quarrel with the kinds of projects that were approved.
Clearly they dealt directly with the objective of making what was known more
readily available to the patient.

 

 
 

 

Recognition of the fact that dissemination of new technology must, in.
-che face of reality, drop back from a position of top priority came slowly.
It is the nature of things that professionals in medical schools are better
positioned to take the time to prepare grant applications than those more

immediately tied to patient care. As might be expected, applications from
medical schools dominated the scene in the early years of the Program. To
some degree this seemed toe support the notion that RMP was a tool of the

medical schools to disseminate their "superior knowledge," and it concealed

from general notice for awhile the fact that little of this knowledge was
really an advance in the state of the art. There are still those in medicine
who find it difficult to accept the reality that has emerged. ,

RMP AS A FACILITATOR OF PROCESSES TO IMPROVE PATIENT ACCESS TO HEALTH CARE

As technology transfer dropped from a position of top priority, those
concerned with the establishment of policy and program in the Regional
Medical Programs began to look at the Law with a new perspective. They rec-
ognized that the Law put initiative in the Regions, and with it responsibility
to set new priorities. °

Public Law 89+239 made it clear that RMP was to focus its energies on
making quality care available to the victims of heart disease, cancer, stroke,
and related diseases. It placed the profession in the forefront of the

Program. *

A very significant emphasis on voluntary cooperative arrangements had

‘been added before RMP became law. While Medical centers and clinical re-
search centers were to play an important role, hospitals, practicing phy-
siciens, and other persons and institutions related to medicine, as well as
laymen familiar with the need for services, were to be included as active i
voluntary participants. Regionalization began to take on new meaning. , |

eo — ,

 

*Whereas the comprehensive Health Planning Councils under P.L. 89-749 were
required to have more than 50% public members, RMP Regional Advisory Groups

had to have merely an unspecified proportion of public members. The Regional

Advisory Groups were to be themselves constituted in such a way as to bring
together all those interested in health in the region. By law, membership

. of an individual Regional Advisory Group would have to include:

@ practicing physicians .

emedical center officials

ehospital administrators ©

*representatives of appropriate medical societies

evoluntary health agencies ,

e representatives of other organizations, institutions, and agencies con-
cerned with activities of the kind to be carried out under the program

emembers of the public familiar with the need for the services provided
under the program

 

 
If lack of general knowledge of new medical technology was not a prime
_ - ajuse of the poor health statistics of the Country, then "Where is the gap
petween our obviously superior medical knowledge and the observable level of
delivered health care?"

It was at this point that the wisdom of the Congress in insisting on
regional cooperative arrangements finally became clear. In the process of
trying to get all interested parties to cooperate, the RMP's quickly dis-
covered that the medical system is the victim of its own institutional bar-
riers: mutual town/gown distrust, "guild warfare," defensive referrals,
neighboring community hospital rivalries, and other serious interferences in
the free flow of the most appropriate care to the patient.

The concept of mutual confrontation of common problems was essentially
anew one, only just approaching a level of acceptability under the enormous
pressures that had begun to beset everyone connected with medicine. And only
RMP, of all the public programs in being, offered a charter to the medical
profession to voluntarily address itself to lowering those institutional
barriers. Here, then, began to emerge a new sense of mission in the most
advanced RMP's,

This new mission led naturally to a need to learn where the system of
delivery of health care was failing to reach people. Almost immediately,
attention was drawn to the poor, both urban and rural. Whereas the middle
income and well-to-do are suffering the effects of the institutional barriers
v~eferred to earlier, the poor are really cut off from the mainstream‘ of the
-adical system even when covered by Medicare and Medicaid.

 

Dr. English, at the meeting referred earlier in this paper, presented
some facts that point up the significance of the desperately bad health con-
dition of the poor:*

"A poor child in this country in 1969 has twice the risk of dying before
reaching his first birthday as your child would have, and four times the
risk of dying before reaching the age of 35 than your child would have."

“The difference in incidence of chronic disease per 1,000 population...
[is] in orthopedic impairments... 32 to 15; in heart conditions of 30

to 12; arthritis and rheumatism of 27 to 8.7... in high blood pressure...
of 17.3 to 4.2."

Dr. English also called attention to the disparity in age-adjusted death
rates in 1966 per 100,00C population between whites and non-whites. For heart
disease, cancer, and stroke his data compared as follows:

Heart Disease Cancer Stroke
' Whites 270.5 125.9 ° 67.3
Non-Whites 324.3 152.7 125.5

 

Poor is defined as under $2,700 annual family income.

 

 

 
 

 

Now the significance of these figures for RMP is inescapable. A program
— .....shose ultimate objective is, as the Surgeon General said, "...[to] permit the
best in modern medical care for heart disease, cancer, stroke and other re-
lated diseases to be available to all" cannot ignore them. Indeed, if the
medical profession is intent on raising U.S. health statistics to a level equal
to the best in the world, they cannot do it without directly confronting the
problems of the poor and the non-whites. And the Regional Medical Programs
is the only ready yehicle through which all medical professionals can join
forces in that confrontation.

Let it be said that the various branches of the medical profession cannot.
do the job by themselves. Until other equally severe problems of the poor and —
underpriviledged -- unemployment, inadequate housing, limited education, and . .
malnutrition —- are dealt with effectively, no amount of the best quality care
will bring the health of these people up to the national average.

SPECULATIONS ABOUT RMP

RMP will almost certainly shift its center of gravity toward the outreach
of the medical system away from the medical centers. Indeed, this has already
begun in most Regions.

As was mentioned earlier, medical schools assumed a position of dominance
at first in most RMP's. In a much smaller number of cases regional medical
societies took the lead at the start. However, individual Regions were required
to engage a broad spectrum of participation both as to occupational background
‘and as to geographical spread.

The interaction of many professional subgroupings and many diverse geo-
graphical interests resulted in tensions and conflicts which were destined to
bring about change. The required cooperation led to the thrashing out of issues.
There was an awakening awareness that interaction among diverse groups, under-
taken in a spirit of cooperation, could lead to creative solutions to health
problems.

Region after Region discovered that a balancing of interests was more
attractive and productive than submission to the dominance of any one group.
Reorganizations of boards of trustees, executive committees, and even of Re-
gional Advisory Groups became commonplace after a year or two of experience;
and interest in subregionalization began to mushroom around the country.

As new groups of people began to pick up interest, formerly dominant ones
moved back to a relatively less active role. All this has resulted in a clari-
fication in each RMP of its program objectives. Within the last year there has
been a considerable move in this direction.

RMP will come to believe in and rely more on the quality of local doctors
and the capacity of associated medical personnel to take on greater responsi-~
bilities.* It came as a surprise to most to discover that excellence is not

 

*The shortage of doctors will force this in any event.

 

 

 
 

imply a quantitative accumulation of technical medical knowledge. First

ine doctors, it turns out, know some things about patients that the teach-
ing hospital specialists get little exposure to. The "whole man" concept
of the local M.D. and some of the paramedical professions has a lot to do
with the sense people have of how good their health care is. On the other
hand, the repetitive experience of those who specialize in the larger insti-
tutions sharpens their skills in diagnosis and treatment of the particular
diseases that they have chosen to focus on.

Local doctors usually find themselves treating patients; teaching
hospital specialists most often find themselves managing difficult diseases.
Both are needed; both call for trained skills. Neither one is by definition
more "excellent" than the other. RMP includes them both.

RMP is unlikely to become a powerful force in the economics of medicine.
In any foreseeable future, RMP funding is unlikely to exceed 1/2 of one per-
cent of the total expenditures for health care. At best its role will be
facilitative and catalytic. The significance of project grants will continue
a change that has already begun: it will be just as important that a project
contribute to a strategy of building improved medical system relationships
as that it be professionally sound.

* * * * * * *

The medical system of the United States is on a collision course. Soon,
“rom one source or another, nearly everyone will have money to pay for ade-
uate health care.

But there is a severe and growing shortage of doctors, nurses, and other
auxiliary medical personnel even without the new patients who will come to |
expect care. Even if we were to double the enrollment of our medical schools |
and train other medical personnel at a significantly increased rate over what i
is now being done, in ten years we would no more than hold our own in a posi-
tion of short resources.

There can be no doubt among thinking men but that public pressures will
force some degree of rationalization of our medical system starting in the
near future. Since what we are now doing, even if accelerated, will not meet
the need, it is clear that new concepts, new relationships, new definitions

of professional responsibility will come into being under this public pressure.

If the medical system is to be as radically changed as this suggests, the
profession would be well advised to prepare itself to participate in the design
of what will take the place of the preseht system. Medicine is highly technical,
and professional participation in the design of the system is imperative if the
design is to provide adequate safeguards of quality. A system designed by ad-
ministrative men or money managers would be likely to exert pressures in favor

of the quantitative rather than the qualitative aspects of health care. Incen-
tives would likely be conceived of in these terms, and personal advancement with-

in the system would almost inevitably become responsive to these quantitative
‘easures at the expense of quality. Medicine.could easily be the victim of a

 

 
 

kind of Gresham's law, reducing everything to the lowest common denominator.

All elements of the profession should be involved in any systems
redesign, if what comes out of it is not to be warped all out of shape by
special interests. Consumers, too, must participate in deciding what is
needed.. Regional Medical Programs is at the present time the only insti-
tutionalized ‘arrangement for bringing all of these elements together. And
it does so in a climate of cooperation and voluntarism that will prove
invaluable when it comes to destroying old prejudices and building anew.
 

APPENDIX

In June, 1968, Arthur D. Little, Inc., and the Organization for Social
and Technological Innovation (OSTI), both of Cambridge, Massachusetts,
commenced a two-year study of the Regional Medical Programs for the Division
of Regional Medical Programs (DRMP) of HEW. In essence we were asked what
are the Regional Medical Programs as they are developing out there in the
country.

We are now about two-thirds of the way through our study. We have spent .
upwards of 60 man-days in each of three regions and will shortly have done
the same in a fourth. In addition, we have spent from two to ten man-days '
in each of about a dozen more. We have attended several regional group meet-
ings and all national meetings that have been held to discuss RMP matters. }

In Bethesda, our study had included many discussions with senior offi-
cials in HEW, the National Institutes of Health (under which RMP commenced|
its existence), the Health Services &Mental Health ‘Administration {under |
whose jurisdiction it now comes), and the Division of Regional Medical Pro-
grams itself (later incorporated into the Regional Medical Program Services
under HS&MHA). We have regularly attended meetings of the National Advisory
Council and the Review Committee of RMPS as they have established policies,
approved procedures, and reviewed program and project applications from the
individual RMP's. |

We have been studying a fast-moving target. The experiences of building
regional programs against a background of growing public concern about health
care have brought forth new concepts and new alignments of people, both pro-
fessional and lay. It has been an exciting time.

 
An Approach to Evaluation for the

 

Regional Medical Program

 

Donald A. Schon

Organization for Social and Technical Innovation

Summary of this paper
presented by Dr. Schon,
on September 28, 1970
at the Regional Medical
Programs' Evaluation
Conference and Workshop
in Chicago, Illinois.

 

 
 

Introduction.

The questions in which we are primarily interested are

these: -

. What are the criteria, methods, and measures per-
tinent to evaluation of the activities of the
Regional Medical Program?

- How can evaluation be linked most effectively to
the planning process?

. What are the appropriate roles for those engaged in
evaluation at project, regional, and national levels?

These questions have a deceptively simple ring. “They

raise, in fact, not only the special problems stemming from
the nature, context and history of RMP but several more

fundamental questions of theory concerning the evaluation

of any activity.

 

 
 

Section 1. Toward a General Theory of Evaluation.

Evaluation is an essential part of intelligent individual

and organizational behavior.

Action by individual
(Work)
(Implementation in organization)

Perception of consequences > Reformulation of action

by individual by individual
(Judging) (Planning)
(Evaluation by and of organization) (Policy formulation by
management of organiza-
tion)

It is the process through which individuals or organizations
perceive the consequences of action, assess their meaning for
future action, and reformulate plans and policies.
Within this framework, evaluation serves three distinct
purposes:
- Justification: to defend what's planned or what has
been done. We justify in.order to assign reward or
punishment (as in "grading"), to decide what resources

to commit to an activity, or simply to place an activity

on a scale of excellence. In any case, justification

 

 
 

concerns itself with identifying what has been done,
or what is proposed, and appraising it against some
standard, -
- Control: to monitor an on-going activity in order to
make it conform to standard,
- Learning: to change activity, to do it better.
Learning may be limited to the selection of means
to achieve goals or to conform to standards, or it
may encompass change in the goals and standards them-
selves.
For any program such as RMP, there are always demands for
justification, control and learning. But it is not always
recognized that these several purposes have different implica-
tions for methods and systems of evaluation.
We are accustomed to think about evaluation from the
point of view of a rational manager who supervises the business

of an organization or program. The rational manager takes

as his reference point a systems rationale -- that is, a set

 

of formal objectives, operations for achieving them, and

methods for appraising the effectiveness of operations in
achieving objectives. In a business firm, the systems rationale
makes reference to profits and return on investment; in the

public housing system, to the provision of standard housing
 

for persons cut off from access to the market; in the health
care system, to improvement in people's health, in the quality
of care, or in equitable access to care.

According to the rational manager's model of evaluation,
the systems rationale is fixed and given. Justification con-
Sists, then, in assessing the impact of past or proposed
activity on established systems objectives. How effective
are these activities in meeting objectives? How efficiently
do they use resources? Control consists in monitoring on-
going activity to make it conform to established standards.
Learning is limited to the selection of means for achieving
objectives.

The evaluation process appropriate to the rational
manager's model depends on the assumption that everybody
in the system is to some extent a rational Manager. People's
accountabilities for activities within the system are supposed

to mirror the systems rationale.

Level 1 | Top Management
Level 2 :
» J snance

Production Sales

Level 3 ] | | \ | | } | |

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
Within the organization or program, as within the systems
rationale, activities are organized hierarchically. Each
person is accountable for the activities of his component,
whose goals are keyed, in turn, to the objectives of the
system. The job of evaluation is to compare accountabilities
with the actual behavior of individual components within the
system. Evaluation tends, then, to become an auditing pro-
cess in which a third party assesses behavior in terms of
the systems rationale, and sends information toward the top
of the system. On the basis of this information, decisions
flow downward to influence the behavior of the components
below. At each successive step of the way, the primary use
of information is in justifying and then in controlling the
performance of the components the information is intended

to characterize.

All variants of the rational manager's model and the
evaluation systems that flow from it suffer in practice from
an overriding constraint. Characteristically, systems do
not behave as they are supposed to. Even the most bounded
organized activities result in social systems that do not
behave exclusively in terms of the rational purposes assigned
to them. As distinct from the rational manager's model,
there is always a real system of actors and agencies which

interact with one another in the ways they are found to do

 
 

and with the interests they are found to have. Their dis-
covered interactions and interests may have little to do with
the interactions and interests imputed to them under the
systems rationale.
| The "discovered systems" of organizations and programs
tend to have certain features in common. Regardless of
systems rationale, individuals tend to be interested in:

. their own survival in their positions.

- independence of action.

- local conditions and needs (as opposed to "central's"

view of them). .

» protecting and extending territory.

» Maintaining stability.
These interests characterize the informal, homeostatic struc-
ture of organizations and programs. But discovered systems
tend also to be open-ended, associated with emergent objec-
tives and swift changes in goals which correspond to individual
interests in creativity and responsiveness. Often the rational
manager's model constrains creativity, responsiveness and -
freedom of action in ways that run directly counter to the
interests of actors and agencies within the system.

Within any on-going program, the rational manager's model

and the discovered system always co-exist. The state of
 

their relationship critically determines the nature of evalua-
tion.

When the two systems have little overlap and little
interaction, evaluation is limited to retrospective justifi-

cation,

Performative Retrospective

 

The System of the

Rational Manager *

wevinmea LLLLLL LLL LL

System

 

 

 

 

 

 

 

 

In this condition, the evaluation system produces state-
ments believed neither by the producer nor by the consumer,
which are generated ritualistically in response to formal
demand. Rational manager's produce justifying statements at
regular intervals, expressed in the language of the systems
rationale, and resources continue to flow into the system.
Evaluation processes have i other output than justification.
They are used neither to modify the systems rationale nor to

force the real social system to conform to it.
 

Where there is little overlap, but the rational manager
seeks to impose a systems rationale on the discovered systen,
several things may happen: .

(1) The discovered system may respond verbally without
other changes in behavior, by offering pro forma retrospective
justification long on language but short on substance, a pro-
cess generally known as "conning." The two Systems operate
substantially in parallel.

(2) The discovered system may respond to the controls
that the rational manager seeks to impose by adapting to the
evaluation measures he prescribes but continuing to operate
as much as possible as before. Measures of performance are
always different from performance itself. For example, in
an effort to control expenditures of the vocational rehabili-
tation system, Congress demanded to know how many "rehabili-
tations per year" the agency effected for a given investment.
“Rehabilitations" were defined as job placements lasting
three months or more. As a consequence, the vocational re-
habilitation system began to "cream" its clientele for those
most likely to graduate to job status leaving out those who
were most in need and least able to qualify; to select low-
level jobs for graduates so as to facilitate entry; systemati-
cally to avoid distinguishing between a "case" and a person,

So that a graduate who had achieved job Status, lost it and

 

 
 

returned to training, could be counted as another "rehabili-
tation"; and systematically to avoid follow-up of clients
after three months. .

(3) The discovered system and the rational Manager's
system may fight one another more or less openly until they
reach a compromise. From the point of view of the discovered
system, this is paying a price. Those in the system do some
of what the rational manager wants in order to preserve con-
Siderable ability to satisfy the interests of the discovered
system. From the point of view of the rational manager, the
discovered system is merely distorting system objectives in
the direction of its own interests; but he has to put up with
it to get any response at all.

In none of these dissociated cases is there any interest
in producing or using information that runs counter to the
strategy of evaluation as justification. Where the systems
are operating in parallel but without much contact, there is
common interest in avoiding information that threatens dis-
sociation, In the other two cases, there is common interest
in information that supports the Systems rationale; since
justification rests on the systems rationale, and resource
allocation rests on justification. The discovered system is
content to generate information that conceals how great the

discrepancy is between the goals of the rational system and

the behavior of the discovered system in order to protect

 

 
 

-10-

the resource allocation they need to continue doing more or
less what it is they want to do.

However, where the whole activity is conceived as a
‘learning system, then relationships between rational and
discovered systems can be fundamentally different from those
just sketched. The opportunity for learning is primarily
in the discovered system. The discovered system offers the
most vital basis for reformulating systems objectives and
redesigning systems theory. Discrepancies between the rational
manager's system and the discovered system as perceived by
its inhabitants become the basis for progressive modification
of the system's rationale, of modifying the real interests of
individual participants, and of developing relationships
between the total activity and its constituencies.

It is critical that an evaluation system aspiring to an

 

important role in intelligent management recognize rather

 

than bury discrepancies between systems rationale ard the

 

discovered system. The evaluation system itself must bccome

 

a vehicle for continuing interaction and continuing mutual
influence of the two. Its ability to support intelligent,
direct interactions between the rational manager's system and
the discovered system becomes a central function and a central

criterion of adequacy in an evaluation system oriented to
 

-ll-

learning. While these considerations are important at all
times, they become essential in a period of development or
instability, when new kinds of activity must be devised to
meet established objectives more effectively and when program
environment changes so as to lead to shifts in objectives,

as well.

Learning-Oriented Evaluation in Discovered Systems Hooked

to Rational Systems.

 

When planning begins to incorporate a mutual modification
of objectives and activities, evaluation includes much more
than mere measurement of the extent to which activities con-
form to specification. The evaluation system that is oriented
to learning has special features:

. The conceptual framework for evaluation has to include
a description of the discovered system as well as the rational
manager's statement of systems rationale. This includes a
description of key actors and agencies, actual relationships
and modes of interaction among them, and the several interests
of all of them. It must include also a description of the real
(if informal) evaluation system as discovered ~- the informa-
tion that actors in the system in fact produce, are interested

in producing, and how they use it.
 

-12-

- An analysis of discrepancies and overlaps between the
systems rationale and the behavior of the discovered system.
This analysis takes account of the differing perspectives of
actors in the system.

. Strategies for responding to discrepancies between the
discovered system and the rational manager's system. Mere
analysis is not enough; learning must be capable of applica-
tion. |

These factors focus on gathering accurate information
about the discovered system. The discrepancy between the
rational system and the discovered system, or the response
of the discovered system to the rational manager's efforts
to control it, may mean that the rational manager is simply
precluded from learning what's actually happening in the dis-
covered system. But the rational manager may be able to
bargain for this information by exchanging information about
resources and ongoing administrative changes to which he is
privy for accurate information about what's really happening
in the social system. Even more powerful, when central
rational management gains some freedom to modify systems
rationale to take account of real local interests and activi-
ties, the basis for withholding or distorting information

may disappear. The way may then be clear for central rational

 
 

-~13-

management and local people to bargain effectively and directly
over changés in systems rationale, local behavior modification,
and information flow. As in all such cases, the bargaining
will depend on establishing and maintaining good faith.

Several additional consequences for the evaluation system
flow from these considerations:

- Information intended to modify behavior must flow
upward to influence systems rationale as well as downward
to bring the discovered system into line with pre-existing
systems rationale.

. The evaluation information that is gathered should be
limited to amounts, complexities, and precisions determined
by the capability and willingness of actors within the system
to learn from it, as experienced in actual practice. Nobody
in the system should be presented with more information than
. he can handle, nor information laid out in more precision or
complexity than he can respond to. Analyses should not pre-
sent actors with a greater breadth of alternatives than are
real for them. As a corollary, the evaluation system needs
to be able to detect the changing capability and willingness
of actors to use information, and should itself be capable of
responsive modification in turn.

. The evaluation process should be structured to accomodate

to the different kinds of learning appropriate to different
 

 

~14-

roles and levels within the System (rational managers, project
pushers, evaluators, planners, etc.).

- The learning objective should also determine the con-
tent, extensiveness, duration, and accessibility of informa-
tion in the evaluation system memory. This requirement places
high priority on accessibility and retrieval Capability on
behalf of many different levels Within the system in addition

to that of the rational manager,

- Since the learning derived from evaluation may be
applied to evaluation processes themselves, the conceptual
framework for evaluation may itself be expected to change
(sometimes rather rapidly); so information needs to be
gathered and formulated in ways that make it more or less
equally usable in terms of a broad range of systems rationales.
Priorities should be given to those bits of information that
are likely to retain high relevance across a range of manager's

rationale and discovered systems.

Cases in Which There is No Explicit Systems Rationale.

What if the activity to be evaluated is itself recognized
as so diverse, diffuse, swiftly changing, and open that no
overall systems rationale is credible? This situation may

occur with respect to public problems urgently requiring

solution but for which there are no clear policy answers,

 

 

 

 
 

-15-

where national willingness to devote resources to their solu-
tion is high, though the credibility of proposed rational
solutions may be low. Agencies may be funded to work on such
problems, constrained only within every broad limits as to
what their work should be like. What are the implications
here for evaluation systems?

- Each region or subregion (or other entity) saddled
with a whole problem becomes a center of its own problem-
solving process, The number and location will depend on
the number of centers that turn out to be capable of func-
tioning under their own individually developed systems ra-
tionales. In this situation the distance between information
and analysis is minimized, and responsibility for designing
and conducting the evaluation process is very close to the
actors who are accountable for the activities under evalua-
tion.

- In this case central management's evaluation function
is changed with respect to that of the regions. Central
management may now impose on the localities criteria for the
evaluation process, but it is no longer in a position to

impose criteria for substantive evaluation of concrete acti-

 

vities., For example, central management can still ask whether

regional evaluation processes are differentiated in terms of
 

 

-16-

justification, control, and learning; but the central evaluator
Will accord just as high marks to a region displaying one
workable form of differentiation as to a region displaying
another form. It is only the region that does not explicitly
attempt through its own evaluation processes to. accomplish
justification, control, and learning that is downgraded. Ac-
cordingly, the evaluation information flowing to central from
the local regions normally reflects the nature of the processes
developed for raising and answer ing evaluative questions in

the localities rather than the answers to any specific questions

 

thought up by central management.
- Central also takes on the role of building a network
learning system, facilitating information-transfer from

locality to locality and encouraging specific local experi-

ments.

 

 

 
-17-

Section 2. RMP in the Context of Evaluation Theory.

To place the Regional Medical Program in the evaluation
context developed in the previous section, some of RMP's
principal characteristics should be recited.

1. There is no single organization corresponding to RMP.
RMP is a broad-aimed Federal program concerned with introducing
changes of various kinds into a number of more or less inter-
connected systems of actors and agencies involved in health
care. Within these sy$Stems, RMP attempts to play a variety of
related roles with respect to other actors and agencies; but
for the most part it cannot directly control them. RMP does
not, therefore, have to do with a single rational "system,"
in the sense used earlier, and its boundaries are vague and
shifting. |

From the point of view of evaluation, this assertion
has several implications. RMP's scope and turf do not have
sharp boundaries. We cannot go about analyzing RMP as though
it were a unitary organization, like the Veterans' Adminis-
tration, for example. And while RMP has formulated broad
objectives for itself, its fundamental activity in relation
to these objectives must be understood for the most part as
"influencing" or "facilitating" rather than direct control.

2. There is no single, established systems rationale

either for the health care system as a whole or for RMP in
 

-18-

particular. There are various rationales, held at various
times and in various contexts by different actors in the
system. .

3. The larger health care system and the RMP are change-
able. They are not in a stable state. The character and
functions of these systems are themselves in process of
constant change. Within them, the key actors are often un-
sure of their principal functions or of how best to carry
them out, and they tend to shift behavior as they learn and
as the system around them changes.

4, Nevertheless, as a Federal program RMP is locked
into a structure of controls and demands for justification.

At the national level these include regular reviews by the
Congress, the Bureau of the Budget, and the Department of
HEW. These demands for justification and for controls over
the expenditure of funds are, of course, passed on to the
regional program level.

The problem of devising approaches to evaluation for
RMP is essentially that of meeting what may well be conflicting
requirements for learning, on the one hand, and for justifica-
tion and control, on the other. The vagueness and changeable-
ness of objectives, lack of program control over components
to be influenced, and sources of methodological uncertainty

all argue for a flexible, process-oriented approach to
 

~19-.

evaluation-as-learning; whereas the agents of rational adminis-
trative control tend to press for firm, quantitative measures
of program impact. .

Like most broad-gauged Federal programs, the legislation
establishing RMP represented a series of compromises among
the diverse interests of various concerned groups. The
authorizing legislation is, therefore, a kind of mosaic of
objectives, values, and constraints. Among the more impor-
tant elements of the mosaic are these:

- Emphasis on the provision of means to improve the
treatment of the three "categorical" diseases --
heart disease, cancer and stroke.

- Emphasis on the transmission of advanced techniques
and knowledge relating to these diseases.

- Emphasis on the method of continuing education as a
device for this transmission; and on the major academic .
medical center as the principal source of expertise.

- Emphasis on maintaining or improving the quality of
medical care,

- Concern with the region as the principal unit of activity;
concern, that is, that the program be a regional one,
with regional centers of activity throughout the country;
‘concern with recognition of regional diversity of prob-

‘lems and resources; and concern with "regionalization"

 

 
 

 

-~20-

as a process of knitting together or building regional
resources to realize the purposes of the Act.

.- Emphasis on the establishment of voluntary arrangements
among regional institutions as the dominant mode of
program activity.

- Specific warning against "interference in the inter-

face between patient and doctor."

The authorizing legislation made no attempt to rationalize
these elements or to resolve potential conflicts among them.
It was understood by many of the key actors that, as the
program matured, the specific meaning of its legislative
provisions would develop and clarify. |

It is not surprising, then, that there have been per-
ceptible shifts over time in the dominant systems rationale
for RMP, even though no element originally considered as
the legislation evolved has altogether ceased to exert some
influence.

Let us be explicit about an evaluation scheme that is
generally accepted as appropriate to one of the simplest and
accordingly most easily rationalized interpretations of RMP. mS
We refer to the center~-periphery regionalization model based

on the diffusion of technology and information that is assumed

to be stored in the great medical centers. In this instance,

 

 
 

 

-21-

it is seen as desirable to judge the program initially, at
both national and regional levels, by its effectiveness in
reducing rates of mortality and morbidity for heart disease,
cancer, stroke, and related diseases. . Individual projects.
are seen as means to these ends, and fall basically into
the following categories: deployment of new facilities
(for example, coronary care units); establishment of new
linkages between medical centers and peripheral care-providing
centers (for example, exchange of personnel); the development
of new working relationships (for example, changes in referral
patterns); continuing education (for example, training of
physicians and other medical personnel); and information
dissemination (for example, DIAL access).
The major kinds of evaluative questions under this inter-
pretation of the RMP system are these:
1. What are the kinds of baseline data and measures
of performance by which the impact of diffusion
‘projects on mortality and morbidity can be assessed?
2. What is the relative effectiveness and effectiveness
in relation to cost of the various technologies
diffused, seen as means of achieving reductions in
rates of morbidity and mortality?
3. What is the related effectiveness, for particular

technologies and for particular regional situations,
 

o22-

of the various methods of diffusion?

This question leads, in turn, to questions about

the optimal "regions" for diffusion, the forms of
greatest "diffusion impact" for a given investment
of dollars and other resources, patterns of utiliza-

tion of new facilities and the like.

Other aspects of the activities within the center-periphery
model of RMP -- for example, the management of new institutional
arrangements at the regional level -- must be judged in terms
of their effectiveness in leading to enhancement of the quality
of care through the more effective diffusion of advanced tech-
nology, with the ultimate effect, of course, of reducing
mortality and morbidity from the categorically identified
diseases. .

In the minds of many key actors in Washington and in
the regions, the DeBakey model came to dominate the conceptual
climate of the early phases of RMP. But it was not always
or everywhere the dominant view of RMP activity. In the dis-
covered systems of some of the regions, regional co-ordinators
and other key actors took as primary the sorts of changes in
institutional arrangements which, from the point of view of
the DeBakey model, figured only as secondary means to an end.

In this interpretation:

. RMP's central concern may be expressed through cate-

gorical diseases or with the diffusion of advanced medical

 

 
 

-23-

technology, but RMP consciously concerns itself with overall

 

improvement in quality of care and equity of access to care.

 

- But these sorts of improvements require changes in the

structure and modes of interactions of care-providing insti-

 

tutions which no single agency controls -- changes that can

be generally described as knitting together components of

 

the system that are now fragmented so as to permit more

 

effective and rationalized planning and action.

 

» These systems changes are necessary conditions for

 

improvement in quality or equity of care. They must precede

 

any significant improvement along these lines.

 

In the past year, systems transformation has begun to
dominate among competing systems rationales for RMP (without,
of course, completely displacing other views) at national as
well as some regional levels. While it is to some extent
a subject for guesswork why this shift has occurred, certain

factors suggest themselves.

®
"RMP as process," "RMP as facilitator," "RMP as opportunistic
change agent" were expressions heard as carly as 1967 and
conveyed the underlying idea behind systems transformation
before this rationale became as significant as it now is.
Recent legislative proposals convey the idea even more ex-
plicitly.
 

-24-

There has been a movement into good currency of certain
basic concerns about the national system for providing medical
care -- concerns about rising medical costs, about the effective
exclusion from the health care system of large numbers of
disadvantaged people, about shortages of medical manpower,
about the difficulties of negotiating the medical care system
even for ordinary middle class people, —

The effects of substantial investment in Medicare and
Medicaid have begun to convince observers that no amount
of investment in payment for care will suffice to introduce
necessary changes in the provider system. There is clearly
need for some forms of intervention on the provider side as
well.

There continue to appear to be overriding objections
either to the development of nationalized systems of care
or to such decentralized solutions as community-based group
practice, on a large scale. Shortages of scarce resources
of medical manpower suggest that changes in the system will
have to work with existing personnel and, very largely, with
existing institutions. This means , to a great extent, at-
tempting to facilitate voluntary re-arrangements of existing
institutions.

Of the available program instruments (Neighborhood Health

Centers, Comprehensive Health Planning, Community Mental Health
-25-

Centers), RMP presents itself as perhaps the most promising
candidate for intervention of this kind. What RMP has been
going, initially en route to the DeBakey model in some regions
or in other regions as a matter of primary though informal
agenda, now is emerging as a more dominant (though not ex-
Cclusive) rationale for the program as a whole. It must be
added, or course, that by no means all regions regard them-
selves as primarily involved in systems transformation. Some
RMP's still regard themselves as solicitors and screeners

of proposals, and do not yet conceive of themselves as "pro-
grams" in any sense other than as clearinghouses for projects.
And in nearly all regions, there is the residue of the view
of RMP as a conglomerate of projects centering around con-
tinuing education, training, coronary care units, and the
like. At the very least, then, co-ordinators face, as part
of the task of systems transformation, the problem of what

‘to make of and what to do with the projects initiated under
earlier views of RMP.

Under a systems transformation model for RMP:

- The primary unit for evaluation becomes the program;
and since RMP is conceived as an essentially regional
enterprise, this means the regional program. It will
be necessary to reach both "above" this level to the
national program and "below" it to the project; but the

regional program is primary.
 

-26-

. Every element of RMP takes on a dual aspect. As we
seek to assess projects, regional program and national
program, we must ask both about substantive changes in
the provision of care -- changes in the quality and
configuration of services, changes in access to services,

changes in health -- and about systems transformation.

Seen as systems transformation, RMP functions in two
ways: through the direct efforts of the regional co-
ordinator and those he works with to knit together or
otherwise influence elements of the medical care system
of his region, and through the shaping and selection of
projects which become occasions to effect systems trans-
formation.

. Evaluation must take account of regional diversity.
The starting conditions of the region, the array of
resources, the problems to be attacked, the level of
development, the regional strategy -- there may be as
many of these as there are regions. From the point
of view of evaluation, therefore, the content of re-
gional programs should be expected to be different.
There is no "model" of a regional program to be ap-
plied to all regions, although we should be able to
develop a conceptual framework which will allow assess-

ment of diverse regional models,

 

 
 

~28-

The questions of justification demand separate treat-
ment. Given the multiple impacts of RMP activity, justifi-
cation requires methods for identifying baseline data, ends-
in-view, and indicators of change at the several levels of
change in health, access to health care, quality of care,
configuration of health resources, as well as changes in the
institutional arrangements, interactions and attitudes charac-
teristic of the health care system. The issue of justification
raises sharply the problem of what it is possible to know
about these matters, and at what level of generality it is

x

it is possible to know it. -

The remainder of this paper will be taken up with ques-
tions (1) and (2), above. We will focus on the view of RMP
as systems transformation and will attempt to spell qut the
bases on which, in spite of regional diversity and open-

endedness, judgments about regional performance may be made

and learning about systems transformation may be fostered.

 

 
 

-29-

Section 3. The Central-Regional Dialogue.

 

There is a conceptual framework for systems transforma-
tion in RMP from which we can derive criteria and questions
useful in undertaking and assessing systems transformation,
without violating regional differences and without second-
guessing particular regional answers to the substantive ques-
tions of medical care.

The essential elements to which attention must be paid
are these:

- Starting conditions (What is to be changed?).

- Ends-in-view (Changed to what end?).

- Processes and techniques (How can change be accomplished?).
Broad regional strategies for systems transformation express
directions for the process through which the region may be
brought to move from its starting conditions (as they are
conceived in a particular instance) to particular ends-in-
view. Characteristically, such a process proceeds in stages
of:

- Diagnosis (getting started, casing the region).

. Involvement (engaging these individuals and agencies

whose interaction is taken to be critical).

. Planning and goal-clarification (discovering feasible

processes and choosing and testing specific ends-in-

view).
 

~30-

These stages are apt to be cyclical rather than sequen-
tial. The passage from diagnosis through implementation leads
to a revised picture of starting conditions, and through the
cycle again. Because several streams of activity often pro-
ceed concurrently, the region may at a given time engage simul -
taneously in all stages. As the region moves through stages of.

systems transformation, in its developmental cycle, it may ex-

 

tend the scope and depth of the issues it tackles.

Given this skeletal view of systems transformation, an
evaluative process oriented toward learning must take the
form of a dialogue--a continuing process of inquiry in which the
regional co-ordinator* and RMPs both raise and respond to
questions. This is for several reasons. Given the open-end-
edness of "systems transformation," prospective systems rationales
for RMP must be inferred from (rather than imposed on) regional
activities. Systems rationales and systems activities must modi-
fy one another. The evaluative process must cetect discrepan-
cies between systems rationales and discovered systems, and
tactics for responding to those discrepancies. Moreover,
project and program goals shift over time. That is often a
sign of progress; and the evaluative process should help to
discover whether it is, and in appropriate cases both reflect
and encourage it.
* We will use “regional co-ordinator" as shorthand for

those agents involved in formulating and carrying out
RMP strategy at the regional level.
 

~31-

In what follows, we list guidelines for the kinds of
questions to be raised in such a dialogue; criteria for systems
transformation, from which these questions flow; and, in some
instances, illustrations of response.

One test of the dialogue is that both co-ordinator and
"central" become able, on the basis of it, to form continuing,
grounded judgments of regional program performance. A second
test is that as a by-product of the dialogue the co-ordinator
becomes more proficient at designing and carrying out the
process of systems transformation. A third is that the national
staff is enabled to formulate progressively more adequate
“systems rationales" for RMP,

The dialogue follows what we have identified as the three
main elements of systems transformation and, within them, the
stages of development. |

(1) Starting conditions.

 

The co-ordinator should be capable of articulating a
regional diagnosis which holds water, and which provides
the basis for the formulation of directions of systems
transformation. .
The subject has to be probed to the point that both partici-
pants in the dialogue are convinced that: |
- The evaluator understands the spokesman's view of the
region and has stated enough of it clearly enough to

reassure himself and the spokesman.

 
-32-

- The spokesman has stated whether he believes this par-
ticular array of starting conditions is tough, average,
or a bit simpler to deal with than average (assuming
for the moment the accuracy of what the spokesman has

said).

- All likely emphases have been tried out by the evalua-
tor in an effort to test and understand how the starting

conditions fit together dynamically.

An adequate response constitutes a diagnosis of the regional
health care System. It also furnishes the evaluator with some
beginning hypotheses about how skillful the regional care staff
is in casing the region.

When well explored and laid out in the dialogues, the diag-
nosis includes the data crucial to working out Strategies of
Systems transformation, both those which define health issues and
health needs and those which define the Organizational and poli-.
tical character of the health care system. |

- What is the character of the principal health problems

of the region? What is their distribution?

. What is the character of. the present configuration of

health care facilities and resources? What is the

nature of the health care delivery systems that are

dominant in the region?

 

 
 

 

-33-

. What are the patterns of access to care among the

principal population groups?

The foregoing questions aim at establishing starting conditions
at the level of health, access to care, and configuration of
care-providing resources.

- Who are the key actors and powers within the health
care system of the region? How do they relate to the
power structure and to the politics of the region as
a whole?

. What is the nature of the linkages, the relationships,
the patterns of referral, the tensions and conflicts,
among these key actors?

- What do the central actors perceive as the major issues
of health care for the region--whether these are identi-
fied in disease-specific terms, in terms of access to care,
quality of care, or in terms of costs, manpower, patterns.
of dominance and distribution, or other facets of the
health care system?

This next set of questions aims at an understanding of the
"political" forces that can be used or that must be dealt with
in any strategy for systems transformation.

Out of responses to these questions come regional diag-

noses which provide the material for designing Strategies of

Systems transformation for the region.

 
 

~34-

At the point of establishing agreement on starting
conditions, the evaluative dialogue has to involve:
- Feed-back to a widening circle,
- Testing the perceptions of those who first describe
Starting conditions, strategies, or other aspects of
RMP and the territory in which it functions.
- Some appraisal (i.e., development of a more or less
acceptable description) of the way the local RMP
went about data selection and gathering.
. Gradual clarification, through the dialogue itself,
of the specifics on which detailed information is
needed,
The following are excerpts from regional diagnoses which
illustrate something of the variety of starting conditions to

be discovered.

- xX Region. X is a prosperous, relatively homogenous
society. Good medicine is practiced here, and the profession
is in relatively good repute with the local political-social
establishment. As yet medicine and the other health profes-
Sions are facing only tentative questions about the "relevance"
of where sub-specialization and bigger-better hospitals take

us. But something very real is brewing in the state legis-

lature's effort to force a "Family Practice" Department on

 

 

 
 

-35-

the distinguished specialists of the University medical
faculty. Additional intimations exist in the reluctance and
opposition of the Academy of General Practice to the way the
medical faculty had first planned to go about teaching family
medicine.

Layer on layer of competent, skilled, devoted people
working in hospitals and other health care institutions all
over the state, all of which tend to emulate or somehow react
or respond to the presence of the internaitonally famous in-
stitutions: the Central Clinic, the University, and Reha- ~
bilitation Foundation. There is an apparent shortage of
manpower willing and able and wanting to perform health care
services on the level of ordinary care for ordinary conditions.
Town-gown issues are real, but because "gown" somehow includes
Central City as well as "The U," and because "everybody"
was trained at "The U,"' the issues take a special form.
Centralization of the Clinic and decentralization of the Uni-
versity complicates their association, whenever joint commit-
ments are required or contemplated. Good acute care general
hospitals are a dime a dozen, and coming to view one another
as competitive whether they are or not. Many are trying to
become referral centers both in big specialist consulting
staffs and many high technology services.

Generally the establishment, medical and non-medical

exhibits a tough-minded, "show me" conservatism, tempered
 

 

~36-

by a very active consensus and willingness to try out credible
ways of improving the situation (e.g., 40% of X-State private
physicians have tried out group practice, They and their
patients like it well enough to stick with it.)

RMP has to make its way among a number of giants, all
zealous defenders of quality medical care, each with its
own tradition of constructive innovation, each with its own

considerable institutional inertia and sense of independence,

- Y Region, In the region's largest city there is one
large medical school and one large community hospital. The
region consits of five quite different counties. Three
counties made common cause with RMP from the outset, Two
are left. In one, a private physician has his own comprehen-
Sive health plan; prepaid medical care has been attempted
under his auspices; success is believed to be uncertain;
critics prophesy failure. The other county is simply cut
off and disinterested. It is difficult to get medical or
consumer representatives from either county even to meet
for reasons that pre-date RMP, but embrace it: several of
the major counties are joined in uneasy alliance, with many
Yivalries, all felt particularly strongly in the smaller

cities,

- 4 Region, The major hospitals and associated medical

schools, are all in the major city and dominate the region.

 

 

 
 

 

~37-

These are set against the smaller community hospitals, each
of which in turn is trying to be a medical center. Not sur-
prisingly, there is relatively thin patient use of these ex-
pensive facilities in suburban hospitals. Not surprisingly,
too, there are parochial and compartmentalized referral pat-
terns disturbed by conflicts among the several large medical
schools and hospitals. There tend to be economic and social
distinctions drawn between the largest and the other medical
school complexes, though these may be decreasing, and certainly
keep changing. With all, the distribution of physicians to
patients is highly inequitably spread over the region.

- ghetto areas: 1/3000 to 1/5000

- center city: 1/200
-. suburban: 1/700 to 1/800
» rural: 1/1000 to 1/2000

The 5 medical centers have limited goals. All are under
great financial pressure, pressure relative to income, to
student load, and pressure to pay attention to the ghettoes,.
They are beginning to believe that is where the money is.

In the meantime, the cultural institutions of the major

urban center continue to tend to turn inward, there is very
little that can happen "unless you own it."' So the tendency

is rather stronger than average to want to turn RMP and training

dollars to the enhancement of existing institutions and depart-

ments,

 

 
 

 

-39-

crucial substantive issues of health care, issues

relating to the political and organizational structure

of the health care system, and key actors and initiators
of innovation in the health care system.

While the co-ordinator should be capable of arguing for
these directions of movement, on the basis of the regional
diagnosis, these preliminary views about strategy should
remain developmental, in two senses. They should take account
of the issues they do not address, and there should be some
thought as to the means by which these other issues may come
to be addressed. And they should be responsive to changes
in the regional diagnosis which come to light in the course
of RMP activity.

The basic question is "How have you gone about formulating

 

preliminary strategies for systems transformation?"
- Through what process have you gone?
- What is the substance of the Strategy as so far
developed?
. Why this far, and no further -- or why so far in this

direction?

Often, the best way of getting at these issues in the dialogue
1s through questions such as these:
- Where are the outstanding strengths and weaknesses

among key agencies and actors in the medical care system?

 
 

 

~40-

- What are the patterns of alliance and conflict, and
how are these changing?

- For key actors in the System, and for the issues they
regard as critical, what are the ends-in-view both
for changes in the delivery system and for changes
in their own position within the system?

- What are the critical "starting issues," and how might
these be used to move toward systems transformation?

But the specific forms of these questions must come from the
regional diagnoses, and must elicit the ways in which pre-
liminary strategies address themselves, or fail to address
themselves, to the issues raised in these diagnoses.

The following are examples of some of the preliminary

strategies emergent from the fragments of diagnoses listed
above, and questions that the evaluator can or should raise

about these strategies, to push the dialogue a step further:

~ xX Region.
| The primary problem is the isolation of many small com-
munities, especially rural communities from which physicians
are slowly disappearing, and their disinclination to colla-
borate. Corollary to and underlying this is the past success

of medical education in selecting and training physicians to

want to work in sophisticated hospital settings, thus creating

 

 
 

-41-

strong impetus for hospitals to compete, even within com-
munities, and to attract physicians by offering ever more
highly differentiated and costly services, without careful,
credible investigation of community needs and how they are
satisfied.

The function of RMP should be (and is) through projects,
membership on advisory committees, and core-staff activity
to facilitate connections and collaborations among elements
of the medical care system, particularly among small com-
munities and particularly among physicians. The connections
and collaborations should be multiple and small-scale, so
as not to ruffle too many feathers.

So RMP, for example, should serve as broker and supplier
of seed money for the merger of hospitals in adjoining rural
market towns; should support short-term in- residence programs
for GPs at the Clinic; should dot coronary care programs
around the State; should promote outreach programs from the
Clinic and the University; should use the RAG and its committees
to involve all elements of the medical care system and repre-
sentatives of its consumers, in order to connect small com-
munities with one another and With the centers.

The object is to build larger movements toward collabora-
tion and more ambitious ends-in-view from the success and the

fallout from many small-scale efforts, in the process of
*

 

 

 
 

-42-

learning what is feasible and helping the various interests
and groups involved to assume as constructive leadership roles
as possible.

Some questions:

, Will the small-scale collaborations ever get big enough
to make an impact on medical care in X Region, and will
they happen so slowly that one is forgotten before the
next happens? What is the threshold level of scale
and pace for facilitation if it is to have a building
effect?

- Have you taken into account what needs to happen in
order to get the Clinic and the University really in-
volved in the medical problems of the smaller communi-
ties? How much "involvement"' do you want and why?

Can you do that without confronting the "family prac-
tice" issue, and helping to attain a viable resolution
to the conflict among the Academy of General Practice,
the University medical faculty department heads, and
the legislature? Would sponsoring more activity
within the allied Health Manpower field force or en-
courage a more valid solution to the general practice-
family practice problem -- or just convince the MD's

that RMP is against doctors?
-43-

How do you propose to respond to the conservative
stand of many GPs, particularly in southern area,

who don't see what RMP has in it for them, and who
feel threatened by or disagree with what they hear?
What stance will you take toward groups currently

left out of the strategy -- for example, hospital
administrators, dentists, mental health practitioners?
Are there parts of the State in which it would make
sense to do so?

Does the current mix of efforts respond, at the level
required, to the serious problems you have identified --
i.e., to the problems of rural medicine, isolated
communities, care for the small but clustered popula-
tions of minorities, the deficiencies associated with
the (otherwise desirable) proliferation of specialist
physicians and the disappearance of family physicians,
both in the central parts of the large cities and in
rural areas? If you cannot envisage any adequate res-
ponse in first-round activities, how do you plan to
build toward such a response? If manpower shortages
seem to you the central questions about the response,

how do you plan to attack the question of manpower over

time?

 

 
 

~44-

Often the formulation of preliminary strategies depends
upon the involvement of key actors and agencies.

The co-ordinator should have found ways of including
actors and elements of the region's medical care system
identified as key in the regional diagnosis; where some
of these cannot be included at the outset, the problems
about their inclusion should be explicitly confronted
and strategies developed for overcoming these problems

over time.

"Inclusion" may be indicated by participation in a range
of RMP-related activites, including involvement in RMP com-
mittees, in project work, or in ventures initiated or supported
by RMP. The difference between significant and pro forma
inclusion must be resolved by tests that vary from case to
case.

What is to be appraised includes:

', Whether there has (or has not) been a real attempt
to arrange for specific people to be included in RMP,
(Was the labor union representative really invited
to RAG meetings? Did he feel invited? Was there any-
thing for him to do?)

- How well. the attempt is related to the eo-ordinator's

sense of starting conditions and his strategy and ob-
jectives (which depends on hav ing learned those things

first).
 

 

-45-

- How explicit the co-ordinator can be about who is not
to be included, and under what circumstances those
persons would or should be included.

« How much the co-ordinator and core staff learns about
the process of including people from the experience
of doing it. (If they had it to do over would they
do it another way? Are they increasingly imaginative
and increasingly direct in their approaches to people?)

- The impact on others of the co-ordinator's attempts
at including people (clumsy or skilled, relevant or
irrelevant, useful or useless, well planned and well
understood or otherwise). |

A case in point is the following:

- Y¥ Region, |

The RMP has taken the position that it is a clearing-
house for projects; it solicits and processes applications
from elements all over the region. RMP is, therefore, a
conglomerate of projects; how can it have a program strategy
for systems transformation or anything else?

But there is the sense of need to involve the two counties
currently disengaged from the program. The preliminary strategy
has impacted on the starting conditions in a way that permits,
encourages, and partly specifiés a revision in approach,

One county, medically under the leadership of a strong

physician, has no involvement in the RMP program. And there

 

 
 

-46-

are 250,000 people there. The belief in the county is that
the big city always wins, and that's where the money is.

In spite of its apparent role as a "clearinghouse for
projects," the RMP turns out to be operating on a strategy
which says, "Get every major actor and every county active
in RMP." Their tactics are based on this strategy.

The major physician in the isolated county is concerned
about diagnosis of cancer, and about the 100-mile round trip
required to get specialized diagnostic screening in the large
city. He is encouraged, therefore, to propose the establish-
ment of a diagnostic center in his county.

Some of the relevant questions, especially appropriate
to early involvement phases:

(1) Is the investment worth it? How much does it take
to npurchase" involvement? as a percentage of the
overall budget? compared to the costs of confronting
other urgent health care issues? Are there other
excluded or isolated elements of equal importance
(geographical areas, professions, voluntary associa-
tions, health departments, medical societies, hos-
pitals, or a combination)? What are the potential
future consequences (enmity, retribution, etc.) of

failing to try to involve somebody now? How does an
effort to include Dr. H. relate to the regional diag -

nosis?

 
 

~-47-

(2) What are the signs that investment has been success-
ful in involving Dr. H. and his county? How do you
distinguish pro forma from significant involvement?
For example, visibility at RMP meetings? Attitudes
of Dr. H. toward the proposals of others? Willing-
ness to permit some "teaching days" in the area?
Other projects coming out of the county? Willing-
ness of Dr. H. and others in the county to lend
voices in support of RMP activities? Willingness
of Dr. H. to share his emergent strategies for de-
velopment of medical care system in his county, or
to participate with others in formulating such

strategies?
~48-

(3) Ends-in-View.

- Out of interactions of key actors, ends-in-view should
have been established. These must confront at least
some of the key issues earlier identified as crucial in
the region. On the level of substantive health care,
they must confront at least some of the constant health
problem themes, or emergent issues in health care.

At a zone in time, attention shifts from the problem of
“getting all the key actors active in RMP" to the problem of
formulating the more specific ends-in-view and the strategies
for achieving them which are to emerge from the interaction,
planning, bargaining and negotiating of the key actors,

These ends-in-view are the specific rearrangements sought
in systems transformation. They, too, have many qualities
that are subject to evaluation. +The emphasis, again, is first
to discover what attempt has been made to identify these quali-
ties, and to deal with them. Evaluation of specific content
makes sense only after it's clear and more or less agreed what
has been attempted, and the context for attempting it.

The following are examples of appropriate questions:

- Have the issues earlier identified as crucial in the

region found their way into the formulation of ends-
in-view?

This is an illustration of what such a list of issues

 
-~49-

might look like:

"-~-Guidance to get people into the health professions.
--Coordination and involvement of the voluntary agencies.
--The urgent need for dental care in the north,

--The lack of out-patient care centers except for emer-
gency rooms,

--Essentially no preventive medicine is done in the
State, |

--Too many community hospitals trying to become medical
centers. .

-~-There is no weekend and almost no night-time medical
coverage now in a major rural county area."

Is the RMP engaging some of these issues through the de-

liberations and interactions stimulated among elements of

the health care system? "Engaging" means, here, facili-
tating the formulation of ends-in-view and strategies
adapted to them.

. Certain general criteria cut across regions and across
possible activities within regions. Questions about
"relevance" of particular activities apply not only to
the match between ends-in-view and judgments about issues,
but to the need for some attention to these criteria.
--Costs of care, particularly for hospitalization, ex-

tended care, and costs as experienced by lower- and

lower-middle income persons as well as others.

 

 

 
 

-50-

--Quality of care, and the distribution of quality of
care across the region.

--Access to care, and equity of access to care, across
socio-economic strata, minority-and-majority-groups,
and geographic subregions.

- Have the processes making for inclusion, discussed
earlier, extended beyond formal membership in RMP
activities, to formulation of ends-in-view and Strategies
for achieving them?

- How are priorities formulated?* Are priority issues
being confronted explicitly at all? By whom? Do pri-
ority considerations enter explicitly into the delibera-
tions and interactions of elements of the medical care
system, or are they handled by the coordinator or core
staff alone, or ostensibly. or really left to Washington?
If there are conflicts among elements judged to be cru-
cial to the region -- for example, conflicts between
major, hospitals and medical schools, between town and
gown, between professional providers and representatives
of users -- are these conflicts allowed and encouraged
to enter into the formulation of priorities? Does the

coordinator intend to attempt to build clusters of these

*This may be the first time that themes of RMP activity become
explicit and that questions of priorities hecome real issues
(often first stimulated by conflicts over ownership of limited
funds).

 

 
 

 

-Sl-

elements into working groups, through explicit confron-
tation of these questions? If he is not doing this, is
it a matter of deliberate intent? Is he working --
temporarily, or as a matter of continuing strategy -- on
a model of compartmentalization, in which conflicts‘ over
priorities and ends-in-view are not allowed to come up,
except within limited subsets of elements? Is he 'sub-
regionalizing" in this sense? If so, does it make sense
to do so?

Is conflict of ends-in-view being handled as a matter of
“dividing up the pie" among competing actors, or is there
also an attempt to relate such judgements to shared judge-
ments about the urgency of health issues, or about the
usefulness of issues as ways into systems transformation
in the region? |

Major themes of RMP activity should be developed and
stated. These should be not merely a reflection of what
is common to ongoing activities, but a source of guidance
for the generation of new activities. Questions of pri-
orities among ends-in-view should have been confronted,
through a process in which key actors in the region work
on their conflicting interests not only on the levei of

ownership of RMP resources but on the level of substantive

health issues and strategies.

 

 

 
 

-52-

. How appropriate, acceptable and feasible are thé strat-
egies being developed for achieving the ends-in-view
adopted? For example,
~- an outreach center, as a way of involving a major

‘hospital and medical school in the problems of an adja-
cent ghetto? Who will make it work? Who wants it?

-- a joint coronary care project as a way of encouraging
collaboration and rationalization of planning among a
set of community hospitals? What will make it transcend
its original focus?

Questions about such strategies will focus on a number of

dimensions:

-- Adequacy of scale of the "solution" to the "problem."

-- Feasibility of the methods proposed.

-- Appropriateness of the strategy to objectives on mul-
tiple levels of the activity (e.g., substantive health

impact, as well as systems transformation ends-in-view;
clarification of ends-in-view as well as involvement).

-- Appropriateness of the strategy to the constraints and
problems perceived to be underlying the issue. One of

the questions to arise at this point is the question of
"teeth." Is the issue one that will yield best, or at
all, to voluntary involvement on the part of the key
actors concerned? Or does it require some forms of sanc-

tion and compulsion? This is a question of ideology,

 
 

 

-~53-

Strategy and legislative mandate for RMP, as well as of
‘propriety: possibly some other agency is more appro-
priate.

Where the focus is on learning, attention will go not only

to questions of this kind but to questions about the ways

in which the development of strategies is handled:

-- Is there evidence of the active consideration of alter-
native ways of achieving the same ends-in-view?

-- Does the deliberation over strategies carry with it con-
Sideration of effectiveness of the Strategy in relation
to the costs of carrying it out, and consideration of
the cost/effectiveness characteristics of alternative
strategies?

-- Are there timetables for accomplishment? How realistic
are they?

-- Has there been consideration of ways of determining over
time how effective strategies are in achieving ends-in-
view? Tests for their achievement?

Where the focus is successfully placed on learning, the

impact of such questions will not be to "grade the strate-

gies at this zone in time where emphasis is on the devel-

opment of specific ends-in-view, but to influence their

development positively, by "accelerating" and "enriching."

 

 

 
 

 

-S4-

(4) Implementation.

The process of implementation should be characterized by
involvement of implementers in selection of ends-in-view
and strategies for achieving them; and by a relationship
of co-ordinator or core staff to implementers which permits
continuing mutual modification of strategy and end-in-view

and of implementing activity.

The implementation of strategies toward ends-in-view may

- take the form of core staff activity, of the conduct of speci-
fic RMP projects, or of the activities of committees or ad hoc
groups, under the aegis of RMP. The end-in-view and the strate-
gy may be specific enough to lend themselves to only one of these

kinds of activity, and to a well-defined unit of implementation,

or they may lend themselves to a widespread cluster of activities.

For example,

End-in-view Implementation

To foster collaboration and A coronary care project
rationalization of planning jointly granted to the 13
among 13 community hospitals. _ hospitals, requiring the

use of common facilities.
To encourage multi-level : Brokerage functions by core
collaboration between two . staff, RMP support of one
hospitals in adjacent rural hospital staff member charged
communities. | with working out details of

the merger. —

 

 
 

-55- “

To increase the "power base" A series of projects, funded
of the medical community in that area, linked to major
"on the other side of the medical institutions. Broker-

age activities. Use of RMP
committees to establish rela-

- tionships crossing the moun-
tains.

“Some of’ the relevant questions are these:

. Are initiators and leaders of the activity aware of the
ends-in-view, and the processes leading up to their
formulation, on the basis of which the activity actually
came to be undertaken by RMP?

- What are the patterns of access to resources required
for implementation? Is there a basis for judgments to
be made, on a continuing basis, as to the adequacy of
resources to the task?

- Is attention given to the possibility of shifting defi-
nitions of ends-in-view as more of the reality of the
discovered system comes to light? Is the project or
activity leader locked into a potentially stultifying
view of what constitutes "success"?

. What constitutes progress? Are there operational tests
of performance, short of more nearly final judgments
of impact, which can help ‘to guide performance in the
course of the activity?

- What is the relation of the regional co-ordinator and
his staff to the activity? If it is not their activity,
do they have, in relation to it, a continuing monitoring,

learning-evaluative contact which allows mutual

 
~56-

modification of the ends-in-view and the strategies by
which the attempt at implementation is being made?

. How compartmentalized is the activity? Is it connected
to analogous activities in the region, or to activities
which are parts of the same program strategy, so that
both learning and concerted action may occur, where
appropriate?

- What is the relationship of these processes of imple-
mentation to the overall strategies of systems change
held by the coordinator and/or his collaborators? Has
the coordinator attempted to be explicit about these?

Is there an effort to relate them to particular strate-
gies for achieving particular ends-in-view? For example,
to connect a particular activity as a feature of a
"master plan"; to identify a particular negotiation as
part of an overall strategy which seeks to involve key
actors in a process of negotiation over their interests
and conflicts in relation to the system of medical care.
Is the coordinator able to use the experience of particu-
lar activities to learn from or to influence his over-
all strategies of systems change?

There is one side of the question of impact which should

be treated separately here, because it involves the impact of

the process of implementation, which can reflect back both on

 
 

-57-

the formulation of particular ends-in-view and on the region's
capabilities for carrying out further systems transformation
activities. This is the process through which the definition
of accepted ends-in-view may shift.

. The connections established and reinforced in a particular
activity may lay the groundwork for new forms of collabo-
ration, e.g., the joint planning of a coronary care unit
which leads to joint planning of a range of common facili-
ties; the diagnostic screening project in a county pre-
viously cut off from the medical System of the region,
which leads to a series of boundary-crossings. Are
these things happening? Are there attempts to make them
happen?

- Learning from an implementation process can lead to changes
which facilitate new processes, e.g., the cumbersomeness
of a process of review and monitoring can lead to simpli-
fications which make it easier and more attractive for
others to enter the orbit of RMP activity.

- Processes of implementation can display or enable devel-
opment of "role models" which influence the character
of new activities undertaken, e€.g., the impact of Jim
Musser as broker-facilitator on other key actors in the
North Carolina region, or of Paul Ward in California,
e.g., the influence of the few emerging medical cure

corporations in California on similar, varying upproaches

to medical corporations.

 

 
 

a

Questions about impact f£ implementation, then, need also
to be addressed to the impact of the process of implementation
“itself. | | | a

At this point, RMPS criteria for Systems transformation in
the region take the form of meta-criteria for the evaluation
processes carried out in the region. |

: Without specifying evaluative criteria to be used in

assessing the impact of implementation on any of the
levels of change, RMPS should require that such criteria
be developed and that they be appropriate to the ends-

_in-view and strategies adopted. Dg

. These criteria should not be limited to programmatic

criteria (e.g., how many nurses trained? how many calls
received?) but should attempt to assess change at one or
more of the several levels of change in substantive health
care. |

- In each instance, consideration should have been given to

the choice of level at which change is assessed, aiming
at health outcomes, then at access to delivered care, and
so on. There should have been review of the definitions,
test-methods, and measures appropriate to the end-in-view
and strategy involved.

- With respect to the process of evaluation, the evaluative

framework should have been developed collaboratively

between the regional center and the implementing agency.

 
 

 

~59-

There should be an openness to modification, through the
process of evaluation, both of the implementing activity
and of the original choice of end-in-view and strategy.
This openness should be evidenced in the demonstrated
Capacity of evaluative activity to influence the planning
of the implementing process, and in the evolution of the
-concept of end-in-view and strategy during the course of
implementation; and the frequency and pattern of contact
between core staff and implementing agency should be such
as to make that kind of mutual influence feasible.

- The evaluative processes adopted by co-ordinator and core
staff should be conducive to learning across sub-regional
boundaries, so that those engaged in analogous activities
(continuing education for GP's, for example) can learn
from one another's experience, and those whose activities

are elements of a larger strategy can interact in the light

of that strategy.

 

 

 
(5) The Developmental Cycle.

 

Regional programs develop iteratively, if at all. Cycle
succeeds cycle, each growing out of, but resembling, its pre-
decessor. A regional program, seén as systems transformation
moves through its cycle: casing the region, planning, and imple-
menting. Then through another cycle widening and deepening its
rings of activity. The evaluative questions of any one phase
continue to be relevant; only, new sets of questions are also
relevant to established activities, and to other sets of activ-
ities. The process of bringing new elements into RMP, for
example, continues even as the ends-in-view emerging from earlier
processes of inclusion begin to be carried out.

The most relevant new questions help uncover the directions
of change in the scope and purchase of the whole program as it
moves through successive interactions of the process. These
questions are of several kinds:

- Is the process increasing its scope?

-- Is it increasing in the overall volume of activity,
as measured by actors involved, dollars mobilized,
number of separate activities undertaken?

~- Is there a widening range of partics involved in inter-
action and negotiation? Is the level of aggregation
of the parties increasing? For example, is the inter-
action beginning to involve clusters of community

hospitals rather than individual community hospitals?

 

 

 

 
 

~61-

Is the level of aggregation also decreasing? For ex-
ample, are individual physicians as well as medical
society representatives coming to be actively involved:
in a way that extends the scope of the program? |
Is there an increase in the number of health issues
engaged? Is there an increase in the coverage of the
region represented by those issues and by the ends-in-
view and activities generated? Within each phase, the
map of the issues confronted and their location in the

region should reveal changes of the following kind:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Issues —
x x
Xx
Phase 1
Regional Location
Issues

 

~ |
oe
~*~

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phase 2

 
 

 

-62-

- Is the process increasing in depth and intensity?

-- Is there an increase over time in the perceived im-
portance, urgency, and ambition of the issues engaged
and the ends-in-view formulated?

~-- Is there an increase in the connectedness and "clout"
brought to bear on the issues engaged?

-- Is the level of aggregation of the parties decreasing?
Are individual physicians as well as medical society
representatives coming to be involved in a way that
deepens the program?

We can provide an example of the development of ends-in-view
and strategies in a regional program as it begins to go through

a succession of cycles:

The K region:

Dr. P., the coordinator, came from a program of continuing
education in the one large medical school, a program of continu-
ing education for GPs which, by his own present view, was not
too successful. He began by seeing the creation of RMP as an
opportunity to expand his own educational program, and obtained
a planning grant to create K-RMP.. He visited local medical
societies over the region and with them set up a program around
tumor registry, coronary care units, and continuing education.
Boundaries of the region were set up by the expression of interest

of the parties approached who attended the meeting.

 
 

-63-

As the program has begun to expand, its emphasis has shifted
away from the categorical approach. The RAG, which began with
30 physicians, has begun to change composition to include lay-.- -
men. In view of the relative weakness of other institutions,
including the State Health Department, KRMP has moved toward a
controlling position for health planning for the State.

Concentration at the beginning has been on work with indivi-
dual physicians and community hospitals, with an emphasis on
education, viewed as the easiest and least threatening way in. ~
At the same time, core staff became involved in project -writing
for individual hospitals, KRMP has now withdrawn from CCU pro-
grams, except for continuing education. However, a similar
effort based on the earlier experience (establishing facilities,
loaning equipment to communities who could not afford to buy it)
is now being carried out for respiratory programs.

Dr. P. now realizes that in his region, which is poor in
physicians and clear in its referral patterns and which has one °
medical school and not much institutional rivalry, the provision
of continuing education to physicians and others is not enough.
What is needed is the provision of a system of care and appro-
priate facilities within which the fruits of education can be
realized.

Here, since the structure of the program as a whole is built
around the coordinator, the development of ends-in-view becomes
very much the development of his own views of the issues that

need to be confronted and the ends-in-view adopted.
 

~64-

. Is the process characterized by an evolution of issues,
ends-in-view and strategies, which reflects learning?

The regional diagnosis of the coordinator, the issues
he takes to be important, the ends-in-view and strategies
to which he is committed -- in Short, his own systems
rationale -- may shift in response to new perceptions of
the discovered system of the region, as regional activities
bring that system into focus.

This learning may take the form of an explosion of
"rational" plans for the building of the health care sys-
tem, by contact with the political interests and powers
of the real-world actors in the system. It may take the
form of a shift in priorities about health issues, as pre-
viously "hidden issues" -- for example, the depth of in-
adequacy of health care in ghettos -- come to the surface.
It may take the form of perceiving the extent to which
the needs of physicians and community hospitals in “have
not" areas are inadequately served by diffusion of the
technologies and research findings gencrated at the major
medical center.

In each instance, the discrepancies between systenis
rationale and discovered system, at the regional level
may lead to the reformulation of regional diagnosis as
well as of ends-in-view and the strategies corresponding

to them.

 
 

-65-

It is not reasonable to set uniform standards for the
periods of time within which regions should have reached certain
levels of maturity in their developmental cycles, just as it is
not reasonable to apply uniform standards across regions to the
time periods within which the various stages of development
should be completed. On both levels, the time intervals will
vary with regional conditions. The key factors here are not so
much the size of the region as its complexity, its internal
connectedness or disconnectedness, the number of conflicting or
. disconnected elements within it, and the seriousness of their
conflicts or isolation from one another.
Elements that affect the speed of motion include:
-- Simplicity of the politics of the medical care system.
Few elements to be connected; few conflicts to be re-
solved. | | . |
-- relative weakness of other elements of the system,
permitting RMP to function from the beginning in domi-'
nant or unusually significant health planning role.
-- relatively high degree of connectedness among elements
of the medical care. system.
It may be possible to establish a typology of RMP regions
in terms of their potential for movement, similarities in strat-
egy, and characteristic types of activities chosen to carry out

the RMP program. There are, for example, many instances of

efforts to stimulate collaboration among community hospitals

 

 

 
 

through their joint involvement in some program of approach to
categorical disease; to establish outreach arms of major medical
centers; to reach isolated subregions through programs using
paraprofessionals, continuing education, and the secondary sup-
port of specialists. Regions and subregions differ as to the
constraints they put in the way of these kinds of activity, but
they, too, can be grouped in terms of the seriousness of those
constraints. |

The purpose of such a typology would not be so much to permit
judgements of the effectiveness of one region against another as
to provide guidelines both for RMPS and for regional coordinators
as to the rates of movement it is reasonable to expect in a
given region and for a given kind of activity.

Judgements about a region's progress in systems transforma-
tion may be made on the basis of its ability to meet criteria
within any given stage of development; its rate of movement
from stage to stage, given the constraints under which it is
operating; and the level of scope, depth and learning cvidenced
by its overall cycle of development.

In point of fact, most of the RMP regions are still primarily
involved in the problems of inclusion of key elements of the
medical care system in RMP activity and on the formulation of
preliminary directions of movement and strategies. In spite of
the number of operational projects, most regions are only begin-

ning the work of fitting projects into strategies for achieving

 
 

-67-

specific ends-in-view. Most are only now at the stage where the
formulation of themes of RMP activity and the confrontation of

questions of priority among ends-in-view become feasible tasks.

~

 
 

~68-

Conditions for the Central-Regional Dialogue.

 

Having sketched out a national-regional dialogue aimed
at fostering learning in relation to systems transformation,
there remain questions about the particular vehicles through
which such a dialogue may be brought to reality and the con-
ditions under which it can be effective.

- The two parties to the dialogue must begin with some
commitment to and understanding of the goals and methods of
this kind of evaluative process, The requirements here re-
late both to the theory of the evaluative process and the
role of the dialogue within it, and to the particular skills
and techniques involved in carrying it out.

- Although we have used simple words like "central" or
"RMPS" and "co-ordinator," the parties to the dialogues will
be complex. On the regional Side, the dialogue will be
carried on by groups of varying kinds, depending on the
makeup of those involved in Carrying initiative at the regional
level. In one region, it may be a "strong man co-ordinator,"
his key assistants, and from time to time others that he may
wish to bring along in order to involve or educate them. In
another region, it may be the team the co-ordinator has been

trying to assemble out of core Staff, certain RAG members,

and certain key actors in the medical care system of the region,

 

 

 
 

-69-

- On the side of the national staff, there is a key re-
quirement for continuity of involvement in the dialogue with
region over long periods of time -- ideally, over the life of
the region's development under RMP. The requirement for
continuity becomes particularly critical, given the diversity
and open-endedness of regional approaches to systems trans-
formation; it is only out of intimate knowledge of the content
of earlier stages of development that central can be effective
in dialogue with the region.

But, given the realities of life in both central and
regional bureaucracies, continuity of this kind is to be
achieved not through one man but through small groups whose
members overlap in the course of time.

From central's point of view, the small group permits
the inclusion of the varieties of competence required to carry
out effective dialogue with the region -- competence to ques-
tion and respond on issues of substantive medical care and on
issues of systems transformation, and skills in the evaluative
process of the dialogue itself.

There will be no need to distinguish the central-regional
dialogue from funding decisions, and, concurrently, .to move
away from the usual mode of central-regional contact, in which
the region displays its wares for central and central and the

region then engage in a game of attack and defense, For the

 

 

 
central-regional relation to be solely or primarily in this
mode prohibits learning, in the senses outlined above, and
makes it difficult or impossible for central even to gain in-
formation about regional activities.

On the other hand, the dialogue requires that the RMPS
staff be capable of being tough with the region, raising issues
hard enough to be heard and challenging the region in the
light of findings and commitments which emerge from the dia-
logue over time.

In order to make these things feasible, there is first
a need to model the roles involved and to set the tone for
such a dialogue, and concurrently to set apart and formally
distinguish the funding-justification process from the central-
regional dialogue. The dialogue will surely feed into RMPS
judgments about regional funding, but should be formaily and
operationally separate from the funding process.

Will such a distinction be feasible, given the tendency
of the region to view central as monolithic and the region's
knowledge that funding decisions will be made by central?
This problem is comparable to the problem of the regional
evaluator in establishing his "helping" role, in spite of
the fact that his findings will be influential for decisions

on project funding; indeed, the problem is central to uny

process of good management in which the Manager seeks both to

 

 

 
 

 

-71-

facilitate learning and to exercise control. The feasibility
of the effort will depend ultimately on the good faith that
central and the region are able to establish with one another,
and on the extent to which the dialogue is found to facilitate
learning. . | |
The dialogue requires a certain frequency of contact
between central and regional groups. Given the rate of move-
ment in most regions, once-a-year is not often enough. Within
the interval of a year, too much happens, and too many decisions
are made which lock the region into patterns of activity. Fre-
quency of contact should be determined by the time required
for the co-ordinator to take Significant steps, or for the
regional situation to shift in Significant ways that mark
important milestones in the Stages of systems transformation.
Intervals are likely to vary over the course of the region's
cycle of development. For example, contacts might be established.
around key events such as the first formulation of regional
diagnosis, the establishment of themes of RMP activities and -
the first effort at establishing priorities for specific ends-
in-view, or the first phase of experience in implementing a
specific strategy. Within the range of frequency indicated
by "oftener than once a year," there should be provision for
flexibility increases if a representative of central and the

regional co-ordinator can maintain contact during intervals

 

 
 

~72-

between meetings of central and regional groups.

The central-regional dialogue offers another perspective
on the role and conduct of regional site visits, and on the
proposed process of anniversary review.

The central-regional dialogue could become the main
function of the site visit. The site visit team would then
become central's party to the dialogue. Such a concept would
answer to some of the problems currently reflected in regional
and central reactions to the conduct of site visits -- for
example, the pattern of regional display and of attack-and-
defense which make it difficult or impossible to find out what
is really happening in the region; lack of continuity in the
Site-visit team; lack of feed-back to the region; inability
of the site-visit team to respond to the region by Clarifying
or modifying central's "signals."'| There are also Significant
potentials of the site-visit as a vehicle which the central-
regional dialogue may help to tap: the opportunity for on-
site contact with regional actors and agencies, and the
presence in the region of persons regarded as pecrs by many
of those undertaking regional activities.

There is the further issue of the manpower requirements
RMPS would experience if it took seriously the conduct of
central-regional dialogues with all of its regions. The site-

visit team concept, in which outsiders are mobilized along

 
 

 

-73-

central personnel, would provide a crucial extension of
central staff. But the concept would also require intensive
efforts at internal training and team-building for the sites,
visit teams,

With respect to Anniversary Review, that event would
have a very different significance if it were to function
as the yearly culmination of central-regional dialogue, rather
than as an isolated contact which will tend to be seen, what-
ever the intent, as a funding -justification process. The
Site-visit team would then come to play a critical role in
the anniversary review process, and the results of earlier

phases of the central-regional dialogue would then provide

the basis for the inquiry conducted and the judgments made

in the course of anniversary review.