The program under review in this study was called the chronic care model program

Hierarchical organizations are generally resistant to change that threatens their power. Despite numerous federal class-action lawsuits brought against CDCR throughout the 1980s, 1990s, and 2000s, a receivership that severed control of health care from the agency was required to fix the problems. In essence, this meant the bifurcation of the organization and dismantling of structure, splitting health care and custodial functions, in order to achieve change within the agency. Health care reform was the goal, but developing the proper structure and program around the new receivership governance structure was both a key obstacle and the research focus of this paper. Programmatic implementations are often complex, requiring the coordination of resources, personnel, and new processes or technologies. Managing implementations from the perspective of change management alone is a big topic in both research and practice . The addition of a highly bureaucratic environment on top of the other complexities makes for challenging implementations. Public-sector implementations of large-scale programs face this additional environmental challenge. Pollitt and Bouckaert define public management reform as “deliberate changes to the structures and processes of public-sector organizations with the objective of getting them to run better” .

Reform here is a synonym for improvement efforts. Generally speaking, vertical growing towers organizational changes for survival are associated with improving dated or simply ineffective methods. The ways in which these changes are made are based on implementation of new programs, which hold the DNA for the new processes and structures thought to be required to make the improvement. As the effort of reform progresses forward, the implementation process encompasses larger issues than just the program itself. For the public sector, the judgment of successful reform is based on final impact to the community . The program implementation process itself may be successful in terms of new structure and processes adopted by the internal staff; however, if impact to the community is not perceived as positive, then the program itself may be deemed a failure. The Drug Abuse Resistance Education program is a classic example of this. As the nation’s most widely employed school-based drug prevention program, it has processes which are deemed efficient; however, final impact on the community has been less than fruitful in its mission to reduce the number of young people on drugs . Achieving successful program implementation within a large public sector organization is then a function of being technically proficient in the details of implementation, as well as producing tangibly visible outcomes for public view. This study investigates one possible path to achieving success and the challenges that the agency faced.

Over the past two decades, reform efforts in the public sector have been characterized by the use of management practices and techniques originally developed within the private sector. These reforms have ranged from budgeting methods to performance management . There are significant differences between public and private sector organizations as it relates to organizational change. Models and processes that are transferred from one sector to the other can lead to contradictory results. In comparison to private organizations, public organizations tend to be characterized by a multitude of decision-makers, a larger diversity of stakeholders, more intensive organizational dynamics and a more bureaucratic structure . This concept will be explored in greater depth and detail in Chapter 2. Reform efforts in the public sector’s human health services industry over the past twenty years have been beset with numerous challenges in the quest to adopt models from other sectors. Programs in the human health services industry are generally considered to be more complex than programs in other areas. This is due to the fact that human service technologies are delivered through the actions of individuals and organizations, which exist within multilayered social contexts . The setting of a department of corrections further adds to the complexity of the multilayered social context in that the prison system is highly segmented and institutionalized . The adoption of private sector models by public correctional organizations has thus been not often undertaken.

The literature offers no framework for successful implementation within the very complex health care correctional system, although reform efforts are unquestionably required for this sub-sector. To improve the delivery of health care services and advance overall outcomes of treatment, the chronic care model was selected for implementation in the CDCR because the private , not for profit sector had demonstrated evidence of success in improving care using this model . This model originated in the not-for-profit sector and was selected based on coordination of care, attention to patients with multiple comorbid chronic conditions, and emphasis on the adherence to practitioner guidelines. It was a particularly complex effort that required integrating the demands of six disciplines that generally work separately, and three federal courts—each represented by a panel of court monitors, each with their own set of demands. Due to the organizational and environmental complexities, the challenges to implementation appeared insurmountable. Organizational structure, size, and the requirement to integrate the disparate objectives of various entities were all issues facing the receivership in its attempts to improve health care and meet federal requirements. These issues will be reviewed in greater detail in Chapters 2 and 3.Implementations of public-sector health care programs originating in the not-for profit sector are rare. Therefore, there are few such examples in the literature. Subsequently, there is a lack of guidelines available to facilitate implementation efforts. A public-sector administrator cannot readily look to the literature for answers on how to effectively adopt a successful private-sector model to solve a current organizational problem. The distinct variables one must take into account in order to make the successful implementation are not well explicated in the few examples available in the literature. Broader generalizations, however, may be derived from existing academic and practitioner publications. Planned implementation can be viewed as the expression of rational organizational behavior with the manger functioning as a technician whose primary task is to make the appropriate actions, with respect to established knowledge, to achieve efficiency and effectiveness .

Within the health care literature, a recent study suggested that planned implementations in the mental health services field can be successful if attention is giving to the needs of staff,container vertical farming which can be facilitated by proper management . Australian researchers, Rooney et al. support the claims made by McCrae and Banerjee , in their review of large scale change at a public hospital. They concluded that planned organizational change can be effectively managed when employees have established a strong sense of connection to the workplace. These studies reinforce the central objective of this study, which is to provide an example of planned organizational change that was staffed with capable management, who were properly engaged around the implementation activities. Readiness for change is also noted as an important aspect of the planned organizational change cycle . Readiness is defined by Holt et al. as the degree to which individuals involved are primed, motivated, and capable to deal with the change. It is best when combined with well-constructed and directed communication efforts as suggested by Jordan et al. , to build social interaction competence during the change effort. At a broader level, Kotter provides an 8-step guide for managing change which starts at developing a sense of urgency about the change and cumulates in institutionalizing the change culture. His work tends to lack references to extant literature ; however a compilation of works from the various organization literatures is given by Burke . Burke provides insight into the broader theoretical issues related to organizational change and serves an excellent basis for understanding the more complex model of evidence-based implementations given by Aarons, Hurlburt, & Horwitz . In their advancement of an implementation science conceptual model, Aarons, Hurlburt and Horwitz suggest a 4-stage implementation process for public sector service systems. They assert that program implementation starts with exploration, then advances to adoption , followed by actual implementation, and ending in sustaining of the changes. The research undertaken in this paper follows the Aarons, Hurlburt, and Horwitz model, and while it does not delve deeply into the final stage of sustainability , it fully endorses this as a requirement for implementation. This study seeks to provide an example of successful program implementation while providing some guidelines for the administrator. Success in this study is measured by improvements in health care outcomes, as outlined in Chapter 4. Achieving this success will be argued to be a function of proper program development and middle manager involvement. To begin, a distinction must be made between leadership and management in order to frame the discussion around the role of the public-sector administrator in program implementation.

An administrator could be a leader, a manager, both, or neither depending upon the time and scenario under review. As noted by Bass and Avolio , “Leaders manage and managers lead, but the two activities are not synonymous . . . management functions can potentially provide leadership; leadership activities can contribute to managing. The research undertaken in this dissertation looks at managers in their ability and capacity to manager and direct program activities and tasks. Management that is engaged and committed to the work under there area of responsibility is seen to be critical to implementation and organizational success . A framework to understand management behavior in relation to program implementation performance is provided in Chapter 3, using techniques from the organizational-development field. This study seeks to add to the literature on health care by providing an example of program implementation that emphasizes managerial behavior as central to its success. At the core of the managerial behavior leading to program success were interventions performed on the executive and mid-level management layers—interventions that were designed to improve managerial capacity within this public-sector environment. Managerial capacity in this study is defined as the ability for a manager to understand the work and react appropriately to achieve objectives. It is theorized that the more a manager is capable to understand the work, the better the outcome of the work, assuming that the manager is additionally empowered to alter the work as the need arises. By altering work, it is meant that resources may be differentially applied to get the work completed. Within this setting, the managers were empowered to alter the work performed under the receivership. Greater clarity and treatment of this important topic is provided in Chapter 3. It is important to understand how managers engage with their staff within a program implementation setting to achieve successful outcomes. This knowledge is fundamental to replicating success in other, similar implementation efforts. Two concepts or types of behavior are developed in this study as central to program implementation success in the public sector: managerial confidence and engagement in work. These aspects of managerial behavior relate directly to the previously provided definition of managerial capacity. Confidence in the work underway and being engaged in the details of how that work is carried out are functions of understanding the work at hand . These behaviors are viewed as skills that can be taught to managers, and it is theorized that improvement of these skills leads directly to program performance. These skills are considered to be fundamental to the management of organizational change . Fernandez and Rainey’s treatment of organizational change within the public sector identified eight factors pertaining to the development and progression of organizations. Their propositions are summarized in Table I, as taken from Packard et al. .Fernandez and Rainey’s factors provide an understanding of the management processes involved in change management. It was noted at the start of this chapter that change management is a primary obstacle to success in program implementation. The guidelines that Fernandez and Rainey provide are intended to help promote an environment of trust and confidence for an organization in moving forward with a planned implementation . Ultimately it is the trust and confidence of the employee that leads to organizational success when managing change . Gaining and maintaining that trust is the responsibility of managers. Chapter 3 will explain in greater depth how managers can be taught how to manage change in this manner.This research attempts to assess and quantify the successful aspects of public-sector administrative behavior to implement complex programs in a generally hostile and bureaucratic environment. In support of this, a tool to assess management behavior is developed and, based on its results, interventions to improve organizational performance are designed.