Week 3 - Assignment: Write a Personal Memo Relating Management and Organizational Behavior to Your Dissertation

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P A R T O N E

The Implementation

Landscape

Reformers are institutional gardeners more than architects and engineers. They reinterpret codes of behavior, impact causal and normative beliefs, foster civic and democratic identities and engagement, develop organized

capabilities, and improve adaptability.1

The great thing about [gardening] is the way something new is always happening . . . Each year there are new varieties to discover in the annual

crop of seed catalogs, new trends to dabble with and new planting schemes to explore. And apart from the dazzling variety of the plants themselves, there are the imponderables of pests, problems and weather that combine to make each season a new gardening adventure. But some things never change—the

basic skills of sowing, planting, and cultivation.2

Sandfort, J., & Moulton, S. (2015). Effective implementation in practice : Integrating public policy and management. ProQuest Ebook Central <a onclick=window.open('http://ebookcentral.proquest.com','_blank') href='http://ebookcentral.proquest.com' target='_blank' style='cursor: pointer;'>http://ebookcentral.proquest.com</a> Created from ncent-ebooks on 2021-10-04 17:07:46.

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In part 1, we describe the landscape of our approach to policy and programimplementation. While we integrate prior approaches to understanding imple- mentation in public contexts, we devote attention to describing an alternative way to view implementation, suggesting criteria for assessing effectiveness, and explaining why things happen the way they do. Chapter 1 presents our definition of effective implementation and key elements in our approach. It is worth noting that this approach is purposefully pragmatic, grounded in academic thinking, but also drawing considerably from experience and reflection. And it is context dependent. Effective implementation cannot be reduced to a generic set of skills that can be applied universally across all settings. Policy-specific expertise is essential, and we introduce case examples that we follow throughout the book to elucidate the dynamics of implementation analysis in specific settings.

Chapter 2 situates our approach within the context of three other traditions of scholarship and practice: political processes and authority, governance and man- agement, and policy and program evaluations. One of our motivations for writing this book is the cognitive dissonance we often feel when engaging scholarship in any one of these areas. On one hand, each directly speaks to the implementation system and its challenges. But on the other hand, each informs only one piece of the implementation puzzle—political and power dynamics, the governance sys- tem, or interventions targeting behavioral change. In our work as practitioners and now scholars, we navigate across these artificial boundaries, borrowing from each the relevant aspects for implementation. We think that this is an important con- tribution for future students and practitioners and therefore share these insights in chapter 2.

Finally, in chapter 3, we apply the concept of strategic action fields to the imple- mentation system as a way to suggest a systematic way to explain what happens in implementation systems. By doing this, we emphasize that these systems are complex, not merely complicated. They cannot be neatly reduced to a set of fac- tors or variables that predict success, but rather must be viewed as dynamic, living social systems. Each level in the implementation system is a strategic action field with a unique social structure and dynamics that shape the core program. The core program is what distinguishes implementation from other change initiatives—it involves establishing viable options, using a logic of change, and selecting a means

2 Effective Implementation in Practice

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for activity coordination. This is a new way of thinking about the implementation system. And like any other new idea, it may take some time to digest the concepts. We continue to weave the concepts presented in this chapter throughout the rest of the book. By its end, we believe this new way of thinking can become second nature and improve your own endeavors as implementation practitioners.

Part One: The Implementation Landscape 3

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c h a p t e r O N EFraming Implementation

By April 2014, Sandra Martinez, manager at Connect with Health Colorado,could finally stop to breathe and reflect on the events of the previous year.1 The federal Affordable Care Act (ACA) was a major change in public policy (see box 1.1), and her organization, a nonprofit formed by the legislature to implement the state’s health care insurance marketplace, was at the center stage of Colorado’s efforts to get the first wave of citizens enrolled. While in late 2013 public and national media attention reached fever pitch when operational challenges threat- ened the federal insurance website marketplace, Colorado was not caught in that controversy. Because it was one of the seventeen states that elected to operate its own insurance exchange, she and other leaders in the state’s public, nonprofit, and private health organizations focused their attention on other important imple- mentation activities. There had been some delays in the state-run enrollment pro- cess, largely because of the state’s effort to sign up as many people as eligible into Medicaid to reduce citizens’ expenses. Yet a sizable number had completed an application, some drawing on the support of navigators contracted to provide indi- vidual support in making insurance selections.

Box 1.1 Overview of National Health Care Reform

Lauded by some as the most significant social welfare law passed in the United States for half a century, the signing of the Patient Protection and Affordable Care Act by President Obama in March 2010 set into motion a complex series of events. Termed “Obamacare” by political adversaries, the law’s goals focused

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(Continued)

on increasing the quality and affordability of health insurance, decreasing the number of uninsured Americans, and reducing health care costs. Implementa- tion of some features began immediately, but political controversy and legal challenges created initial uncertainty for states as they considered how to craft their own health care policy in relation to federal action. When the Supreme Court ruled the act constitutional in June 2012, states began deciding which of the many options offered in the act they would pursue. For example, states had the option of expanding the Medicaid program to provide more afford- able insurance for low-income people, creating health care marketplaces or exchanges to help individuals and small employers purchase private insurance, or making changes to existing state-based health programs. Other states chose to let the federal default options take effect.

Like other states, Colorado had established the Connect with Health exchange as a quasi-governmental agency, governed by a legislatively appointed board representing a range of stakeholders to oversee the program’s direction and ensure public accountability. They had convened working groups to establish the plans and strategies of implementation focused on health care plans, disadvantaged communities, small businesses, and consumer services. Other groups in the state raised funds from private sources to investigate models for consumer support and public education. Martinez, along with some members from these work groups, participated in a number of national events and networks funded by private foundations that brought together state leaders to share the strategies being used to resolve implementation challenges. She found these efforts invaluable; they provided a neutral learning place and valuable information that helped improve decision making.

The need for health care reform in Colorado was high. Compared to other states, a large number of uninsured children and adults either had no health care or paid high out-of-pocket expenses.2 In 2011, the governor had signed into law the state’s policy authorizing Medicaid expansion3 and the development of the insurance exchange. As in other states, eligibility for support was tied to income eligibility: the lowest-income citizens accessed health insurance through expansions in Medicaid, another group was eligible for tax credits to decrease out-of-pocket costs, and others could now access insurance through an unsubsidized marketplace benefiting from group-negotiated insurance terms. But

6 Effective Implementation in Practice

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in May 2013, following the lead of the Colorado Health Foundation, the governor also declared a goal of making the state the healthiest in the nation, raising the urgency and political salience of the issue in the state. Over the previous year, there had been an unprecedented number of public-private initiatives focused on the governor’s goals of promoting prevention and wellness, improving service coordination, and making operational changes in payment and information technology. And while sometimes tensions had erupted between state leaders about the pace and consequence of the changes, the network between major organizations had held together.

The Colorado Department of Health Care Policy and Financing played an important role in the state as the agency that authorized many of the public programs. The department’s managers, such as Maurice Brown, entered into the contracts with the ten insurance plans advertising on the Connect with Health Colorado website. Accountable to the federal Department of Health and Human Services, ACA activities were significantly influenced by the department’s years of experience administering Medicaid, Medicare, and the Children’s Health Insurance Program. The new policy also fit solidly into the organization’s new articulated mission of improving health care access and outcomes for citizens while demonstrating sound stewardship of financial resources. Managers had developed six organizational goals, including strategies to improve services and align communication, technology, and staffing. The overarching intent was to transform the health care system from a traditional fee-for-service model into a regional outcomes-focused coordinated system of care. The ACA programs were included in this larger structure promoted by the department, although compared with his peers, Maurice was more extensively involved with external groups such as Connect with Health, the Colorado Health Foundation, and other implementation working groups because of the policy’s visibility.

While the policy had an impact on many organizations that interacted with citizens—health insurance companies and co-ops, health providers that now pro- cessed bills for fewer uninsured people, mental health practices that now faced economic pressure to join larger groups to ease billing—the agencies providing outreach to disadvantaged groups were particularly important in the first few years because of the law’s goal to enroll the uninsured. Informed by research conducted by a coalition of consumer advocates, the state contracted with public health and community-based agencies to provide exchange navigation, education, and sup- port about the various insurance options. In original discussions, some exchange

Framing Implementation 7

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planners had believed it would operate like the travel website Travelocity, which allows easy comparison among various options. Yet the unveiling of Connect with Health Colorado revealed that enrolling in health care insurance is much more complex than booking an airline flight. At one time there were over sixty-five policies to choose among, and managers like Noah Manning soon discovered that enrollment assistance took considerably more time than what his organization had originally budgeted.

The face-to-face work fell to the cadre of navigators and health advocates who provided enrollment counseling. Yet at the front lines, the dynamics were complex. On the one hand, while navigators such as Cynthia Wang provided information for free to low-income citizens, other certified health advocates received commissions for their services. And consumers’ needs were complex, often requiring individ- ualized assistance. Cynthia had to remind some people to save documentation of expenses to qualify for tax credits at the end of the year. For others, after they had received their insurance cards, she coached them on how to find and use the health care, which many had been putting off for years. Outside of the metropolitan areas, this task was even more challenging because of the limited numbers of clinics and hospitals in many communities. As Cynthia sat with people, she heard each story in turn—the recently laid-off construction worker who couldn’t afford the insur- ance fees, the elderly retail worker whose employer had joined the exchange but offered inadequate coverage for his needs, the disabled veteran who had a difficult time driving the long distances to get her regular checkups.

From each of their positions, Sandra, Maurice, Noah, and Cynthia face cer- tain issues that must be resolved in the process of implementing the ACA. While resolving ideological debates among large institutions might seem quite different from responding to customers’ confusion, these issues are interconnected. One level directly influences the implementation tasks and results at another; the Con- nect with Health Colorado working groups create the plans and online forms that the frontline navigators like Cynthia must fill out. The lessons Noah learned about work flow in outreach agencies are relevant to objectives articulated by the Department of Health Care Policy and Financing. The first policy implementation scholars described this reality as the “complexity of joint action” and, because of it, subtitled their book “why it is amazing that federal programs work at all.”4

In this book focusing on policy and program implementation, we are more optimistic. We believe the more that people like Sandra, Maurice, Noah, and Cynthia recognize their interdependence and have ways for talking about

8 Effective Implementation in Practice

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and analyzing the complex implementation system they are part of, the more likely that policy and program implementation can help deliver desired results. However, this vision depends on implementers recognizing their essential roles in these systems. It requires professionals who will work hard to cultivate the analytical and social skills necessary to understand and intervene in complex systems. It requires courage to acknowledge ambiguity and still take action, particularly seizing opportunities to work across the multiple levels of the system.

In our understanding, implementation is a form of policy practice, distinct from yet influenced by policy debate. It is centrally important to democratic gover- nance. And in its complexity, it can be both fascinating and challenging—solving one problem can reveal another layer needing to be addressed. In this book, we invite you to engage in the endeavor of studying implementation. Be curious about implementation dynamics, develop new conceptual language, and cultivate skills that will help you resolve the implementation quandaries you encounter. Through- out, keep in mind that while your actions are merely one part of the larger system’s dynamics, sometimes small interventions can improve whole system operation. Opportunities present themselves, often in unexpected ways, to better align an implementation system toward improving public value results.

EXPLORING POLICY AND PROGRAM IMPLEMENTATION Implementation issues appear in less-dramatic gestures than the passage of major health care reform. In fact, when any new program or idea for an initiative is shared, practical questions about implementation often follow right behind. How do we take these mandates and make them real in our state? How do we pull together the right people to respond to the large foundation’s request for proposal? When a grant proposal is funded, how do we empower the program managers to develop procedures and training for staff? While we both recognize the urgency of these questions, we also believe that it is important to understand each question in its larger, systemic context. The first step in developing this ability is to internalize helpful lessons from social science that provide new ideas and consistent language for your analysis.

By definition, policy and program implementation is complex. The issues that make their way into the public arena are significant, the solutions illusive. Energy conservation, affordable and adequate housing, educational effectiveness—all are desirable goals that require changes in personal, market, and organizational

Framing Implementation 9

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behavior to attain. Very few policies or programs designed to achieve such goals are self-implementing. And yet the means, the how of developing these solutions, is often quite illusive. Merely acting from organizational or professional interests does little to create integrative solutions that foster collective action across boundaries to advance the common good.

This process is made more challenging because, as in Colorado’s ACA example, much of policy and program implementation devolves from the central government. Around the world, traditional public bureaucracies directly provide fewer services than they used to, depending instead on private organizations under contracts, grants, or subsidies to deliver public services. The diversity of organizations and varied government tools in use raises the substantive importance of improving implementation, but it is not easy. Public sector managers, accustomed to focusing their attention on how best to navigate bureaucratic structures and legislative oversight, must acknowledge how much of policy implementation falls outside the direct control of publicly employed staff. They must cultivate skills of network management, such as facilitation and negotiation, to work effectively in implementation systems. Private business and nonprofit managers, accustomed to acting on narrow conceptions of their organizational bottom line or interests, must recognize the significance of their involvement in public service provision. They must recognize the legitimacy of public accountability and yield some autonomy to be part of larger solutions to public problems. Both must reorient themselves away from organizational interests toward attention to the policy or program target population, to under- standing their behaviors, motivations, and concerns. Teachers, police officers, unemployment insurance clerks and doctors must recognize how their daily decisions—decisions to go beyond the formal requirements of their job in responding to students, citizens, and needy patients—often become the face of public policy.

It is common for public managers, private and nonprofit leaders, and direct service professionals to complain that target groups often do not follow policy or program requirements; they often fail to act in ways that designers intend. This disconnect between systems operation and target group behaviors is a fundamen- tal challenge in most implementation projects. Yet seeking to understand the way such behavior is indeed logical by attending to the actual motivations and real- ities of these target groups is often essential for orienting what implementation improvements should address.

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Compared to previous political science and public affairs scholarship, our notion of policy and program implementation grows more directly from sociology and organizational theories. As we discuss in chapter 2, many other scholars anchor implementation on policy intent or the characteristics of a par- ticular legislative statute.5 In this conception, policy implementation is focused on trying to bring the ideas of formal policy into reality. Policy implementation is viewed as the activities carried out by various institutions and implementers in pursuit of adherence to formal public policy and laws. As proponents of a government-centered, top-down approach to implementation, Dan Mazmanian and Paul Sabatier state, “Implementation is the carrying out of a basic policy decision, usually incorporated in a statute but which can also take the form of important executive orders or court decisions.”6 From this understanding, program implementation follows linearly from policy implementation. Imple- menters, county or regional governments or local service organizations, try to interpret and integrate policy directions into their ongoing operations through specific programs; they are a necessary component of policy implementation, operating at a smaller, more localized scale.

But this linear relationship does not hold. Many times national policy is created after the documented impact from programmatic innovation at state or local levels. Kindergarten, electrical smart grid, HIV/AIDS services, and countless other examples evolved in this way. These programmatic ideas can be described, evaluated, assessed by others, and adopted by other states before national legislation is forthcoming. As a result, we join other scholars in challenging how policy implementation is often described in textbooks, as a stage in the policy process that comes after policy adoption.7

Instead, we define effective implementation as deliberate, institutionally sanctioned change motivated by a policy or program oriented toward creating public value results on purpose. When implementation is successful, it becomes incorporated in everyday work and part of standard operating procedures. Effec- tive implementation is deliberate because it involves conscious design, planning, and assessment of what occurs. Effective implementation also is institutionally sanctioned, backed by political authority and a pragmatic understanding of reasonable actions within the operational constraints of the setting. Yet effective implementation is focused on change, introducing new or modifying existing patterns of actions. But many times the process of change proceeds in unexpected ways. There are a number of important indicators of implementation effectiveness.

Framing Implementation 11

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When successful, policy and program implementation creates public value by enabling collective impact beyond the narrow self-interest of any particular actor or institution.8 When policy and program implementation is successful, what once was new and foreign becomes incorporated in everyday work, with the requisite resources necessary to sustain the change in behavior among program implementers. When successful, implementation also helps achieve changes in the target group as imagined by policymakers or program developers.

Rather than assuming a linear relationship between policy and program imple- mentation, we understand implementation as a process of change occurring, sometimes simultaneously and in contrary directions, at different scales within a complex system.9 It happens in a context where often there are already established ways of working. Said another way, it rarely happens on a clean slate. As a result, policy and program implementation requires continuous and intentional learning about changes focused on publicly desired results. And it raises significant ques- tions: What is significant about a context that shapes change? How can changes yield publicly desired outcomes and minimize unintended consequences? How can others be engaged so that what was once new or threatening can be integrated into daily practices and operations? To help us begin to provide answers, we harvest insights from social science theory and research to ground us in concepts important to developing more skill in implementation practice. But there is also mystery in implementation, much like a gardener feels when watching spring flowers emerge from the ground. There is a social dimension to this type of policy practice that operates in unpredictable and sometimes awe-inspiring ways. To be effective, actors must cultivate subtle social skills that engage others in being part of the change.

DEFINING IMPLEMENTATION EFFECTIVENESS To carry out programs successfully, it is essential for implementers to have a clear sense of the results desired to help shape implementation activities. But often it is difficult to narrow down the possible options. One can easily ask, “De- sired results according to whom, and for what purpose?” However, just because desired results are often subjective it does not imply that anything goes. While this is not true for all implementation more generally (such as the implementation of a new technology in a private corporation), policy and program implementation systems normatively should ultimately create public value. It is what justifies the

12 Effective Implementation in Practice

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change that is being attempted—change that tries to counteract the tendency in large systems for inaction and drift.

But pursuing outcomes in line with public value requires explicit consideration of the public consensus regarding how a program ought to be carried out and the desired changes that should result.10 Sometimes this public consensus is docu- mented through democratic processes, in policy or legislative intent. As described in chapter 2, classic implementation scholars described effectiveness as whether the implementation achieved the policy intent. But many times, the formal policy intent is unclear or lacking altogether. When present, policy or program state- ments often identify large-scale desired results. For example, for the ACA, three results were articulated by national law: expanding health coverage to 25 million Americans by 2023, lowering costs and increasing benefits for consumers, and incentivizing quality and innovation in our health care system. While laudable, each is vast and difficult to use to anchor the numerous implementation decisions being carried out in the states and localities. It is well established that in public programs, definitions of effectiveness vary dramatically because of political differ- ences, competing vantage points, and multiple goals.11 Desired results often are left intentionally vague in formal policy statements not only to provide political cover, but also to allow localized interpretations and evaluations of effectiveness. In fact, many scholars note the irony that what is good for implementation—clear assign- ment of responsibilities, specification of change processes, and clear outcomes—is often very bad for politics.12

But public values explicitly extend beyond conventional notions of efficiency and effectiveness.13 One can look to other sources beyond the formal policy to reflect public value consensus regarding a particular program, such as nonprofit membership associations within a certain policy area or accrediting bodies that define quality practices in a field.14 In her research on mortgage lending, Stephanie has often found that institutions in the local community can be a stronger influence on public value outcomes than formal legislative policies.15

And policy field and organizational actors can initiate processes of citizen engagement where members of the public are convened to provide feedback about desired activities and results.16 Indeed, an important first-order task for implementation is to specify the desired outcomes given the formal policies and other assessments of public consensus in a particular policy area.

But what outcomes are important? As others have argued,17 often people inter- ested in public policy tend to ignore administrative and organizational processes

Framing Implementation 13

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