The CSFs are well defined at the program level, at which level of analysis they detail the key metrics of success that guide the program. Qualitative differences in CSFs exist between private- and public-sector entities for the same types of programs . When a program from the private sector is adapted for use in the public sector, achieving success is likely to be more difficult due to the differences in the CSFs. Further, once an operational program derived from an environment external to the public sector is applied within the public-agency setting, the ongoing strategic management of the implementation faces challenges not seen by private-sector counterparts. CSFs are only one type of catalyst that drives administrative behavior. Recently within the public sector, a movement toward administrative reform has led to increased adoption of operational practices that originated in the private sector . Although both structural and legal obstacles act to contravene managerial actions in the government sector , the prevalence of operational practices designed to improve operating efficiency is increasing. Operational practices are defined as organizational or administrative behaviors intended to alter performance in some meaningful manner . Improved transparency in the public sector amid this movement of administrative reform has increased the use of new private-sector-based operational-process techniques. An example is the increased use of the process improvement technique called “Lean,” vertical farming equipments which is used to improve efficiency by public agencies . Other examples of these practices include the use of balanced scorecards and also pay-for-performance models by agencies .

These operational practices are quite prevalent in the public health care sector, with agencies such as Centers for Medicaid and Medicare Services and local, county-level health departments using reported health data on screenings and treatment of the chronically ill to differentially pay bonuses to providers of health care under their contractual terms. Despite evidence questioning their efficiency and efficacy , these models continue to be used—likely due to their ability to provide legitimacy, as suggested by Scott, Ruef, Mendel, and Caronna . Operational practices are often shared between sectors—or, at the minimum, these practices originate on the for-profit private side and are adopted by agencies when environmental changes call for such. The catalysts for these changes are not well identified within the literature. It appears that, unlike in the for-profit sector, these changes are adopted more slowly and not necessarily due to the vagaries of economic necessity . They are more politically motivated and place emphasis on the appearance of efficiency . While the literature describes the differences between public-sector workers’ behaviors and those of their for profit, private-sector counterparts, it does not provide for an adequate understanding of why isomorphic behavior occurs in the adoption of operational programs. Dissecting just one of the above elements described by Boston et al. could provide a significant contribution to knowledge of public-sector or private-sector operational challenges. Combining and understanding of two or more of these dimensions could lead to an understanding of why certain potential catalysts of change are suited to enabling successful change better in one public-sector setting than in another. Such an awareness might even change how we determine which catalysts will create sustainable change. A public agency lacks the profit motive that drives the use financial incentives to motivate employees in the for-profit private sector. However, introducing a new classification of employees at a salary range higher than those of the standard set of classifications might be a technique used by a public agency to attract and motivate employees in order to achieve certain goals.

While the use of these financial incentives alone may not describe the reasons for implementing a new program, it may provide insight as to how such a process enabled success of the program. How the catalysts of change translate into actual decisions to embark on the change process is another microcosm useful in understanding of differences between the sectors . This dissertation contributes to understanding the catalysts to change and the decision-making process by this corrections service agency in a unique way. While changes to operational practices or operational programs within the public sector tend to be slower due to cross-cutting concerns related to administrative oversight tenure, budget, and agency complexities , this case study provides context within the rapid-cycle-improvement setting of a public agency. Administrators in the public sector tend to look to enhance resource capabilities through collaboration over long-term strategic planning, as was shown to be the case in the collaborative governance and public-private partnership discussion earlier in this chapter. The nature of the top-down receivership structure, however, combined with the hiring of several for-profit and not-for-profit private-sector executives into the receivership, led to the environment studied here. Executives were driven by short-term objectives and were required to establish partnerships and collaborative structures in a time frame shorter than what a typical public agency would undertake for such ventures. While the type of work and strategy sought for implementation was familiar to these executives, the temporal element and certain aspects of environment were quite different.

The receivership provided a more autonomous structure under which thoughts and vision could be transformed into action—so long as evidence could be provided by pilot program outcomes and backed up by internal administrative expertise experience. The true catalyst for change in this study was the federal government, by way of federal court order, imposing the demand for change upon the public agency to ensure the humane treatment of persons as stipulated by the Constitution. The translation of that into a viable vision required competent management at the actionable level. Implementation of this vision via a program that enabled positive and sustainable outcomes to improve the health care of prisoners required much beyond the federally ordered catalyst for change. It required a well-planned execution of technical and nontechnical tasks combined with interventions on management to ensure performance. The first step of the program implementation was selection of the right health care delivery model to ensure success in achieving the vision of the receiver.The chronic care model first developed by physician Edward Wagner under the Improving Chronic Illness Care program draws from the best research and practice, and it provides a framework for improving care for people with chronic conditions . A breakdown of the model’s elements and operating framework is provided later in this chapter. Due to its success in improving patient outcomes and enabling organizational change around the model’s elements, it was selected for implementation within the correctional environment to achieve the mission set forth by the receiver. With the decision made to adopt this model, the problem of successful implementation lay ahead. Success was defined as the improvement of health outcomes for the prisoner population. As previously noted, many challenges stood in the way of successfully implementing this program and achieving improvements to the delivery of care that improved health care outcomes. In addition to obvious problems cited by Boston et al. , Carnevale , and Starling ,vertical farms health care delivered within prisons significantly differed from the private-sector model. Custodial concerns—maintaining the order of prisoners and their collective actions— trumped the delivery of health care services. For example, it was observed during this study that medication pill lines were established by health care teams but were modified to suit the needs of custody staff. Were a fight to occur while inmate-patients queued to receive their medications for treatment of their various conditions, then the delivery of medications on that line would cease until the custodial concern were taken care of. If, for some reason, the appropriate custodial officers were not present to assist in the movement of prisoners to receive medication or other health care services, the delivery of care would then be interrupted until such time that custodial personnel became available. The observation that maintaining order among inmate populations takes priority over health care concerns is additionally well documented in the literature . Outside this environment, the potential for violence is not generally present, nor was it considered when the chronic care model was developed.

The closest analogy in the private setting would be the lack of availability of a responsible individual to provide transport for an in firmed person requiring treatment at a particular facility of care. Such details of the logistics of health care delivery are not considered when models of care such as CCM are designed and implemented. The fact that one can simply receive the care offered, if provided in the most efficacious manner of delivery as possible, is assumed in these models. Given the barriers to successful implementation of this particular model in this agency, what conditions are necessary for success in this setting? Removing the layers of complexities mentioned above will provide a solid conception of how generalizable the findings provided herein are. We begin with an explanation of the chronic care model as originally developed and implemented outside the custodial environment.In his work in primary care medicine related to chronic disease, Wagner recognized that there were major impediments to the delivery of high-quality care for chronic illness. He noted that “chronically ill patients need time with their providers, regular assessments of clinical, behavioral, and psychosocial variables, and ready access to other resources such as pharmacists, nutritionists, and social workers” . Figure 1 provides a visual representation of the initial conception of the model used in United States primary care settings. During a nine-month pilot program funded by the Robert Wood Johnson Foundation, an early version of the model was reviewed by an advisory panel of experts and was then compared with the features of leading chronicillness-management programs across the United States. The model was found to have improved care in a meaningful way and, as a result, Improving Chronic Illness Care subsequently became a national program of the Robert Wood Johnson Foundation. It was launched in 1998 with the chronic care model at its conceptual core. Since that time, different sectors of the medical field, beginning with primary care physicians, have begun to implement CCM into practice, helping to manage patients with chronic diseases.The structure of CCM consists of six foundational pillars: community resources, healthcare organization, self-management support, decision support, delivery-system redesign, and clinical information systems . Figure 1 illustrates the integrated nature and intent of CCM. The model calls for the education of patients while requiring them to become active in the care of their chronic illness, incorporating them into a practice team that is striving for improved outcomes. Effective bidirectional communication between the medical providers for a patient with a chronic disease condition such as diabetes is central to execution of the model. The early objectives of CCM included helping people with chronic illness by utilizing a coordinated program of quality improvement, research, and evidence-based practice. To test the efficacy of the chronic care model in the area of quality improvement, the ICIC program looked for the improvement strategy that had the best evidence base while showing the most promise as an effective strategy. The BTS is a collaborative learning method designed in 1995 by the Institute for Healthcare Improvement. The BTS is designed to help organizations close that gap by creating a structure in which interested organizations can easily learn from each other and from recognized experts in topic areas in which they want to make improvements. A BTS collaborative is a short-term learning system that brings together a large number of teams from hospitals and clinics to seek improvement in a focused topic area .The Chronic Care Breakthrough Series Collaboratives began in 1999 in partnership with the Institute for Healthcare Improvement. Using a clearly defined change package based on CCM, the BTS Collaboratives provided participants with proven tools and information to assist them in making the requisite changes within their system. As the collaborative program developed, the Health Resources and Services Administration’s Bureau for Primary Health Care launched a demonstration project to reduce disparities in care quality given to the clients of community health centers. A multidisciplinary research team from University of California at Berkeley and the RAND Corporation undertook a four-year research study of the ICIC’s three earliest Chronic Illness Care Collaboratives . Findings from this joint analysis, entitled the Improving Chronic Illness Care Evaluation, were positive.