An unsuccessful account can provide valuable lessons, as can a tale of success. Whether the research provides understanding of successful implementation or catastrophic failure, a strong analytical exposition of the details germane to the outcome provides opportunities to learn and establish best practices. This research seeks to understand what is required for successful implementation of a program in a public setting undergoing substantial organizational change. Chapter 2 assessed the program implementation in terms of changes in the program to fit the environment. It in essence focused on the technical details of the implementation—the most difficult aspect of implementation, suggest Pressman and Wildasky and Hupe . This chapter will provide insight into what is suggested here as the other major technical detail of implementation: the managerial capacity to perform. The capacity to change is important to the implementation literature at two primary levels: managerial and organizational. The organizational context represents a macro viewpoint, whereas the managerial level is a more micro, detailed look at an entity’s capabilities. These studies review adaptation to internal or external changes with respect to the enterprise level’s resources or ability to flex and perform around the changes. Klarner, Probst, and Soparnot examined the World Health Organization and its organizational level change capacity. Theirs was a unique look into a public-sector example of change capacity because it provided a look at the organizational context,vertical plant tower the change process, and how the organization mobilized around lessons learned from change experiences. The authors concluded that analysis of an organization’s capacity for change better equips that entity to deal with planned change, thereby increasing chances for success .
Building this type of capacity generally requires a focus on three organizational processes: a learning-based culture, general support for change activities across the enterprise, and the change effort itself . An organization’s capacity for change is a direct function of available resources and its managerial adaptability. The managerial capacity for change relates to the ability of the administrative layer to perform and produce successful outcomes. Managerial capacity is the focus of this chapter because it helps to explain the overarching question guiding this work: how can public-sector management overcome institutional-level forces and implement a complex program successfully?When implementing major reform efforts around health care delivery in the public sector, a manager’s capability to act represents a lever for success . A more detailed treatment of what managerial capacity means in this dissertation’s framework is presented later in this chapter. Within the literature, however, a general association is drawn between managerial capacity and administrative flexibility, autonomy, and choice in actions . This association supports the argument that health care reform efforts, such as the one studied in this paper, require an administrative layer that is able to act in a manner not typically associated with a staid, bureaucratic internal environment. Correctional organizations are very bureaucratic , and the California prison system is no exception to this . This became a significant roadblock for the managers in the receivership under examination. An interesting organizational feature of the California prison health system is that it employs its clinical staff and owns its primary care facilities. This model of owning resources rather than contracting out has implications for the nature of management behavior within the organization, and for how intervention programs can be planned and executed within this setting. For prisons located in geographical areas where it is difficult to recruit clinical professionals, CDCR contracts for outside specialty services and acute care on a fee-for-service basis .
As both a purchaser and provider of health care services, the state’s prisons system has complex organizational processes that required the coordination of activities and multiple types of personnel. Prior to the receivership, the breakdown and lack of attention to the coordination of health care activities in the correctional setting led to a degradation of services and negative health outcomes for prisoners. Managers lacked administrative flexibility in their actions and additionally lacked the ability to staff positions over the long term in geographically undesirable areas. The managers in this setting were assigned the task of implementing a series of projects that were distinct parts of a central program of health care delivery reform. Implementation programs themselves serve as the change vehicles for organizations in that they adapt to situations or environmental challenges. The catalysts for change were discussed in the previous chapter, and these catalysts are the starting points for reform. The vision for change is then memorialized as tasks within a project plan, and typically it is the aggregation of related projects that constitute a program. Put another way, a program to be implemented may be dissected into its distinct parts, which are called projects. This chapter seeks to provide an understanding of how managerial capacity is controlled by organizational structure that is guided by project-level structure. The previous chapter used program-level analysis to focus on implementation theory. It provided a methodology that relied on developing program elements in a way that integrates with prevailing institutionalized processes. The underlying theory was that this type of approach would lead to successful program implementation. It relied on looking at program-level variables rather than at the organizational level of analysis. This chapter continues the theme of focusing on program-level variables, this time looking at management and their behavior. It provides an understanding of what managers can be taught to focus on during change inducing processes.
Adapting models having their origin in the not-for-profit sector is not typically done in the public, correctional setting. The application of private-sector tools is a more familiar strategy, and even these require significant adaptation to maximize their understanding of a given situation . Diffusion of innovation tends to be a more successful method for applying private-sector operational strategies within the public agency setting . Similar large-scale attempts at adopting non-public-sector program models for deployment within the vastly different structure of public works have resulted in failure . The public sector is characterized as having a highly bureaucratic organizational structure, being inflexible to change, and behaving in an extremely routinized manner . Within the private-sector setting there exist a different set of rules, structure of accountability, and goals to achieve, as compared with the traditional public sector. As such, difficulty in adapting innovations established in one sector to another is expected to occur. Both the internal and external environments were diametrically opposed to the studied health care reform program,indoor vertical farming and only an external regulator insisted on its use and success. Adding to the complexity of program and environment were the challenges related to the strategy and technical details of the implementation. Previously, those details had only been addressed in private-sector settings, and therefore the nuances related to the public sector were not known. Outside the private sector, issues related to government-level political support is an important factor for public managers, especially under reform programs . The extent to which administrators perceive support has a significant influence on managerial and employee behavior . These external concerns differ significantly from those typically faced in nonpublic sectors. Due to changes in political administrations, many decisions faced by public-sector managers related to the organizational structure are questioned, in order to maintain or bolster performance . The comparative difference between how often, or the degree to which, these environmental challenges make administration difficult between sectors is not well described in the literature. What is clear, however, is that differences in routine administrative life exist between sectors, just as the types of obstacles faced tend to differ . Program implementations that require the establishment of collaborative, cross functional work groups develop their own policies and rules to guide individual and administrative behavior. These rules are defined within project-group-level cultures that form to define the norms of behavior, enabling the groups to work efficiently . According to Schein , this is expressed through development of proprietary languages and parameters of acceptable group behavior. The internal environment of the projects established by the receivership was not exempt from the development of new cultures within the various project groups. The agency under receivership, CDCR, had its own highly institutionalized processes and well-defined set of cultures that had been established at agency inception and evolved over decades. Its structure and operational framework defined both the ends and means under which administrative actions were determined and undertaken .The receivership organization was a much younger entity, with staff at both the management and worker levels less cohesive and culturally structured than CDCR. As a whole, the staff from CDCR was longer tenured within that agency and therefore had well defined social network channels and routinized behavior—in sharp contrast to the newly established Receivership organization.
The programs the receivership implemented, and specifically the CCM program, involved both CDCR and the receivership entities in terms of personnel, resources, time, and communications. This required integration involved establishing cross-functional teams from both organizations to carry out the work. Studying the administrative behavior, then, of both entities at the organizational level, as suggested by the institutional-school approach, may be overly complex and likely entirely inaccurate. Workers had their home organizations in either CDCR or the receivership . Managers were connected across the receivership enterprise due to program-level work that integrated departments. These managers had their performance evaluated at the program level, not at the organizational level. This meant that accolades or retribution were the outcome of performance of the manager’s unit for each project within which they were involved. Their performance was tightly integrated with the output and deliverables produced by sister departments to which they were tied on a particular project. The headquarters structure and its nature of accountability differed from management at the prison-facility level. Within the prisons, managers were evaluated based on their areas’ performance, not overall statewide performance. Whereas successful delivery of project tasks was the headquarters’ focus, inmate-patient health care outcomes and the passing of regulatory audits were the prison manager’s focus. The receiver-level projects were designed to ultimately lead up to the improvement of inmate-patient health and regulatory audit results. Indirectly, the managers at both levels had their missions tied together, but they were separated by a temporal gap. This difference in focus changes the method by which we can understand administrative behavior at both organizations and how work was viewed and approached by these managers. The managers participating in this study primarily held clinical professional managerial posts, such as chief of pharmacy, because they were clinical specialists. Within the receivership, the administrators were bureaucrats and had statewide responsibility, holding the highest-level positions in the department. Job titles for the highest-level administrators within CPHCS often mirrored the titles for their direct reports at the prison level. For example, the highest administrator of the nursing division within CPHCS was titled the statewide chief nurse executive. Each prison also had a classification for its head of nursing, entitled a chief nurse executive . The use of the designation statewide showed the difference in authority level and represented the matrixed or indirect relationship of the CPHCS administrator to CDCR highest-level manager. The prison-level clinicians at the non-management level in the departments of nursing, mental health, dental, pharmacy, medical, and ancillary services all reported to a chief- or director-level individual within the prison. For example, a staff psychiatrist reported to a chief psychiatrist . Below the chief/director level was an intermediate layer of supervisor staff. Nursing and mental health, for example, required far more labor resources than did dental, and therefore the levels of supervisors were greater in these former two divisions. For example, an institution may have had 100 nurses on staff and therefore required three levels of supervisory staff. Each clinical area, with the exception of pharmacy, required significant nursing staff, and therefore this division ultimately had the greatest number of staff throughout the prisons. Division of labor in this group was great and, administratively speaking, the layers of supervisory staff that developed over time within CDCR were commensurate with the highly specialized and large workload carried by the division. Staff-level workers were licensed vocational nurses or registered nurses who were managed by supervisor registered nurses . The SRNs had three levels of successive importance: I, II, and III. Each step up in supervisory level within nursing represented a significant advance within the administrative hierarchy, with both salary grade and workload accountability increasing accordingly.