A Management-Control System to Assistwith the Development, Contracting, andMonitoring of New Services for OlderPeople

You Can Always Get What You Want (withApologies to the Rolling Stones)

STEPHEN JACOBS

Senior Research Fellow, Faculty of Medical and Health Sciences, The Universityof Auckland, Auckland, New Zealand

ABSTRACT: Implementing community services can be a very complexprocess where people end up not seeing the wood for the trees andthen accepting a compromise nobody wants. Neither agency theory norstewardship theory is particularly robust when explaining the reality thatfunders and managers of community health service for older people facein managing contracts. There are particular difficulties with goal di-vergence between policy directives and implementation practices, whichresult from goals not being well understood and performance require-ments being ambiguously defined and infrequently monitored. This leadsto accountability issues for public managers, and raises efficiency andeffectiveness issues. This paper provides an interim report on a projectdeveloping a management-control system to provide a process for healthplanners and funders to use when developing and contracting services.A major focus is inviting stakeholders into a process of communicationthat ensures that they have shared understandings of where they want toget to, and what has to be done to get there.

KEYWORDS: management control; older people; performance manage-ment; contracting; stewardship; community services; health services;aging

INTRODUCTION

In New Zealand, the Government is the major funder of health services forolder people, mostly through allocating resources to 21 District Health Boards

Address for correspondence: Stephen Jacobs, 72 Thompson St., Te Aro, Wellington 6011, NewZealand. Voice: 6443828275.

jacobs.sp@gmail.com

Ann. N.Y. Acad. Sci. 1114: 343354 (2007). C 2007 New York Academy of Sciences.doi: 10.1196/annals.1396.013

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(DHBs) that are charged with providing services that will improve the well-being of their populations. These DHBs then contract their own provider arms,81 primary health organizations, and a myriad of for-profit and not-for-profitorganizations, to deliver services.

Guidance is provided to the DHBs about what they are expected to providethrough both strategiesthere are more than 35 Government health strate-gies14and a number of guidelines.5,6 DHB planners and funders of servicesfor older people theoretically know what they are expected to contract for.However, there is often no clarity about how best to develop and implementservices that will achieve the required goals or vision.

An example of the difficulties of implementation is care-management ser-vices to assist persons with complex and multiple conditions. The effectivenessof the care plan put together after an assessment of a persons needs has beenshown to be reduced (understandably) through failure to follow the recom-mendations by either the person being assessed or the healthcare professionalsinvolved. Often a care plan may be developed but not implemented.6 However,up to 70% of initiatives designed to improve achievement of desired outcomesthrough improving management and organizational performance have beenshown to fail because of poor design or difficulties in implementation.7 Learn-ing from evaluation has also been difficult, because results may be deliveredlate or in a way that practitioners cannot understand or put into practice.8

The quality of public services delivered by contractors depends largely onthe quality of contract management provided by public managers.9 However,contract management for health service provision is difficult, a major factorbeing goal divergence between policy directives and implementation practicesas a result of misunderstandings about policy directives and goals, ambiguousdefinition of performance requirements, and infrequent monitoring. This leadsnot only to accountability issues for public managers, but also raises efficiencyand effectiveness issues. Van Slyke talks of a complex managerial environ-ment . . . devoid of competition, administrative capacity, and clearly definedand agreed upon contractual goals and outcomes (p. PNP:D3).9

This paper is a progress report on a project undertaken in pursuit of a Ph.D.,with the final report due at the end of 2007. The project seeks to develop asystematic approach to developing and implementing new services, that is, tocreate an instrument that will assist planners and funders in developing andcontracting new services. The objective is to enable the development of anaction plan for the delivery of services in which all key stakeholders agree:

on the vision (where theyre going) with, and are committed to, the objectives of the program on the action plan for implementation on the critical success factors and how they will be measured on a feedback loop, so that the action plan can be reviewed on the basis

of evidence.

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The instrument will assist planners and funders to build trusting relation-ships with service providers and other stakeholders on the basis of a sharedunderstanding of goals and success factors, tasks required, task responsibility,and outcomes expected. These can then be written into contracts.

The initial theoretical basis for the instrument was a combination of man-agement control, performance measurement, and management models, andtheories about how people communicate with each other. Performance mea-surement and management theories were used because of the evidence thatbehavior is influenced by somethings being the subject of measurement.10

The key theories used in the initial development are here discussed.

THEORIES USED IN DEVELOPING THE INSTRUMENT

The V-Model

Based on Juergen Habermass Theory of Communicative Action, the V-Model11 postulates that systemic knowledge is holistic understanding of:

a. The norms or expectation of people in a system;b. The technical system; andc. The relationship between the two.

Eliciting systemic knowledge is likened to a journey of discovery, with thesuccess of the journey being validated by the commitment of the stakeholdersto an agreed-upon process for achieving technical excellence. The V-Model(FIG. 1) provides a process for discussion between stakeholders about theirintentions for any program and how they will move from intentions to achievingthe outcomes they desire.

The Balanced Scorecard

Influential in health over the last decade,1215 the key contribution of theScorecard model in this project, is the concept that a number of perspectivesother than financial are needed. Kaplan and Norton12,13 proposed four per-spectives:

d. CustomerWhat does the customer want? This has been translated intoDoes the service meet the goals and needs of the older person receivingservices, and those of their informal carers? This adjustment has beenmade because if the person receiving the service is accessing servicesthrough the public system, which will usually be the case, then they willnot be directly funding that service.

e. Internal businessWhat must the service excel at?

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FIGURE 1. The V-Model: the journey from vision to wanted reality.11

f. GrowthHow can the business continue to improve?g. FinancialHow do funders perceive the service?h. CommunityHow does the service have an impact on the health status

of the population?16 This fifth perspective has been added for healthservices that are publicly funded.

The Performance Prism

The Performance Prism17 is an approach that raises the concept of the stake-holders contribution. In health, very few people are passive receivers of ser-vices. As shown by the example of adherence (or not) to care plans, it canbe seen that the person receiving services contributes positively or negativelyto the successful implementation of those services, as has been shown by theimpact of adherence or non-adherence to treatment and/or care plans.6

The Results-Based Logic Model

Developed in Canada by the Treasury, the Results-Based Logic model18 putsforward the concepts that:

i. Accounting for results means demonstrating that you have made a dif-ference; and

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FIGURE 2. A process for engaging with the stakeholders.

j. A common theory of logic links can be used. Evidence of the mosteffective method of operating is often not available. By using consultationas well as evidence, linkages can be drawn between the set of activities thatmake up a program and the sequence of outcomes that can be expectedto flow from those activities.

This project has involved working with three DHBs, with Capital and CoastDHB (CCDHB) being the first. CCDHB is responsible for health services toapproximately 250,000 people in the lower part of the North Island of NewZealand. Seeking to find ways to implement the Health of Older People Strat-egy within community-based services, CCDHB faced issues of service stabilityand sustainability, high worker turnover, quality and safety, service gaps, inap-propriate existing services, and services that created dependency in patients.CCDHB consulted its population to develop a new agreed-upon approach tointegrated home and community care, working within the principles that olderpeople want to have control over their own lives and to maintain and regainhealth and function as much as possible. The Planning and Funding team wascharged with designing the service framework and developing the appropriateservices to deliver the new integrated restoration-focused approach. CCDHBanticipated working with both existing and new providers to shift to this newmodel of operation.

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FIGURE 3. Key describing desired outcomes and processes.

FIGURE 4. The discussion template.

THE INSTRUMENT

From the theoretical base, a process was developed for engaging with thestakeholders within CCDHB to develop an agreed implementation plan todevelop the new services. The process is shown in FIGURE 2.

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FIGURE 5. The revised V-Model.

FIGURE 6. The one-page map for the second DHB.

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FIGURE 7. The target diagram for the second DHB.

The researcher (S.J.) met with the CCDHB Planning and Funding staffto clarify their understanding of the vision in their consultation document.First, the researcher identified what appeared to be key words in the documentreferring to outcomes to be achieved and processes to be followed to achievethose outcomes. These are shown in FIGURE 3.

After discussion, these became stated as the following principles:

1. Client mana and dignity are preserved.2. The client receives a service focused on restoring and/or maximizing

health and functional ability, with the care and/or service plan developedand delivered in a manner that:

a. meets their goals, needs and manages their risks, including the goalsand needs of their informal/family/whanau carers

b. ensures that the client receives integrated and coordinated services.

3. Social support for the client is enhanced.4. The services the client receives are solution-focused, flexible, responsive,

and provide different options.5. The client receives a service that is sustainable.

Next these principles were presented to providers of community support ser-vices in a format that aimed to assist with discussion about how the principles

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FIGURE 8. A template for discussing stakeholder contribution.

FIGURE 9. A template for discussing measurement.

would be put into action by the providers. The templates shown in FIGURE 4were used to guide discussion on each principle, seeking agreement about whatwould actually have to be done, and how success would be measured.

The providers involved were resistant to the process and the approach provedto be very unsatisfactory. It was learned that:

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Stakeholders may interpret the same words differently. Agreement toa written statement may not actually be agreement about what has tohappen.

Providers may think they understand what is required, and may feel theyare already doing it. While they may expect only a minor tweaking ofwhat they already doing, this is in actuality a major issue for which asignificant shift in provider culture is required.

Providers want to show they understand, even when they dont, especiallywhen contracts and future funding are involved.

Talking about measurement and linking the achievement of outcomes topayment for services at an early stage in the development process causescaution and anxiety.

Academics can use terms that every day providers dont understand easily. The templates used had a sound theoretical base, but they did not work

as a mechanism for assisting communication. People felt overwhelmedand threatened by a plethora of empty boxes that they were asked to fillin for each principle.

It became clear that all stakeholders, but especially providers, need to beinvited into an experience that they value, rather than being faced with anexperience in which they felt out of their depth and threatened.

A new approach was developed for a second DHB that was also workingto develop a community-based integrated continuum of care. At this stage,learning theory as applied in computer-game development was accessed. Inthis approach success lies in weaving the learning experience into the playingexperience, so that the user as hero finds it easy to begin and fulfilling to con-tinue, with an emphasis on Giving your users an I rule experience.19 TheV-Model was redesigned to be more user-friendly to a non-academic audience;this is shown in FIGURE 5.

A new way of presenting the vision or direction of travel was developed.The idea was that if a one-page pictorial map showing the destination thatpeople were working to reach was agreed upon, that would provide a startingplace for discussing what success would look like and what needed to bedone to achieve that success. In discussing the one-page map, stakeholderswould also enhance their understanding of the concepts plus identify any realdisagreements or issues. This approach builds on the V-Model theory that ifpeople cannot agree on what success will look like, they are unlikely to agreeon what has to be done to achieve it. The one-page map that the second DHBagreed on is shown in FIGURE 6.

This map was then turned into a target diagram (FIGURE 7). This pictorialformat was developed to assist people to understand the process. A CommunityConsultation Group (consisting of representatives of older people, communityproviders, hospital providers, and funders) was shown the three diagramstheV-Model, the map and the target.

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After discussing the presentation, the Group was invited to form small teamsto identify what each stakeholder would have to do to ensure that a particularcapability or set of capabilities was present in their district, and how theywould identify success. The templates used to assist them to do this are shownin FIGURES 8 and 9.

The process and templates used with the second DHB were much moresuccessful than the initial process and templates had been with the CCDHB.The Community Consultation Group willingly participated and produced a setof necessary activities and indicators of success for the DHB to act on.

The model is being further refined and tried with a third DHB, with ideasfrom other theories being included, particularly theories about contracting.This management-control system provides a mechanism for funders to developshared understandings and trust relationships with service providers, whilealso providing for the development of agreed-upon indicators of success, thusgiving the funders an accountability mechanism. This provides an organizedapproach to contract management in an area in which neither agency theory norstewardship theory is particularly robust when explaining the reality fundersand managers of community health service for older people face today.

ACKNOWLEDGMENTS

Thanks go to members of the DHB staff that have been so helpful, particu-larly to Shereen Moloney from CCDHB, who assisted with a presentation ofthis project at the International Conference on Healthy Ageing and Longevityin Melbourne.

REFERENCES

1. MINISTER OF HEALTH. 2001. The Health of Older People Strategy. Ministry ofHealth. Wellington, NZ. www.moh.govt.nz.

2. MINISTER OF SOCIAL DEVELOPMENT. 2001. New Zealand Positive Ageing Strategy.Ministry of Social Development. Wellington, NZ.

3. MINISTER OF HEALTH. 2001. The New Zealand Disability Strategy: making a Worldof Difference. Ministry of Health. Wellington, NZ.

4. MINISTER OF HEALTH. 2001. The Primary Health Care Strategy. Ministry of Health.Wellington, NZ.

5. MINISTRY OF HEALTH. 2004. Guideline for Specialist Health Services for OlderPeople. Ministry of Health. Wellington, NZ.

6. NEW ZEALAND GUIDELINES GROUP. 2003. Assessment Processes for Older People:best Practice Evidence-Based Guideline. Guidelines Group. Wellington, NZ.

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aphru.ac.nz/services/services/pdaea2001.htm. This paper won the AmericanEvaluation Association (AEA) 2001 Presidents Prize.

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14. PINENEO, C.J. 2002. The balanced scorecard: an incremental approach model tohealth care management. J. Healthcare Finance 28: 6980.

15. PINK, G. et al. 2001. Creating a balanced scorecard for a hospital system. J. Health-care Finance 27: 120.

16. LEGGAT, S.G. & P. LEATT. 1997. A framework for assessing the performance ofintegrated delivery systems. Healthcare Mgmt. Forum 10: 1118.

17. NEELY, A., C. ADAMS & P. CROWE. 2001. The performance prism in practice.Measuring Bus. Excel. 5: 612.

18. TREASURY BOARD OF CANADA. 2001. Guide to the Development of Results-BasedManagement and Accountability Frameworks [monograph on the internet]. Trea-sury Board of Canada Secretariat. Ottawa, Ontario, Canada. Available fromhttp:/www.tbs-sct.gc.ca/eval/pubs/RMAF-CGRR/rmafcgrr e.asp.

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