managing health programs and projects filecontents. figures, tables, and exhibits xi preface xv the...

Managing Health Programs and Projects

Beaufort B. Longest, Jr.

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Beaufort B. Longest, Jr.

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Copyright 2004 by John Wiley & Sons, Inc. All rights reserved.

Published by Jossey-BassA Wiley Imprint989 Market Street, San Francisco, CA 94103-1741 www.josseybass.com

This publication is designed to provide accurate and authoritative information in regard to the subject mat-ter covered. It is sold with the understanding that the publisher is not engaged in rendering professional ser-vices. If professional advice or other expert assistance is required, the services of a competent professionalperson should be sought.

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Extract on p. 264 is reprinted with permission from Crossing the Quality Chasm: A New Health System for the 21stCentury by the National Academy of Sciences, courtesy of the National Academies Press, Washington, D.C.

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Library of Congress Cataloging-in-Publication DataLongest, Beaufort B., Jr.

Managing health programs and projects / Beaufort B. Longest, Jr.1st ed.p.; cm.

A Wiley Imprint.Includes bibliographical references and index.ISBN 0787971855 (alk. paper)

1. Public health administration. 2. Organizational change.[DNLM: 1. Health Services Administration. 2. Organizational Innovation.

3. Total Quality Management. W 84.1 L852m 2004] I. Title.RA427.L64 2004610.685dc22

2004007486

Printed in the United States of AmericaFIRST EDITION

HB Printing 10 9 8 7 6 5 4 3 2 1

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www.josseybass.com

CONTENTS

Figures, Tables, and Exhibits xi

Preface xv

The Author xxi

1 Management Work 1

Health and Health Determinants 3

Health Programs and Projects as Logic Models and as Organizations 3

Program and Project Management 8

The Work of Managers: Activities and Roles 8

Managing Programs and Projects Ethically 24

Managers and the Success of Programs and Projects 30

Summary 31

Chapter Review Questions 33

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Appendix A: Example of a Health Program 34

Connecting Lifestyle and Health: A Grassroots Program Reaches Out to a Specific Community Group

Appendix B: Example of a Health Project 37

National Standards for Culturally and Linguistically Appropriate Services inHealth Care

2 Strategizing the Future 39

Conducting a Situational Analysis 41

Reconsidering and Revising the Logic Model 50

Developing Operational Plans to Accomplish Desired Results 53

Assessing Progress and Controlling Performance 56

The Link Between Strategizing and the Performance of Programs and Projects 63

Business Plans 64

Planning for Interventions Undertaken by Programs and Projects 66

Summary 72


3 Designing for Effectiveness 75

Designing Logic Models 76

Designing the Processes Component of Logic Models 82

Creating Organization Designs 84

Key Concepts in Organization Design 84

Application of the Key Organization Design Concepts 99

Informal Aspects of Organization Designs 104

Summary 108


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4 Leading to Accomplish Desired Results 111

Motivation at Work 112

Influence and Leading, Interpersonal Power and Influence 128

The Ongoing Search to Understand Effective Leading 131

Toward an Integrative Approach to Effective Leading 140

Summary 143


5 Making Good Management Decisions 145

Decision Making Defined 146

Involving Other Participants in Decision Making 147

Characteristics of Management Decisions in Programs and Projects 150

The Decision-Making Process 152

Summary 182


6 Communicating for Understanding 184

Communicating: Key to Effective Stakeholder Relations 185

A Model of the Communicating Process 189

Barriers to Communicating Effectively 192

Communicating within Programs and Projects 197

Communicating with External Stakeholders 202

Communicating When Something Goes Wrong 209

Summary 214


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7 Managing QualityTotally 216

Quality Defined 218

Measuring Quality 219

Managing Quality 220

A Total Quality (TQ) Approach to Managing Quality 221

Summary 240


8 Commercial and Social Marketing 243

Commercial Marketing Strategies in Health Programs and Projects 244

The 4 Ps of a Commercial Marketing Strategy 249

Social Marketing in Health Programs and Projects 259

Ethics in Commercial and Social Marketing Strategies 263

Evaluating Commercial and Social Marketing Strategies 266

Summary 268


Epilogue 271

References 276

Index 287

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FIGURES, TABLES, AND EXHIBITS

Figures

1.1 The Logic Model of a Program or Project1.2 A Projects Life Cycle1.3 The Core Activities in Management Work1.4 The Core and Facilitative Activities in Management Work1.5 The Managers Roles1.6 Relative Mixes of Skills Needed for Effective Management Work in a Large

Program2.1 Template for Developing Desired Results for a Program or Project2.2 Control of Performance in an HIV-Screening Programs Laboratory2.3 Model of Interventional Planning3.1 A Hierarchy of Organization Designs3.2 The Staffing Process3.3 Contrasting Spans of Control3.4 Simplified Organization Design of a Functionally Organized Health Care

Organization3.5 Simplified Organization Design of a Functionally Organized Program or

Project

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3.6 Organization Design with Program or Project Embedded in a Health CareOrganization

3.7 Programmized or Projectized Organization Design3.8 Matrix Organization Design3.9 A Contact Chart3.10 Informal Group Structure4.1 The Motivation Process4.2 Comparison of Content and Process Perspectives on Motivation4.3 Maslows Needs Hierarchy4.4 Basic Model of Expectancy Theory4.5 Comparing Three Approaches to Understanding Effective Leading5.1 Vrooms Decision Process Flowchart5.2 The Decision-Making Process5.3 A Fishbone Diagram of Possible Causes of Nosocomial Pneumonia5.4 Pareto Chart of Possible Causes of Nosocomial Pneumonia5.5 Decision Grid for Possible Addition of Satellite Clinic in a Program5.6 Payoff Table5.7 Decision Tree5.8 PERT Network of Project to Develop an Open-Heart Surgery Program5.9 Beta Curve for Optimistic, Most Likely, and Pessimistic Time Estimates5.10 Conceptual Model of a Decision Support System5.11 Lewins Three Steps in Implementing Changes6.1 External Stakeholder Map for a Health Program6.2 Typical Relationships Between Programs or Projects and Their Stakeholders6.3 A Model of the Process of Communicating6.4 Communication Flows in Programs and Projects6.5 Common Communication Networks in Programs and Projects6.6 Influencing Public Policy6.7 A Frame for Advocacy6.8 Types of Errors in Clinical Settings6.9 Management Approaches When Something Goes Wrong7.1 What Patients/Customers Should Expect of Health Care Services7.2 The Guiding Principles of the Total Quality (TQ) Approach7.3 Documenting a Patient/Customer Focus in the Baldrige National Quality

Award7.4 FOCUS-PDCA Model7.5 Pre-Intervention Flowchart of Patient Care Process7.6 A Generalized Fishbone or Cause-and-Effect Diagram7.7 Run Chart of Intervention to Shorten Waiting Times7.8 Key Determinants of Team Effectiveness

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7.9 Model of Problem-Solving Process for Improvement Teams8.1 Elements of a Marketing Strategy8.2 Phases of the Social Marketing Assessment and Response Tool (SMART)E.1 The Logic Model of a Program or ProjectE.2 The Core and Facilitative Activities in Management Work

Tables

8.1 Examples of Patient/Customer Market Segments8.2 Options for Evaluating Commercial or Social Marketing Strategies

Exhibit

2.1 A Programs Operating Budget for Year X

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For Carolyn

Oh, the comfortthe inexpressible comfort of feeling safe with a personhaving neither to weigh thoughts nor measure words, but pouring them allright out, just as they are, chaff and grain together; certain that a faithful handwill take and sift them, keep what is worth keeping, and then with the breathof kindness blow the rest away.

Dinah Mulock Craik

A Life for a Life, 1859

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PREFACE

This book is about managing health programs and projects. I provide infor-mation drawn from a number of areas of management research and litera-ture with the intent of helping the reader develop an evidence-based approachto the practice of management in health programs and projects. A focused readerwill take away a solid overview of the current best practices in management thatapply to managing health programs and projects.

I think it is important to focus on managing at the level of programs and proj-ects because these are the mechanisms through which a great many health ser-vices are organized and provided in both the public health and private healthsectors. For example, at the prevention end of the health services spectrum, peo-ple receive information about safe sex practices through health education pro-grams, or learn how nutrition affects health. At the advanced acute care end ofthe spectrum of services, individuals receive kidney transplants within the struc-ture of relatively small transplant programs.

A persistent, decades-long trend has created ever larger and more elaboratestructures that organize and deliver health services throughout the industrializedworld. Evidence of this trend can be seen in the organization charts of majorpublic health agencies(such as California Department of Health Serviceshttp://www.dhs.cahwnet.gov/home/organization/), as well as in the size andcomplexity of large private-sector health care organizations (such as the Uni-versity of Pittsburgh Medical Center http://www.upmc.com/Overview.htm).

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However, within these large and complex structures, public and private healthservices often are provided directly through health programs and projects. A sub-stantial amount of literature exists about managing large and complex public andprivate-sector health agencies, organizations, and systems. I have contributed tothis literature myself. However, there is relatively little literature about manag-ing at the level of health programs and projects, where so much of the direct de-livery of health services increasingly occurs. This book focuses on managementin health programs and projects.

The intended audience for this book includes students in public health,health management, and other health professions who wish to prepare them-selves for the challenges of managing health programs and projects. Even thosewho aspire to high-level positions in large agencies, organizations, and systemsare likely to begin their management careers at the level of programs and proj-ects. The book is also intended for those in management positions who seek cur-rent information about managing.

Health programs and projects are defined as groups of people and otherresources formally associated through intentionally designed relationships inorder to pursue desired results. Beyond this definition, programs and projects aredescribed as logic models, or depictions of how they are supposed to work. Alogic model presents a schematic picture of relationships among the inputs or re-sources available to a program or project, the processes undertaken with the in-puts, and the results the program or project is intended to achieve. It is notpossible to fully understand a program or projector to manage it effectivelywithout first understanding its logic model.

Health programs or projects target any of the determinants of health, suchas the physical environments in which people live and work, peoples behav-ior, peoples biology, the social factors that affect people, or health servicesprovided to them. Thus, there is a broad array of health programs and projects.Health programs and projects might focus, for example, on cancer care, nutri-tion, geriatric care, womens health services, palliative care, health education, mi-grant worker health care, safe sex practices, cleaning up the physicalenvironment, cardiac rehabilitation, or smoking cessation. The most importantdistinction between programs and projects is that projects form a subset of pro-grams, distinguished by the fact that projects are time-limited. Projects have pre-determined life cycles, while programs are managed as ongoing entities.Otherwise, their management is essentially the same.

In both public and private sectors, health program or project managementis defined as the activities through which the desired outputs, outcomes, and im-pact of a program or project are established and pursued through variousprocesses that use human and other resources. This definition of management

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requires consideration of management work in terms of the activities that makeup the work.

All health program and project managers engage in three core activities asthey perform management work: strategizing, designing, and leading. In perform-ing these core activities, managers also engage in other activities that facilitateand support accomplishment of the core activities. These facilitative activities aredecision making, communicating, managing quality, and marketing. The core and fa-cilitative activities that make up management work give this book its structure.

Chapter One, Management Work, provides an overview of managementwork in health programs and projects, as well as some key definitions and con-cepts, all of which serve as a framework for the remainder of the book. The cen-terpiece of this chapter is Figure 1.4, which depicts the core and facilitativeactivities of management work.

Chapter Two, Strategizing the Future, discusses how managers, often withthe involvement of others, establish the desired results to be achieved througha program or project and conceptualize the means of accomplishing the goals.This chapter is organized around how managers in an ongoing program or proj-ect answer four critical questions:

What is the current situation of our program or project?

In what ways do we want our program or projects situation to change inthe future?

How will we move our program or project to the preferred future state?

Are we making acceptable progress toward the desired future state?

Chapter Three, Designing for Effectiveness, discusses how managers shapetwo important aspects of their programs and projects. Consideration is given to how managers establish and revise the logic models of their programs and projects. Consideration is also given to how managers establish and revise theorganization designsthe intentional patterns of relationships among human andother resourcesof their programs and projects.

Chapter Four, Leading to Accomplish Desired Results, defines leading bymanagers as influencing others to understand and agree about what needs to bedone in order to achieve the desired results established for a program or project,and facilitating the individual and collective contributions of others to achievingthe desired results. As managers seek to influence other participants to behavein contributory ways, they must understand how to help them be motivated todo so. Thus, the relationship between human motivation and success in lead-ing is emphasized.

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Chapter Five, Making Good Management Decisions, focuses on deci-sion making as a pervasive facilitative activity in management work, permeatingthe core activities of strategizing, designing, and leading, as well as the other fa-cilitative activities of communicating, managing quality, and marketing. Althoughdecision making is defined simply as making a choice from among alternatives,the decision-making process is discussed in terms of seven steps: (1) becomingaware that a decision must be made, whether the decision stems from a problemor an opportunity; (2) defining in as much detail as possible the problem or op-portunity; (3) developing relevant alternatives; (4) assessing the alternatives;(5) choosing from among the alternatives; (6) implementing the decision; and(7) evaluating the decision and making necessary follow-up decisions.

Chapter Six, Communicating for Understanding, discusses a facilitativeactivity that is both vital to the successful performance of management work anda challenge for managers. Communicating is described as an activity that involvessenders. Senders can be individuals, groups, or organizations, conveying ideas,intentions, and information to receivers. Receivers can also be individuals,groups, or organizations. Communication is effective when receivers understandideas, intentions, or information as senders intend, but several environmentaland interpersonal barriers must be overcome to communicate effectively. Thecommunicating activity is discussed as a key to managing relationships with aprogram or projects internal and external stakeholders.

Chapter Seven, Managing QualityTotally, discusses why managers ofhealth programs and projects typically give a high priority to effectively man-aging the quality of services provided. Not only is quality important to those whoreceive the services of a program or project, quality is important to participantswho work in programs and projects. This chapter stresses that, above all else,managing quality in a program or project requires a systematic approach. Threeprinciples that can guide managers in pursuit of what is called a total quality (TQ)approach to managing quality in health programs and projects are presented: patient/customer focus, continuous improvement, and teamwork.

Chapter Eight, Commercial and Social Marketing, as the title suggests, dis-cusses two important ways managers of health programs and projects can use mar-keting to facilitate success. The financial or commercial success of many programsand projects is affected by the use of commercial marketing. In addition, especially inprograms and projects focused on health promotion and education, social marketingis used in the provision of services. The so-called 4 Ps of successful commercial marketing strategies are discussed: product or service, price, place, and promotion.Social marketing is discussed in terms of using elements of commercial marketing

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to influence the voluntary behavior of individuals and groups of people for theirown benefitand in some instances for the larger societys benefit.

It is convenient for purposes of discussion or description to separate into in-dividual chapters the core and facilitative activities that make up managementwork. Doing so, however, might incorrectly suggest that the core and facilitativeactivities are a series of separate activities, perhaps performed in a particular se-quence. In practice, managers of health programs and projects engage in these ac-tivities as a whole in which the various activities are highly interrelated andinterdependent. When managers integrate and perform the activities well, they aremore likely to be satisfied with the performance of their programs and projects,and with the results achieved. My main purpose in writing this book, then, is tohelp managers achieve desired levels of performance in health programs and proj-ects and accomplish the results they seek through those programs and projects.

Acknowledgments

I wish to acknowledge the contributions made by several people to this book andto thank them for their assistance. At the University of Pittsburgh, which has beenmy professional home for twenty-four years, Linda Kalcevic provided superb ed-itorial support throughout the many drafts. Denise Warfield provided cheerfuland helpful secretarial support. Mark Nordenberg, Arthur Levine, Bernard Goldstein, and Judith Lave provided an environment conducive to and sup-portive of scholarship. At Jossey-Bass, Andy Pasternack saw the potential for thisbook and has been a partner in its development and publication. I also wish tothank Jessica Egbert, Gigi Mark, and Seth Schwartz for their professional ex-pertise in this project. Most of all, however, I want to thank Carolyn Longest,whose presence in my life has made many things possibleand doing them seemworthwhile.

June 2004 Beaufort B. Longest, Jr.Pittsburgh, Pennsylvania

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THE AUTHOR

Beaufort B. Longest, Jr. is the M. Allen Pond Professor of Health Policy and Management in the Department of Health Policy and Management in theGraduate School of Public Health at the University of Pittsburgh. He also holdsa secondary appointment as professor of business administration in the KatzGraduate School of Business, and is director of the University of PittsburghsHealth Policy Institute.

He received his undergraduate degree from Davidson College and receivedhis M.H.A. and Ph.D. degrees from Georgia State University.

Longest is a fellow of the American College of Healthcare Executives andis a member of the Academy of Management, AcademyHealth, the AmericanPublic Health Association, and the Association for Public Policy Analysis andManagement. He was elected to membership in both the Beta Gamma SigmaHonor Society in Business and the Delta Omega Honor Society in Public Health.

His research on issues of health policy and management has generated sub-stantial grant support and has led to the publication of numerous peer-reviewedarticles. In addition, he has authored or co-authored ten books and twenty-eightchapters in other books. Two of his books, Managing Health Services Organizationsand Systems and Health Policymaking in the United States, are among the most widelyused textbooks in graduate health policy and management programs.

Longest consults with health care organizations and systems, universities,associations, and government agencies on health policy and management issues.

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Health is often pursued through a variety of health programs and projects.For example, when a young adult achieves academic success and starts apromising career after overcoming a drug addiction, an effective treatment pro-gram may deserve much of the credit for the turnaround. When a person withtype 2 diabetes leads an active and productive life, her health improvementsmay well be attributed to a program that helps her understand the disease andtake an active role in controlling it. When a county health department mountsa project to enroll children in an innovative insurance plan, the impact on thosechildren may be felt throughout a lifetime of better health.

One of the distinguishing characteristics of successful programs and projectsis how well their managers perform. This book is about the work these managersdo. This chapter provides an overview of management work in health programsand projects, as well as some key definitions and concepts, all of which serveas a framework for the remainder of the book. Management work is describedin terms of the core activitiesstrategizing, designing, and leadingmanagers undertake in performing this work. After reading this chapter, the reader shouldbe able to do the following:

Define health, health programs and projects, and management Understand the core and facilitative activities of managers work

CHAPTER ONE

MANAGEMENT WORK

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Understand the roles managers play as they do management work Appreciate the underlying skills and competencies used by managers in doing

management work Understand the importance of applying well-developed personal ethical stan-

dards in doing management work

As a backdrop for considering management work, it is important to knowthat three distinct types of work occur in health programs and projects (Charnsand Gittell 2000). Direct work entails the actual provision of services or creationof products for which a program or project exists. This type of work is done bycounselors, nurses, therapists, physicians, health educators, and others who formwhat Mintzberg (1983) terms the operating core of a program or project.

A second type of work done in health programs and projects is support work.This work is a necessary and facilitative adjunct to the direct work. In health pro-grams and projects, people performing support work are involved in such ac-tivities as fund raising and development, recruiting patients for a clinical trial,providing legal counsel, marketing a program or enhancing public relations fora project, or providing accounting and financial services.

The third type of work done in health programs and projects is managementwork. This work involves establishingoften with the direct participation of othersthe results a program or project is intended to achieve and creating thecircumstances through which the direct work, aided by support work, can leadto the desired results.

An example will clarify the different types of work. A manager may estab-lish the desired result of a project as enrolling one thousand children in an in-novative insurance plan. The act of enrolling children in the plan is the directwork of the project. The manager may also arrange for publicity about the planto increase awareness and encourage enrollment. The provision of publicity issupport work. Establishing the desired result, assigning and training project staffto help parents or guardians enroll children, and arranging for publicity is man-agement work.

As we will see in this chapter, there are two basic ways to assess and studymanagement work. It can be approached in terms of the activities managers en-gage in as they do their work and in terms of the roles they play in performingthis work. We will examine management work from both perspectives. We willalso discuss the skills and competencies needed to do management work well. Be-fore considering management work, however, it will be useful to define key termssuch as health, health programs and projects, and management.

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Health and Health Determinants

The World Health Organization (http://www.who.int.htm) provides a long-standing definition of health as the state of complete physical, mental, and socialwell-being, and not merely the absence of disease or infirmity (World HealthOrganization 1948, p. 100). Another version of this definition views health as astate in which the biological and clinical indicators of organ function are maxi-mized and in which physical, mental, and role functioning in everyday life arealso maximized (Brook and McGlynn 1991). The state of health in human be-ings is a function of many variables, or health determinants, as they are often called.The wide variety of determinants means that health programs and projects havean enormous range of possible foci.

Health determinants for individuals or populations include the physicalenvironments in which people live and work; their behaviors; their biology(genetic makeup and the physical and mental health conditions acquired duringlife); a host of social factors that include economic circumstances, socioeconomicposition in society, income distribution, discrimination based on factors such asrace/ethnicity, gender, or sexual orientation, and the availability of social net-works and social support; and the health services to which they have access(Evans, Barer, and Marmor 1994; Berkman and Kawachi 2000). Health programsand projects can be focused on any of these determinants, as well as on combi-nations of them.

Health Programs and Projects as Logic Models and as Organizations

The most useful way to get a clear picture of what a program is and does is tothink of it as a theory (Patton 1997; Weiss 1998) or hypothesis. Like all theories, thetheory of a program or project is simply a plausible, sensible model of how it issupposed to work (Bickman 1987). The way a program or project is intendedto work can be described as a theory or hypothesis by developing a series of if,then statements about it. For example, a particular program or project can becharacterized as follows: If resources a, b, and c are assembled; and then processedby doing m, n, and o with the resources; and if the processing is done well, thenthe results will be x, y, and z. Using its underlying theory or hypothesis as a guide-line, any program or project can be described in terms of the inputs available for

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it to use, the processes it undertakes with the resources, and the results it achievesby processing the resources.

Implicit in the hypothesis or theory of a program or project is its underlyingrationale or logic (Renger and Titcomb 2002). In fact, for any program or proj-ect, it is possible to draw a logic model of how it is supposed to work (W. K. Kellogg Foundation 2001). A logic model presents a schematic picture of the relationships among the inputs or resources available to a program or proj-ect, the processes undertaken with the inputs, and the results the program or project is intended to achieve. Figure 1.1 depicts a basic logic model for a program or project.

This logic model shows how inputs and resources are processed in attempting toaccomplish the program or projects desired results in the form of outputs, out-comes, and ultimately impact. In effect, the logic model provides a road map ofhow a program or project is intended to work. There is a feedback loop from de-sired results to inputs and resources and processes indicating that adjustmentswill be necessary in them in an ongoing program or project. Very importantly,it shows the program or project existing within a larger external environment.

The external environment of a program or project includes many variablesthat can influence its performance. These are illustrated in Figure 1.1 by the arrow that flows from the environment into the program or projects logic model.These external variables include everything from the cultural milieu of the com-munity in which the program or project is undertaken to its physical climate. Italso includes economic conditions, the state of health of the population the pro-gram or project might serve, housing patterns, demographic patterns, politicalenvironment, background and experiences of program participants, media in-fluence, public policies, and the priorities and resources of the larger organiza-tion in which a program or project may be embedded.

External variables can influence almost everything about a program or proj-ect including whom it seeks to serve, the extent of recipients needs for the pro-gram or projects services, the resources available to the program or project,the quality of its staff and volunteers, how smoothly implementation occurs, andthe pace at which results are seen. A program or project cannot be completelyseparated from its external environment. All programs and projects are affectedby and affect their external environments.

The results of a program or project flow out into its external environment.This is shown in Figure 1.1 by the arrow that flows outward into the external en-vironment. This arrow means that the outputs, outcomes, and impact of a pro-gram or project flow outward and affect the individuals and populations that itserves. The concept of the logic model of a program or project will be usefulthroughout this book, beginning with how we think about programs and projectsas organizations.

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managing health programs and projects filecontents. figures, tables, and exhibits xi preface xv the...

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