wave

 

 

 
REVIEW OF H.R. 13995 FOR ALTERNATIVE
ORGANIZATIONAL STRUCTURG&S

Fors Division of Comprehensive Health Planning
Bureau of Health Resources Development
Health Resources Administration
U.S. Department of HxwW

_Bys Mary F. Arnold

t

_ When one reviews H.R. 13995, one is struck by the variety
of activities the area-wide health planning agency (the HSA) will
be expected to perform. There seem to be three types of major |
activities representing three types of functions:
4A) the planning function which tmeludes the technical activities
of determining the types and kinds of health services and other
community needs to assure a healthy population. This set of
activities includes the development of criteria, in coordination
with state and federal standards, against which services now or
in the future can be evaluated. Under this function is also
included the development of the Health Systems Plan (the HSP);

_ the Annual Implementation Plan (the AIP); end the analysis and
assembling of data concerning health status, health resources, and
utilization of the health delivery system(613 A, Del» 2, 3e4)-

2) the evaluation function: fhat is, the critical assessment,
evaluation and review of current and proposed health services}
review and approval of proposed use of Federal funds in certain
health areas{613 e);review and comment for Sec.1122 of the Social
Security Act (613 f);certificate of need reviews (613 «). Although
sanctions differ within these different types of evaluative
actrvities (e.g. withholding of Federal funds versus state

disapproval as in certificate of need), the function is essentially

an evaluative one. Included here is also the technical assistance

 
~2= :

and other means of assisting providers not approved to change
the service in the desired direction or to eliminate the service.
3) the developmental function, that is, the encouragement of the
development of new services, whether through demonstrations, ,
innovation, or just adding services not previously available.
Technical assistance activities may also be a part of this
function, Its main emphasis, though, is that of encouraging a
planned change process witnin the community.

All of the activities involved in these three functions are
expected to be administered efficiently; and the agency is
expected to coordinate its activities with those of other agencies
such as PSRO’s whose functions somewhat overlap with those out-
lined for the HSA.Provisions are included in the legislation for
at least, annual reporting to the public; for holding public
meetings: and for approval by the Governor of the State.
Conflicts Within and Between Functions

It is important to this analysis to note that the evaluation
function and the developmental function are essentially anti-
thetical in that they represent two opposing views of the meaning
of planning. The first implies that planning is control while the
second implies planning is guided growth, In reality both meanings
may be of importance to a community. However, usually separate
institutions or agencies have served to carry out conflicting
purposes in a community; thus, allowing the processes of accomod-
ation to resolve conflict or to permit it to exist without the
occurrence of social disintegration. In this case, one agency is

being asked to serve conflicting purposes. For example, critical

review of institutional and home health services for certification

 
-3-

purpeses (6132) implies the imposition of control mechanisms

on the netural or ‘normal' development of services. The implic-
ation is that the local community, as represented by the area-
Wide HSA, can apply local, state, and federal standards and
criteria (and these may not always be campatible) for thc
assessment of need for such services within the area. It implies
also that there will be assessment of quality of these services.
(The legislation specifically states that one function of the

HSA is to work with providers not certified as needed for the .
improvament or elimination of such services-613 g). Control here
is the use of Negative sanctions with the threat that unless a
service changes it will be eliminated in-terms of either permission
to operate or of refusal of reimbursement by third party payors.
On the other hand, the availability of developmental funds
‘implies that new services will be added. What the agency
determines as the criteria for developmental funding will, of
eee determine how much emphasis is placed on new services.
But, in general, the use 6f developnental funds implies that
planning is analogous to growth while the evaluative function
implies negative sanctions and control. Again,it should be stated
that both functions may be needed in any one community at the sane
time, but it will be difficult for one agency to serve as both

the advocate for a set of services and. as the critical assessor

in a different context, Project officers become identified with

the projects for which they are responsible and it is not easy

to critically assess a project in which your agency has a financial

interest,

 
ae

Organizationally, therefore, it 1s important that these
opposing functions by integrated and jncorporated as integral
parts of a total planning system. There are many kinds of
strategies that can be used to avoid actual conflict within
the organization. Some of these eres +”

--operate the agency as if it were two agencies.

--contract out one function: for example, the evaluative

function could be taken on by the local health department

or the PSRO for the area.

--contract out developmental activities to the private
sector.

--set up voluntary peer-review type of evaluative process

whereby the HSA finances a self-policing by the

provider system.
More importantly, however, it should be emphasized that unless
a HSA establishes a specific mechanism such as the above, the
agency will not be able to give equal emphasis to all of its
functions. As a matter of fact, no agency can’ give equal emphasis.
to all of its activitiess-- prioities develop; sub-units compete
for resources; and one or another function begins to take :
precedence. ‘It is important that the HSA's be organized on the
basis of a consistent orgenizing philosophy that reflects how the
disparate functions of the agency can be integrated. Some
functions may be played down; and the mode of operations should
differ based on the organizing philosophy. Such an corganizing
philosophy identifies the major mission of the agencys the

prioities given to its various functions; how it relates to its

environment; and what will be its strategic plan for operations.

Obviously, the community milieu in which the organization is

embedded, as well as the state and condition of the health service

 
-5-

systems within the HSA's jurisdiction and the historical context
of social change within the area, will be the determining factors
of a successful organizing philosophy.
- An organizing philosophy is defined here as the sets of
Ege assumptions by which an agency or organization operates. These
assumptions represent a kind of organizational ‘world view’ about
the role of the agency and about the many issues with which such
an organization is faced. The general philosophical’ mission or
&€0al is part of the organizing philosophy. For example, if the
@oal is one of guiding institutional change, staff should work
differently than if the mission is perceived as preventing
unwarranted (however that is defined) activity. Thus, the general
Mission of the agency should indicate its purpose for existence
and something about the ways in which its purposes are expected
. to be achieved. When an agency takes on two or more conflicting
missions, one generally has to take precedence or the agency will
usually default in all functions,
‘Some Overational Issues in Health Planning
There are a number of philosophical issues that effect the
operation of organizations. These are seldon explicitly.identified |
in an agency but the solttions to these problems pattern the |
organizing philosophy of the agency. For health planning agencies
some of these philosophical problems are:
1) What is a plan?
Although there are those who feel.that this should not be
an issue, the meaning of the term plan is variable. A plan can
be perceived as a blueprint for the future; or, as a changing or

evolving matrix of policies about the health system; or as a set
of minimum standards below which the community will not tolerate

I _— _ ee =

 
~6-

a health service, All three perceptions are implied in the
legislation and it 1s likely that different communities at
different stages of existence require these three points of view.
For example, ina sparsely populated State such as Montana,
where they arg losing population.end where only a miracle, would
provide a great infusion of resources, it may be necessary to
perceive the ‘plantas indicating the absolute minimum that will
be tolerated. On the other hand, an area such as the San Fransisco
Bay area may have to work in termsof a continuously changing and .
evolving matrix where some services may be below a minimbm and
others are on the cutting edge of change and innovation in the
systen,. Communities of rapid growth ( e.g. new towns) may have
to focus on the far future becauss dealing with the present would
be complet@ly unrealistic. A stagnant, versus a stable vereue
a rapid growth community requires different approaches to the
connotation and meaning of the term"'plan',
’ 2) What is tne motivation of the providers?

Although this 4ssue is often skirted, it is important to
the ways in which an agency expects to work. May agencies operate
on the assumption that the providers are enemies; other assume treat
the providers are partners; in still others, the providers and
the agency are synonomous. Some agencies defer to the providers
as experts, while others operate on an adversary basis. Again
each situation will warrant analysis but, in general seeing the
provider as protagonist will be unproductive in effecting change

in the health system. Much of the review and comment otevaluative

function implies an adversary context rather than a partnership

 

 
37

context. The sets of assumptions about tne roie and motivation
of the provider will determine the style or mode in which the
evaluation is carried out. Every licensing and inspection agency
in local or state government has had to come to terms with this
eet ype Ol: “besnecf“row the-groups being “texwuizved:should be
perceived. If it 48 expected that the providers are looking to
change then the use of incentives such as developmental funds will
be appropriate, If an adversary position is taken, then negative
sanctions will be more likely to be employed. Although positive .
reinforcement has always been proven to be more effective from the
beginnings of the old saying “honey catches more flies than
vinegar” to social science studies on motivation in recent years;

4

there has been a mythology about the effectiveness of the threat

,

of negative sanctions,
3) What_is the role of the consumer? .
. Although this has been an issue for some time, the assumptions
that are made about the role of the consumer representatives is
| important to the agency's operations. There has been a tendency
to consider ‘representation as "a sample of* rather than as “a
' Spokesman for”, When many sub-classifications of population
characteristics are used to determine who shall be representative
of special groups in the community, there is a loss in the quality
of decision-making that can be expected. It is important that the
special skills of influence, so necessary to community action, be
brought to bear in the health planning process. This is where
the consumer can contribute more than mere information about an

interest group,

-

 
4) What is long-range?

The time frame of a community has always been a difficult
issue in planning. It is extremely difficult for any persons to
think beyond a 20 year span and even 5 years may be too long for
some/ Certain communities are changing so rapidly that fore~
casting beyond a 5-year span would not be vali¢, Obviously, if
@ 20 year span is used as a long-ranze parameter, estimates of the
future will have to be cast in general terms, since the longer the
time frame the more general the forecasts will have to be. The time
frame is also somewhat dependent upon the traditionalism of the
community. This, too, stems from the historical background of the

‘area, Often the more traditional communities are rural or of

a small population. There is distrust of rapid change. Thus, if
the time frame for a health plan implies rapid change, certain
communities will not support the implementation of progran.
Although it may be less effective for enhancing the health of the
population for a traditional community to think in very lonzg-
range terms, this is more likely to be the orientation. Often
such long-range terms are not explicit but are implied. A rapidly
growing community would best think in very long-range terms to
achieve health goals, but may not be able to mobilize interest in
the longer view. thus the time frame that is more appropriate

for certain communities, may be inappropriate in dealing with the
solutions to the problems. Tne HSA will need to find ways to
help the community operate on a more appropriate time frame.

5) Whirh are more izportant--horizontal or vertical relationshivse®

 

Warren in his Community in America indentifies two

 

sets of relationships among agenciess horizontal and vertical. ine

 

 

 
-9~

horizontal relationships are the locality relevant relationships
among the local groups and the vertical relationships are those
with the organizations and groups outside of the local scene..

For example, agencies representing the horizontal relationships

senOf ep cbmalth. planning agency would be the local Chamber of Commerce;

local government; local hospitals, etc. The vertical relationships
would be represented by the state agencies with which the HSA
works, by the U.S. department of HEW, ~by™. national’ professional
organizations, etc.One might conjecture that where there is a very.
diffuse power structure within the community that the vertical
relationships may be the most important and where there is a

strong power base. the horizontal relationships may be the most
important. Often there are conflicting demands upon an agency

from the two sets of relationships, It is logical to assume that

where horizontal relationhips are most important there will be

less emphasis on the evaluative funtion and more’ emphasis on

either planning or development. The issue is one of local
orientation versus a kind: of professional orientation although
one orientation is not less professional in the broad sense than
the other. There has been little study of these relationships and
community action, but they are important in determining organizat-
ional priorities,
6) How much trust is put_in technical competence?

In general, the more complex and populated a community is

the more likely will there be reliance on expertise, In the larger

metropolitan areas, those providers and consumers serving on the

Board and on.committees ere often ێyperts themselves and therefore

 
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they are more likely to expect others to represent a speciai
expertise and competence. In areas with smaller populations, with
less complexity and diversity of occupations, more people are

generalists and distrust expertise. In the areas of smaller

“Yao wpopilatior vith: seovial infrastructare is moreclose to the* surface

and there 4s an interdependence that is not seen in the complex
metropolitan community. One of the basic organizational
aifficulties is that the sparsely settled area that needs expertise
will not accept it. Additionally, because of the sparse population
the HSA has to be organized on a wider geographical basis. Thus
the organization that needs an adequate staff and mechanisms for
engendering trust in small local populations will be inadequately
funded. Without a heavy investment in community organization and
education there will be distrust of the planning process. One
solution is to provide greater resources to such communities for
community education and for strong community organization activities.
Only after such communities trust the process will they begin to
trust expertise. As current legislation stands there will be
inadequate funding for these HSA's. Certainly, any agency serving
communities where there is a distrust of expertise should

emphasize community organization as its main mode of operations.

Skills Required for Planning
Tnere are a variety of tools of planning ana therefore.the

skills required within a planning agency will necessitate developing
particularly those skills required for the organizing philosophy
that will prevail.Not only is there need for technical competence

in prediction, forecasting, decision-making, data analysis, etc.,

 
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there is a need for variation in the conceptual directions of the
planning process. These, however, are all a kind of technical
competence. If planning is to be more than just the design of a

technical plm, then there is another set of skills that is

t

 

réquired: Miller in his study Community Health Action has called
these "skills of influence". The following descriptions are
adapted from Miller, These skills of influence have to do with
how effectively social change can be guided and directed. If
implementation of any program is to occur, especially within a
democracy, then these skills are essential to the implementation
process. Each set of conditions where action is desired will
' require a different mix of these skills, but they are all important
‘at one.time or another. Eight skills of influence seem most.
. importants "

1. The skill of expertise or knowledze.:In special situations
the knowledgable advice of an expert can influence behavior.
An attorney can influence action (or non-action) based on his advice
. a8 to its legality. Too often task forces are set up that may
have certain expertise, but are missing other important expert
knowledge, It is important that committees and task forces be
organized to represent areas of expertise as well as points of
virw,.

2. The skill of maninulation of symbols and of communication,
When action is desired it is important that the persons to take
action understand what is expected of then, Although most people

over estimate their ability to comnunicate, there are persons with

special skills in writing,, in art work, in speaking. Availability

of these skills be vitally important for success.

 

 
~-12-

3) Skill in providing access to special and needed resources,
This skill is more than having power and authority. It includes 2
knowledge of where resources are available and how they may be
tapped. It often is necessary that the person with this skill
4s highly trusted by those who have the resources. Hesournes may
not only be money, but one might include -personnel];speciaj skills,
expertise, or access to other skills of influence,

4) Skill in legitimating action. This 1s a skill in making
the desired action seem to be the right thing to do. In some .
communities 1t 1s often held by one person who, if he supports the

idea, will provide all the legitimation necessary. Too often this

-gkill in mistakenly believed to reside in a position rather than

"in a person. For example, the president of the local medical

association will not have this skill by virtue of his office. He

may have it personally... .
 §) Skill in organizing and arranging people and resources.

This is often thought of as an administrative skill. For example,

there is no one organizational structure that is best for a hospital

or for a HSA, Rather each structure will engender certain types

of problems and the appropriate structure is one that meets the

organization's mission without too many difficulties that are

costly. Certain people have a skill in finding the effective

ways in which to organize people so that work is done effectively

and efficiently.

6) Skill in engendering enthusiasm and _ trust. The need for

 

trust has been mentioned previously. Without it little can be

accomplished, Unless this skill is available to the HSA little

will be accomplished in planning.

 

 
-13-

7) skill in bargaining and in conflict resulution. Often
action cannot proceed unless conflict is resolved or compromises
have been developed. There are some persons who make & career of
this skill as in collective bargaining. It is a skill that is
necessary for every HSA if any change is to come about through
the planning process. .

8) Skill in predicting the effects of action.,or non-action.
Although this is somewhat akin to the technical skill of fore-
casting, it differs in that it represents a kind of intuition based
knowledge of the many complex factors that may be operating.

It is often difficult to articulate why predictions are made, but
there are persons who have this skill and they are valuable to
any planning agency.

. There are no doubt other skills that are of importance to
the implemnetation of health plans. But, these seem to have been
most useful to the communities in Miller's etudy. These skills do
not have to reside in staff alone or in the volunteers alone. But,
these skills are more important for implementation than input from
many special groups through a representative mechanism. Every
 Baard member should be elected .and elected: every task force and

committee member should be slected. and every staff member hired on
the basis not only of technical knowledge or representativeness put
on the basis of what skills of influence he can bring to the

agency's work.

 

 
9

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Organizing Philosophies

 

As stated earlier, an organizing philosophy is defined as
the sets of assumptions by which un agency operates. It includes
the purposs of the organization and the basic strategies by which
it expects to accomplish that mission. Three different types of
functions for HSA's have been discussed: the planning function;
the evaluative function; and the developmental function, and some
of the issues or problems with which HSA's are faced. were discussed.
Given these three types of functions there are three potential .
models for organizing philosophies for health planning agencies.
Each will have a slightly different way of resolving the philosoph-
{eal igsues confronting it; each will require slightly different
sets of skills. No one model is best; rather, each serves to meet

different kinds of community needs within a social context.

The models are as follows:

 

I/Triie Plan Implementation Model:

In this model, the HSA's major mission is considered to be
the implementation of a blueprint for the future. Under such..an
organizing philosophy, emphasis is on the development of a plan
that is focused on the future but that has a great deal of
specificty.for judging current activities and for estimating
future activity of various services and institutions. Once the plan
is developed, then implementation for the future becomes the major
emphasis. Staff emphasis would have to be on developing consensus
within the community for the Health System Plan, and on providing
a strong public education and public relations program to maintain

an informed public that will anticipate needs, demand that services

 
-15-

be developed;and support those developments to meet future needs.
The evaluative functions-- review and comment and assessment of
need--would be minimized with public pressure from an informed
public serving as the main sanction, Staffing would require two major
Skill areas; technical ‘competence in forecasting (or “in” ‘deVeloping
contract for forecasting information); and skills in community
education and organization, Selection of Board members and or
oommittee members would emphasize the skills of legitimation and

of engendering enthusiasm and trust. This model would like be most*
appropriate in terms of planning needs for a rapidly srowing
community; however, it is more likely to work in a Slowly, steadily
6rowing area that includes urban and rural residents but is not

a complex metropolitan area,
Ii The Evaluation Model "
-Under this model the general mission of. the HSA would be the
continuous evaluation of health service needs for its jurisdictional
area. Emphasis here would be on the present rather than on the
future and on future needs, Prioity would be given to review and
comment and asessment of need.There would be some developmental
activity, but the major emphasis would be on the change of current
unacceptable services to those that were acceptable with elimination
of unacceptable services. The major differences from the Plan
implementation: model arethe current orientation versus the future

orientation and the modes of work/ This type of organizationwould

require a strong technical assistance programeither provided through

staff or contract services. The techncial assistance to health
service azendies would possible be tied in withstudy committees

that continually reviewed services.Some developmental activities

would be carried out but these would not take precedence and monies

Ca
-16-—

for developmental purposes would likely go for task force or
study committee ‘planning’. In order to carry out a continuous
evaluative procedure committees would likely be formed on short-
term or task force bases. Development of a strong peer review
mechanism would be of value and coordination would have. to. be:
close with the state certification of need program, and with the
PSRO, Staff skills would of necessity have to be highly analytical
and the major kkills of influence required would be those of -
legitimating action and of conflict resolution. Essentially the
evaluative process would work best if used as an educational
process. The type of community that needs this type of model is
the area with sparse population, low economic base and inadequate
_ services, |
III The Evolving Model r

Although this is also a long-range approach it is not a
blueprint type of planning. Rather the mission is to meet a long
“range set of general policy guidelines that are expected to change
as new information 4s brought to bear. Examples of this type of
guidlline might be ‘“equal access to health care for all” as compared
to a goal of “primary care facilities within 20 miles of every
citizen” that might occur under the blueprint type of plan.
Such general: ghdelines would provide a time span during which as
many options would be left for the community as possible. All
eriteria for health service assessment or institutional certification
of need would be subject to continual review, and would involve
ranges rather than absolutes. Under such an organizing philosophy
the HSA would invite the community and particularly the providers
to participate heavily in the development of the planning vesign.

Some planning activities might be contracted out to providers,

 

 
-17-

Under this type of model the major staffing requiraments would

be for experts in data analysis, in preparing RFP's, and in
overseeing contract work. Developmental funds would be used for
demonstration and innovation and evaluative activities would be

used as information gathering for plan development. Assessment

of need and review and comment would be a minimal activity, except
as a peer activity. There would be local orientation with

expertise coming from the local area. The major skills of influence
would be the skill of expertise; skills in providing access to .
resources; and skills in organizing and arranging people and
resources. *

: Figure 1 (attached) attempts to show the differences between
these three models as discussed above. It should be noted that no
organizational pattern will represent a model exactly. However,
from this analysis it seems that these basic organizing philosophies
would ‘be of value to HSA‘'s, and that one or another of these models
. Bhould fit in gmeral the needs of any one eommunity at a point in
time. To the extent that a HSA mixes approaches, it seems there
will less liklihood of success in the planning process. This
suggests that the guidelines for HSA&S emphasize organizational
consistency with an explicit mission, rather than a preconceived
pattern of organization. The mission, however of each HSA cannot
be based on the same organizing philosophy. They will have to differ
if health planning is to be successful .

There has been some concern as to the size of HSAs and whether
a state-wide HSA would be feasible. This has been of particular

interest in states where the population is sparse. Under such
-18-

circumstances, the most appropriate modelmight logically be the

Evaluation Model where close cooperation with the appropriate

state agencies and the PSRO would be necessary. In some ways the

HSA would become the evaluative arm of the state. This would not

be inconsistent with the reality situation in thsoe States with

a8 very small population. The HSA would emphasize the provision of

technical assistance and voluntary review of the health services

of the area. In miore complex areas where the need is probably

‘for an Evolving model, a state-wide HSA might not be as appropriate.
Three models for organizing philosophies for HSA's have "

been presented with an analysis of how such organizations would

differ in orlentstion and in the skills needed to carry out

their functions. it should be emphasized that these models are

only for analytic purposes and that the important aspect of organ-

izationfor the HSA is in developing a consistent organization that

will meet the planning needs and the work modalities of the area

4t serves,

 
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Figure 1 Elements of

Organizing Philosophies for HSA's

 

 

 

 

ORGANIZING Mission Major Major Time and Staff Important Probable
PHILOSOPHY of Activity Work * Specificity Skill Skills of Type or it
Agency Emphases Strategies Orientation Needed influence Community /
/ l / / / /
‘ Public educ- legziti- _ Reason~
Implement ey eae ation and Long-range Technical, Matidon; ably stable;
PLAN a blueprint 5 a impl public and * planning; manipul- some steady
an . tL n. relations; specific community ation of change; urban-ru
IMPLEMENT# op the mentavion. high education SYmbols; rural, but
ATION consumer communica= not
future participa- tion; metropol-
MODEL tion. engenéering itan
trust
Review and short-term
: u Legiti-~ Foor econ
EVALUATION evaluation comments , Study task technical wecron, omic base; loss
of health ernie forces; Short-ranges especiallyexpertise; of population}
service on Bee technical immediate; regarding conflict sparsely
MODEL needs assistance; specific health resol- settled
coordination service ution
with state. 7
and PSRO
. ~ Expertises complex;
Development mov ereP funding Long-range are oe Aocess tO metro-
of a cone. “enta demonstration but ©18t ontract: resources politan;
EVOLVING activities heavy general and Supei- skill in owing
tinuously provider non-specific VSision; reanizing StoWine
PLAN evolving participation leader- . org population}
plan resource ship strong
ae nom
MODEL development eco ° y