Community Mental Health Journal, Vol. 28, No. 5, October 1992
Neglected Organization and Management Issues in Mental Health Systems Development James R. Greenley, Ph.D.
A B S T R A C T : F r a g m e n t e d a n d often uncoordinated public services for t h e more sev e r e l y m e n t a l l y ill a r e often c h a r a c t e r i s t i c of t h e c u r r e n t U.S. m e n t a l h e a l t h system. The creation of local m e n t a l h e a l t h a u t h o r i t i e s h a s been promoted as p a r t of a solution, as has h a p p e n e d in Wisconsin a t the county level and is c h a m p i o n e d in the ongoing Robert Wood J o h n s o n F o u n d a t i o n funded innovative service sites for severely m e n t a l l y ill adults. There a r e indications t h a t these innovative m e n t a l h e a l t h a u t h o r i t i e s will fall short of fulfilling t h e i r promise. Basic principles from t h e m a n a g e m e n t a n d organizations l i t e r a t u r e are used to identify several o r g a n i z a t i o n and m a n a g e m e n t issues t h a t m a y have been neglected. These include resource m a n a g e m e n t , a t t e n t i o n to s y s t e m goals, m o n i t o r i n g and feedback, and the promotion of desirable i n t e r o r g a n i z a t i o n a l cultures.
For decades prior to World War II, in the United States and much of Europe public psychiatric inpatient institutions comprised the vast bulk of the mental health services system. For the most severely ill, patient care, financial and human resources and administrative control were highly centralized in these institutions (Rothman 1971; Grob 1983). After WWII, this type of mental health service system entered a period of substantial change in the United States. Address correspondence to James R. Greenley, Ph.D., University of Wisconsin-Madison, Room 2454, Social Science Building, Mental Health Research Center, 1180 Observatory Drive, Madison, WI 53706. An earlier version of this paper was presented at the 1991 annual meeting of the Midwest Sociological Society, April, 1991, Des Meines, Iowa. The author wishes to thank Leonard Stein, Rockwell Schulz, David McKee, Odin Anderson, and Patricia Littman for helpful comments on an earlier draft of this paper. 371
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A rapidly developing and evolving system emerged. It was fueled by an expanding professional cadre, development of outpatient provider organizations, new therapeutic technologies, increased financial resources, emergence of private (as contrasted to public) mental health care service provider organizations, and a growing acceptance of mental health services (Greenley 1990). It was shaped by values deeply rooted in American culture, including privatization, individual worth and autonomy, entrepreneurship, and an anti-bureaucratic ethos. A new system developed whose strengths included innovativeness, flexibility, outreach to new populations, and multi-disciplinary perspectives. Yet as this new system took shape in the 1950s and 1960s, it became increasingly divided between public organizations, usually serving those poorer, more disabled, and often less desired patients, and the private service providers, often oriented to the more well-off and less disabled patients seen largely in outpatient settings (Riessman et al. 1964). Much of the criticism was focused on the publicly funded part of the overall system (Chu and Trotter 1974). It is this public subsystem to which the comments in this paper are addressed. The problems identified with this public care system included poorly coordinated care, inadequate comprehensiveness of services, little continuity of care, and lack of interest which many clinicians trained in traditional university training programs had in caring for the most severely ill (Brown 1985). These problems in large measure reflected the structural characteristics of the ~system", which themselves grew out of a complex context of federal goals, state policies, and financing strategies, such as those associated with federal community mental health centers, deinstitutionalization, and Medicaid. Basically the system grew as one composed of disparate, separate mental health care providers. The organizational providers were divided in many ways: inpatient/outpatient, public/private, disciplinary perspectives, jurisdictional lines, and service types (e.g., housing and medications) (Shore and Cohen 1990). These separate organizations competed for resources from disparate funding streams. Organizational providers protected their autonomy vigorously. While this system did many things very well, it was less responsive to the needs of the most severely mentally ill. Persons with schizophrenia and other serious disorders were often neglected, pushed aside, bounced around, and inappropriately cared for. Many researchers and administrators interested in reform conceptualized the problem as getting the system to be more coordinated,
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comprehensive, continuous, etc. This conceptualization ushered in an era of research on interorganizational relationships, with an eye to identifying characteristics of organizational relationships associated w i t h cooperation, continuity of care, and so forth (Litwak 1969; Aiken et al. 1975). Studies were done of joint programming, environmental turbulence, boundary spanning personnel, interorganizational networks, and so forth. The breadth and sophistication of the research was impressive, but the results pointed to no generally accepted, effective, or widely adopted solution. As the years passed, evidence revealed a system more intransigent, rigid, and resistant to change than was initially expected. As organizational theorists might have predicted (Thompson 1963) and observers of the system were noting (Kirk and Greenley 1974), interorganizational relationships appeared dominantly driven by the tenacious pursuit of resources by organizations and resolute defense of organizational autonomy. The use of case managers to access and coordinate services was one innovative response (Dill and Rochefort 1989). Case managers were to effect coordination, continuity, and other desired goals by interacting with and building links between service organizations. It was an effort to coordinate at the lowest level, i.e., the level of the individual patient. Other efforts involved linking or integrating a few provider organizations in vertical or horizontal configurations (Grusky et al. 1986), or though blending different professionals and services in a treatment team (Test 1979). None of these proved sufficient (Dill and Rochefort 1989), although all met notable success in particular instances.
I N N O V A T I V E S Y S T E M CHANGE: THE LOCAL M E N T A L HEALTH A UTHORITY
It became increasingly apparent that minor structural and process innovations such as joint planning or boundary spanning innovations, or resource carrots such as monies for interorganizational committees, were not going to be sufficient to accomplish major change. Case management and treatment teams often floundered among resistant provider organizations. Many of the problems were deeply rooted in the system characteristics of independent, autonomous organizations each able to maintain itself through access to diverse resources. One suggested solution was to attack this underlying system resistance by developing authority over organizations and cutting them off from the
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resource streams that independently maintained them. The resultant innovative system change was to place formal authority and control over resources in a local governmental agency, sometimes called a local or sub-state mental health authority (Dill and Rochefort 1989; Gaynor 1990). Initially the suggested system change did not develop from abstract theorizing about interorganizational relations or systems configurations. Rather it grew from observations of systems that seemed to work. Wisconsin's highly regarded system was taken as one model (Shore and Cohen 1990; Torrey et al. 1990). In the early 1970s, Wisconsin had decentralized authority from the state to the county level and bundled resource streams under county agency control (Stein and Ganser 1983). Basically, the Wisconsin model placed responsibility for mental health services and control over resources under the administration of a county-level agency. Systems with various of these emphases have developed in Michigan, Ohio, and elsewhere (Gaynor 1990). The Robert Wood Johnson Foundation funded innovative service sites for severely mentally ill adults which incorporated the central mental health authority concept (Aiken et al. 1986; Goldman et al. 1990; Shore and Cohen 1990). This innovative system solution was a move from the little carrot approach to entice organizational cooperation to the big stick tactic to get the disparate, autonomous provider organizations to respond to client needs in desired ways. There can be little doubt t h a t this is the currently touted model for system development in the 1990s, much as case management was the solution promoted in the 1980s. Descriptions of ideas and experience behind the creation of these authorities stress two principles (Stein et al. 1990; Aiken et al. 1986). First, the central mental health authority is to gain authority or power over the fragmented set of service provider organizations which exist in most systems. In essence, these innovative systems take individual provider organizations and pull them into a single organizational entity, sometimes called a county administered system or a central mental health authority (Stein and Ganser 1983; Stein et al. 1990). These authorities are given administrative authority (Goldman et al. 1990; Stein et al. 1990) or are expected to gain control through their ability to contract for services. Second, control over resources is placed in the hands of the authority. This resource control is aggressively sought such that the organizational subcomponents, often individual organizations themselves, do not have the organizational autonomy they once had. Individual provider organizations become dependent enough on the new system-spanning organization, it is hoped, that their behaviors can be controlled.
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LIMITATIONS OF THESE N E W S Y S T E M DEVELOPMENTS Unfortunately but probably not surprisingly, there is already evidence that these new system developments will not fulfill their sometimes exaggerated promise. I do not believe it is heresy to raise questions about these well meaning and innovative interventions on a system level. Some may say that they need time to prove themselves before being subject to undue scrutiny. Others may believe that raising questions will slow adoption of these innovations and be detrimental in the longer run. But I believe that early identification of the potential weaknesses in these system innovations may allow them to be improved and may help avoid our throwing out the "baby with the bath." I believe that these new system interventions are appropriate and useful, and that their limitations are not due to things that are wrong, but to issues which for various reasons have been neglected to this point. The reason that I believe these new system developments will fall short of fulfilling their promise is that I have observed a large number of these systems in Wisconsin in enough detail to know that they vary greatly in achieving desired ends. The more than 50 such systems are at the county or sometimes multi-county level. In Wisconsin, the structure of the system was changed by law in the early 1970s, establishing local control and responsibility for services. The law leaves wide latitude to county mental health authorities regarding what goals they wish to pursue. Some work aggressively to improve services. But in the words of Torrey et al. (1990, p. 79), "many of the counties simply lack interest." Some patient care improved, and some arguably got worse. In the mid-1980s, they were reported spending all the way from 13% to 73% of their mental health budgets for inpatient care (Goodrick 1985). They also reputedly vary widely in outcomes for their patients and types of services delivered. Some are by reputation and personal observation not supplying state-of-the-art services or even adequate care (Torrey et al. 1990). In one recent account, anecdotal evidence reveals very inadequate care in one rural area (Fishman 1991). Other areas deliver model services, such as the highly regarded, innovative services in Madison (Thompson et al. 1990). The point is that services are highly variable across county systems in Wisconsin. In addition, there is some evidence that some of the RWJ Foundation urban sites in which the mental health authority system administration approach is being tried are having more difficulty than others in accomplishing stated goals. Some of the questions raised about the efficacy of the RWJ Foundation urban authorities concern whether, because of political resistance, they have not yet been sufficiently
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implemented (Goldman et al. 1990; Rosenberger 1990). For example, in the RWJ Foundation sites, the authority's control over state mental hospital budgets and Medicaid dollars is usually minimal (Goldman et al. 1990). Other problems may arise even in instances where full implementation occurred. For example, available clinical personnel may not have been appropriately trained for the service model desired, or funding streams which appeared in place may shrink drastically in times of economic difficulties. This variation, in and of itself, is evidence that the system intervention by itself may not be sufficient to produce the desired outcomes.
A THEORETICAL PERSPECTIVE Abstracting basic principles from the management and organizations literature may help identify other issues that managers and others should pay attention to in order to produce desired outcomes. This literature is vast and disparate. Nonetheless, theoretical perspectives in this area reveal repeated concern with the following four issues (Aldaz and Stearns 1991; Druker 1979). These are issues which managers within organizations and across organizational systems would need to be attentive to in order to be successful. Some of these may be particularly problematic issues in new organizational forms (Sarason 1976). Here they will be described as things t h a t system managers should accomplish vis-a-vis the organizations within their system. Control First, managers must obtain control over the subordinate organizations in their system (Aldaz and Stearns 1991). They need to have the power or authority to get them to do what they want. Particularly in the system innovations described above, managers try to get providers to coordinate services. Managers must focus on this issue, working to gain control through formal authority mechanisms, such as through law and regulation. In this way, supraorganizations are set up to allow managers at the top to control organizations within the system. In addition, for those instances (and there are many) in which provider organizations cannot be brought under formal authority structures, the system innovations attempt to get control of sufficient resources such that these provider organizations will be so dependent on the system for resources t h a t they will fall under its control. This follows directly from power-dependency theory (Emerson 1962). Thus
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the issue of control is not neglected by these system innovations, but rather this principle is the one given most attention, sometimes to the exclusion of other issues.
Resources Second, managers must provide organizations and workers in their systems sufficient resources to do the requested tasks. Thus a major task of managers is to obtain these resources from the organization's environment (Pfeffer and Salanick 1978). Provider organizations need staff, facilities, training, and so forth. The capturing of resource streams by local mental health authorities, as discussed above, may enhance system managerial control, but it does not ensure that the provider organizations and professionals will have enough resources to accomplish what they are asked.
Goal Setting Third, managers need to establish goals for the system. These goals need to be made known throughout the system (Locke and Latham 1984). By setting goals, managers give direction to the system.
Monitoring and Feedback Fourth, managers must be able to monitor the activities in the system in order to establish whether the system is accomplishing the goals (Mintzberg 1973). Also, the information gathered in the monitoring must be used to give feedback to the organizations and workers on how they are doing (Shortell et al. 1976). Monitoring and feedback provide the possibilities for corrective action, guided change, and system improvement. In general, innovative system changes have paid most attention to gaining control, through establishment of formal authority structures and capturing resources. It is the other management issues t h a t tend to have been neglected.
NEGLECTED ORGANIZATIONAL AND MANAGEMENT ISSUES Resources Many system managers have difficulty finding sufficient resources to enable their provider organizations and professionals to do an adequate job. The lack of resources, or at least certain types of them, hardly needs
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stressing. Pooling resource streams is not sufficient if those streams are not large enough to begin with. The RWJ Foundation initiative recognized this in trying to gain Housing and Urban Development funds for housing the mentally ill (Shore and Cohen 1990). They recognized that in addition to system reorganization, more resources were necessary. While insufficient resources may pose a critical problem in some system, it is notable that some excellent systems appear to operate well on substantially less funding than do other systems with poor reputations (Stein et al. 1990). A cry for more resources may, in some settings, obscure a maldistribution of resources, which, for example, may lead to most resources going to inpatient settings, leaving little for the rest of the system. Alternatively, the movement to create new administrative structures, such as these innovative systems, may serve to deflect focus on the major problem of lack of system resources. Organizational change such as the creation of a mental health authority can hold the promise of a solution on the cheap, holding out the possibility that a reorganization of resources may obviate the need for more. While this may be the case, it often is not.
Attention to System Goals Good organizational performance requires that goals be clearly formulated and disseminated to organizational members who become committed to them (Locke et al. 1980). This is also true for the interorganizational system. In addition to discussing the organizational principles of resource control and centralized authority, Stein et at. (1990) list two other principles, both of which translate into goals, i.e., care over long duration and breadth in scope. Thus Stein et al. (1990), without mentioning goals specifically, identify important goals as two of their key principles. Relatively little research is focused on goals of mental health organizations. What research does exist shows the importance of goals to organizational performance in general (Locke and Latham 1984) and to mental health organizations in particular (Schuh et al. 1983). Interventions at the system level have often not paid sufficient attention to these or other goal related issues. Variation across systems in performance appears to be related in part to whether the system administration's goals involve a central commitment to improvement in patient care or not. Some system administrators appear more committed to preserving the status quo, whether this be the historical prerogatives of the local professionals or the institutional strength of places like the county hospital. Others see it as an
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opportunity for change, but this may mean increasing the size of their bureaucracy, promoting a more narrow medical or social service model, or even paring services down to save county money. Managers of these new systems structures, however innovative and well conceived the systems are, will have difficulty improving patient care without clear goals and a commitment to do so. An innovative system structure is only facilitative. In this regard, it is important to recognize that administrators and politicians who gain control of such systems often pursue administrative and political goals. These include financial control, bureaucratic rationalization, and personal aggrandizement. It may be that the goals common to mental health professionals, such as psychiatrists, may be more in tune with the needs of patients because of the professional socialization and selection that leaves most professionals with a deep commitment to patient welfare. Possibly mental health professional staff should have a greater role in formulating policies in such systems because of their commitment to patient oriented goals? Alternatively, mental health professional staff who enter administrative roles themselves come to face pressures and incentives which steer them toward serving organizational goals over those of the individual clients. While there are many suggestions for goal development, a general principle may be to involve a broad range of professionals in planning and goal setting, as well as others from social services, rehabilitation, housing, government financing, consumers, and families of consumers (Stein et al. 1990). The principle of involving various constituents in planning and goal development is a cornerstone of PL 99-660, which guides states to establish plans and goals. As such PL 99-660 can be a useful tool in goal setting, recognizing that this law mandates state level goals that may not be the same as the goals chosen by local mental health authorities.
Monitoring and Feedback Effective organizations need to be able to monitor the quality of their products. It is difficult to imagine a successful automobile company whose leadership could not tell whether a particular car coming off its lines could run or not. While it may be substantially more difficult to tell whether a particular patient's care is appropriate or successful, there must be some standards to give direction to the system. Mental health system leadership must be able to tell whether a particular patient's care is consistent with overall system goals, and vice versa.
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However, all too often innovative systems are built (to say nothing of traditional systems) in which the mechanisms for such monitoring are neglected. In one system I know, such monitoring goes on though the direct contact of an administrative agent with the clients, clients' families, and front-line staff. This person is open to family and client questions and complaints, and may work with or through other monitoring mechanisms that sometimes exist, such as consumer rights or quality assurance programs. He or she seeks out information on clients who show up as having undesirable service histories, such as a revolving door pattern of hospital admissions. My experience is that one person can monitor 500 to 1000 patients, but not much more. Also for management purposes, this monitoring does not have to reach into the realm of questioning professional judgment, such as on medications or such. Rather it needs to watch for solutions and work in partnership with the professionals. Adequate system monitoring is sometimes eschewed out of neglect or ignorance. Yet there are system-relevant reasons also. First, administrators, especially those in larger systems, are often non-clinicians. As non-clinicians, they often feel inadequate to assess the work of clinicians, and professionals usually agree with and promote this perception. Thus administrators concentrate on what they feel adequate to monitor, things such as financial records and patient flows. Yet such monitoring, however necessary, gives only the aggregate amount spent, accumulated patient service information, and so forth. It does not tell whether for a particular patient the funds were available for the correct care response or whether the patient's pattern of service was appropriate. This can only be done at the patient level. While the individual clinician can do this, the individual clinician is usually not in a position to observe the whole system response to even a single patient. The individual patient must also be observed at the system level. Even the patient with a case manager must have organizational leadership that can evaluate the adequacy of the case management. Second, systems tend to be so big in numbers of clients and professionals that administrators feel helpless to observe all but the grossest indicators of success. This may be common to large urban service areas. In such circumstances, administrators may tend to focus on where funds are spent and units of service given, rather than whether care is working for individual clients. Yet manufacturers routinely monitor products coming off multiple lines in multiple plants, even in different
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countries. Computer manufacturing executives may not be able adequately to assess even a single computer, but they can find someone who can and put them where the output is visible. Mental health system administrators, whether they themselves have the ability to assess quality care, need a similar ability to monitor. This may mean breaking down the system into small enough parts to allow observation of quality to occur. In these necessarily oversimplified analogies to computer and automobile manufacturing, it is important to recognize the difficulty of often assessing whether a particular treatment is most appropriate, and also to admit the existence of honest professional differences about the goals and methods of treatment. Nevertheless, the fact remains that for the mental health authorities to be successful, they must place more effort into monitoring in order to assess success and to adjust and refine their interventions. Appropriate feedback needs to accompany monitoring. The purpose of monitoring is to allow feedback to the organization's members so that they can adjust their behaviors and practices to more nearly achieve the organization's goals (Shortell et al. 1976; Schulz et al. 1983). Feedback is necessary if the information gathered in monitoring is to be used to steer the organization in the desired direction. Also, monitoring without feedback can be destructive to morale and have other negative consequences for organizational members.
Promoting Desirable Interorganizational Cultures A final neglected issue is related to the issues of goals, monitoring, and the acceptance of authority, but is also much broader t h a n even these. It concerns the knowledge and commitment that personnel in the system have, not only to a set of goals but also to the methods of achieving these goals, as well as the understandings people have about how they will work with others. Successful administrators must communicate an organizational mission. They must communicate acceptable means to these ends. They must get organizational participants to adopt these goals and methods as their own. They need to promote a sense of community with some trust and respect. They need to transfer their power into legitimately accepted authority. In short, they need to pay attention to what are aspects of the culture of an organization.
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An organizational culture is a set of attitudes, beliefs, and other shared sentiments which are shared by members of an organization (Ott 1989). The popular and professional management literature has stressed the importance of organizational culture in recent years, stemming from attributions of culture to success of Japanese industries, and findings of Peters and Waterman's In Search of Excellence (1982). To the extent that a local mental health system is conceived as a collection of organizations, we may speak of an interorganizational culture or system culture (Mount and Greenley 1989). Administrators must promote strong, appropriate and consistent system or interorganizational cultures, in the same way that managers of individual organizations need to be concerned about their organization's cultures. Interorganizational cultures may be very difficult to influence and manage. The new system innovations, being large supra organizations themselves, are made up of diverse organizations in which are embedded various professions, each with their own unique attitudes and experiences. For these systems to work effectively, system administrators must attend to the communication of goals, methods, and commitment to them. In order to promote a desirable interorganizational culture, managers may need to develop mechanisms to allow informal interaction and reinforcement of attitudes and commitments. People from diverse parts of the system may be presented with opportunities to interact in ways that develop common understandings and trust. This might involve bringing people together across organizational boundaries and also levels in the interorganizational structure. For example, system managers and front-line providers could be brought together to voice their problems and perspectives and listen to each other. Interorganizational system culture should not be neglected.
SUMMARY The implementation of innovative mental health systems opens a variety of great opportunities to overcome traditionally resistant problems in the care of the seriously mentally ill. Yet managers and others in these systems need to pay attention to issues of setting goals, monitoring care, giving feedback, and promoting desirable interorganizational cultures.
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Neglected Organization and Management Issues in Mental Health Systems Development James R. Greenley, Ph.D.
A B S T R A C T : F r a g m e n t e d a n d often uncoordinated public services for t h e more sev e r e l y m e n t a l l y ill a r e often c h a r a c t e r i s t i c of t h e c u r r e n t U.S. m e n t a l h e a l t h system. The creation of local m e n t a l h e a l t h a u t h o r i t i e s h a s been promoted as p a r t of a solution, as has h a p p e n e d in Wisconsin a t the county level and is c h a m p i o n e d in the ongoing Robert Wood J o h n s o n F o u n d a t i o n funded innovative service sites for severely m e n t a l l y ill adults. There a r e indications t h a t these innovative m e n t a l h e a l t h a u t h o r i t i e s will fall short of fulfilling t h e i r promise. Basic principles from t h e m a n a g e m e n t a n d organizations l i t e r a t u r e are used to identify several o r g a n i z a t i o n and m a n a g e m e n t issues t h a t m a y have been neglected. These include resource m a n a g e m e n t , a t t e n t i o n to s y s t e m goals, m o n i t o r i n g and feedback, and the promotion of desirable i n t e r o r g a n i z a t i o n a l cultures.
For decades prior to World War II, in the United States and much of Europe public psychiatric inpatient institutions comprised the vast bulk of the mental health services system. For the most severely ill, patient care, financial and human resources and administrative control were highly centralized in these institutions (Rothman 1971; Grob 1983). After WWII, this type of mental health service system entered a period of substantial change in the United States. Address correspondence to James R. Greenley, Ph.D., University of Wisconsin-Madison, Room 2454, Social Science Building, Mental Health Research Center, 1180 Observatory Drive, Madison, WI 53706. An earlier version of this paper was presented at the 1991 annual meeting of the Midwest Sociological Society, April, 1991, Des Meines, Iowa. The author wishes to thank Leonard Stein, Rockwell Schulz, David McKee, Odin Anderson, and Patricia Littman for helpful comments on an earlier draft of this paper. 371
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A rapidly developing and evolving system emerged. It was fueled by an expanding professional cadre, development of outpatient provider organizations, new therapeutic technologies, increased financial resources, emergence of private (as contrasted to public) mental health care service provider organizations, and a growing acceptance of mental health services (Greenley 1990). It was shaped by values deeply rooted in American culture, including privatization, individual worth and autonomy, entrepreneurship, and an anti-bureaucratic ethos. A new system developed whose strengths included innovativeness, flexibility, outreach to new populations, and multi-disciplinary perspectives. Yet as this new system took shape in the 1950s and 1960s, it became increasingly divided between public organizations, usually serving those poorer, more disabled, and often less desired patients, and the private service providers, often oriented to the more well-off and less disabled patients seen largely in outpatient settings (Riessman et al. 1964). Much of the criticism was focused on the publicly funded part of the overall system (Chu and Trotter 1974). It is this public subsystem to which the comments in this paper are addressed. The problems identified with this public care system included poorly coordinated care, inadequate comprehensiveness of services, little continuity of care, and lack of interest which many clinicians trained in traditional university training programs had in caring for the most severely ill (Brown 1985). These problems in large measure reflected the structural characteristics of the ~system", which themselves grew out of a complex context of federal goals, state policies, and financing strategies, such as those associated with federal community mental health centers, deinstitutionalization, and Medicaid. Basically the system grew as one composed of disparate, separate mental health care providers. The organizational providers were divided in many ways: inpatient/outpatient, public/private, disciplinary perspectives, jurisdictional lines, and service types (e.g., housing and medications) (Shore and Cohen 1990). These separate organizations competed for resources from disparate funding streams. Organizational providers protected their autonomy vigorously. While this system did many things very well, it was less responsive to the needs of the most severely mentally ill. Persons with schizophrenia and other serious disorders were often neglected, pushed aside, bounced around, and inappropriately cared for. Many researchers and administrators interested in reform conceptualized the problem as getting the system to be more coordinated,
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comprehensive, continuous, etc. This conceptualization ushered in an era of research on interorganizational relationships, with an eye to identifying characteristics of organizational relationships associated w i t h cooperation, continuity of care, and so forth (Litwak 1969; Aiken et al. 1975). Studies were done of joint programming, environmental turbulence, boundary spanning personnel, interorganizational networks, and so forth. The breadth and sophistication of the research was impressive, but the results pointed to no generally accepted, effective, or widely adopted solution. As the years passed, evidence revealed a system more intransigent, rigid, and resistant to change than was initially expected. As organizational theorists might have predicted (Thompson 1963) and observers of the system were noting (Kirk and Greenley 1974), interorganizational relationships appeared dominantly driven by the tenacious pursuit of resources by organizations and resolute defense of organizational autonomy. The use of case managers to access and coordinate services was one innovative response (Dill and Rochefort 1989). Case managers were to effect coordination, continuity, and other desired goals by interacting with and building links between service organizations. It was an effort to coordinate at the lowest level, i.e., the level of the individual patient. Other efforts involved linking or integrating a few provider organizations in vertical or horizontal configurations (Grusky et al. 1986), or though blending different professionals and services in a treatment team (Test 1979). None of these proved sufficient (Dill and Rochefort 1989), although all met notable success in particular instances.
I N N O V A T I V E S Y S T E M CHANGE: THE LOCAL M E N T A L HEALTH A UTHORITY
It became increasingly apparent that minor structural and process innovations such as joint planning or boundary spanning innovations, or resource carrots such as monies for interorganizational committees, were not going to be sufficient to accomplish major change. Case management and treatment teams often floundered among resistant provider organizations. Many of the problems were deeply rooted in the system characteristics of independent, autonomous organizations each able to maintain itself through access to diverse resources. One suggested solution was to attack this underlying system resistance by developing authority over organizations and cutting them off from the
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resource streams that independently maintained them. The resultant innovative system change was to place formal authority and control over resources in a local governmental agency, sometimes called a local or sub-state mental health authority (Dill and Rochefort 1989; Gaynor 1990). Initially the suggested system change did not develop from abstract theorizing about interorganizational relations or systems configurations. Rather it grew from observations of systems that seemed to work. Wisconsin's highly regarded system was taken as one model (Shore and Cohen 1990; Torrey et al. 1990). In the early 1970s, Wisconsin had decentralized authority from the state to the county level and bundled resource streams under county agency control (Stein and Ganser 1983). Basically, the Wisconsin model placed responsibility for mental health services and control over resources under the administration of a county-level agency. Systems with various of these emphases have developed in Michigan, Ohio, and elsewhere (Gaynor 1990). The Robert Wood Johnson Foundation funded innovative service sites for severely mentally ill adults which incorporated the central mental health authority concept (Aiken et al. 1986; Goldman et al. 1990; Shore and Cohen 1990). This innovative system solution was a move from the little carrot approach to entice organizational cooperation to the big stick tactic to get the disparate, autonomous provider organizations to respond to client needs in desired ways. There can be little doubt t h a t this is the currently touted model for system development in the 1990s, much as case management was the solution promoted in the 1980s. Descriptions of ideas and experience behind the creation of these authorities stress two principles (Stein et al. 1990; Aiken et al. 1986). First, the central mental health authority is to gain authority or power over the fragmented set of service provider organizations which exist in most systems. In essence, these innovative systems take individual provider organizations and pull them into a single organizational entity, sometimes called a county administered system or a central mental health authority (Stein and Ganser 1983; Stein et al. 1990). These authorities are given administrative authority (Goldman et al. 1990; Stein et al. 1990) or are expected to gain control through their ability to contract for services. Second, control over resources is placed in the hands of the authority. This resource control is aggressively sought such that the organizational subcomponents, often individual organizations themselves, do not have the organizational autonomy they once had. Individual provider organizations become dependent enough on the new system-spanning organization, it is hoped, that their behaviors can be controlled.
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LIMITATIONS OF THESE N E W S Y S T E M DEVELOPMENTS Unfortunately but probably not surprisingly, there is already evidence that these new system developments will not fulfill their sometimes exaggerated promise. I do not believe it is heresy to raise questions about these well meaning and innovative interventions on a system level. Some may say that they need time to prove themselves before being subject to undue scrutiny. Others may believe that raising questions will slow adoption of these innovations and be detrimental in the longer run. But I believe that early identification of the potential weaknesses in these system innovations may allow them to be improved and may help avoid our throwing out the "baby with the bath." I believe that these new system interventions are appropriate and useful, and that their limitations are not due to things that are wrong, but to issues which for various reasons have been neglected to this point. The reason that I believe these new system developments will fall short of fulfilling their promise is that I have observed a large number of these systems in Wisconsin in enough detail to know that they vary greatly in achieving desired ends. The more than 50 such systems are at the county or sometimes multi-county level. In Wisconsin, the structure of the system was changed by law in the early 1970s, establishing local control and responsibility for services. The law leaves wide latitude to county mental health authorities regarding what goals they wish to pursue. Some work aggressively to improve services. But in the words of Torrey et al. (1990, p. 79), "many of the counties simply lack interest." Some patient care improved, and some arguably got worse. In the mid-1980s, they were reported spending all the way from 13% to 73% of their mental health budgets for inpatient care (Goodrick 1985). They also reputedly vary widely in outcomes for their patients and types of services delivered. Some are by reputation and personal observation not supplying state-of-the-art services or even adequate care (Torrey et al. 1990). In one recent account, anecdotal evidence reveals very inadequate care in one rural area (Fishman 1991). Other areas deliver model services, such as the highly regarded, innovative services in Madison (Thompson et al. 1990). The point is that services are highly variable across county systems in Wisconsin. In addition, there is some evidence that some of the RWJ Foundation urban sites in which the mental health authority system administration approach is being tried are having more difficulty than others in accomplishing stated goals. Some of the questions raised about the efficacy of the RWJ Foundation urban authorities concern whether, because of political resistance, they have not yet been sufficiently
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implemented (Goldman et al. 1990; Rosenberger 1990). For example, in the RWJ Foundation sites, the authority's control over state mental hospital budgets and Medicaid dollars is usually minimal (Goldman et al. 1990). Other problems may arise even in instances where full implementation occurred. For example, available clinical personnel may not have been appropriately trained for the service model desired, or funding streams which appeared in place may shrink drastically in times of economic difficulties. This variation, in and of itself, is evidence that the system intervention by itself may not be sufficient to produce the desired outcomes.
A THEORETICAL PERSPECTIVE Abstracting basic principles from the management and organizations literature may help identify other issues that managers and others should pay attention to in order to produce desired outcomes. This literature is vast and disparate. Nonetheless, theoretical perspectives in this area reveal repeated concern with the following four issues (Aldaz and Stearns 1991; Druker 1979). These are issues which managers within organizations and across organizational systems would need to be attentive to in order to be successful. Some of these may be particularly problematic issues in new organizational forms (Sarason 1976). Here they will be described as things t h a t system managers should accomplish vis-a-vis the organizations within their system. Control First, managers must obtain control over the subordinate organizations in their system (Aldaz and Stearns 1991). They need to have the power or authority to get them to do what they want. Particularly in the system innovations described above, managers try to get providers to coordinate services. Managers must focus on this issue, working to gain control through formal authority mechanisms, such as through law and regulation. In this way, supraorganizations are set up to allow managers at the top to control organizations within the system. In addition, for those instances (and there are many) in which provider organizations cannot be brought under formal authority structures, the system innovations attempt to get control of sufficient resources such that these provider organizations will be so dependent on the system for resources t h a t they will fall under its control. This follows directly from power-dependency theory (Emerson 1962). Thus
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the issue of control is not neglected by these system innovations, but rather this principle is the one given most attention, sometimes to the exclusion of other issues.
Resources Second, managers must provide organizations and workers in their systems sufficient resources to do the requested tasks. Thus a major task of managers is to obtain these resources from the organization's environment (Pfeffer and Salanick 1978). Provider organizations need staff, facilities, training, and so forth. The capturing of resource streams by local mental health authorities, as discussed above, may enhance system managerial control, but it does not ensure that the provider organizations and professionals will have enough resources to accomplish what they are asked.
Goal Setting Third, managers need to establish goals for the system. These goals need to be made known throughout the system (Locke and Latham 1984). By setting goals, managers give direction to the system.
Monitoring and Feedback Fourth, managers must be able to monitor the activities in the system in order to establish whether the system is accomplishing the goals (Mintzberg 1973). Also, the information gathered in the monitoring must be used to give feedback to the organizations and workers on how they are doing (Shortell et al. 1976). Monitoring and feedback provide the possibilities for corrective action, guided change, and system improvement. In general, innovative system changes have paid most attention to gaining control, through establishment of formal authority structures and capturing resources. It is the other management issues t h a t tend to have been neglected.
NEGLECTED ORGANIZATIONAL AND MANAGEMENT ISSUES Resources Many system managers have difficulty finding sufficient resources to enable their provider organizations and professionals to do an adequate job. The lack of resources, or at least certain types of them, hardly needs
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stressing. Pooling resource streams is not sufficient if those streams are not large enough to begin with. The RWJ Foundation initiative recognized this in trying to gain Housing and Urban Development funds for housing the mentally ill (Shore and Cohen 1990). They recognized that in addition to system reorganization, more resources were necessary. While insufficient resources may pose a critical problem in some system, it is notable that some excellent systems appear to operate well on substantially less funding than do other systems with poor reputations (Stein et al. 1990). A cry for more resources may, in some settings, obscure a maldistribution of resources, which, for example, may lead to most resources going to inpatient settings, leaving little for the rest of the system. Alternatively, the movement to create new administrative structures, such as these innovative systems, may serve to deflect focus on the major problem of lack of system resources. Organizational change such as the creation of a mental health authority can hold the promise of a solution on the cheap, holding out the possibility that a reorganization of resources may obviate the need for more. While this may be the case, it often is not.
Attention to System Goals Good organizational performance requires that goals be clearly formulated and disseminated to organizational members who become committed to them (Locke et al. 1980). This is also true for the interorganizational system. In addition to discussing the organizational principles of resource control and centralized authority, Stein et at. (1990) list two other principles, both of which translate into goals, i.e., care over long duration and breadth in scope. Thus Stein et al. (1990), without mentioning goals specifically, identify important goals as two of their key principles. Relatively little research is focused on goals of mental health organizations. What research does exist shows the importance of goals to organizational performance in general (Locke and Latham 1984) and to mental health organizations in particular (Schuh et al. 1983). Interventions at the system level have often not paid sufficient attention to these or other goal related issues. Variation across systems in performance appears to be related in part to whether the system administration's goals involve a central commitment to improvement in patient care or not. Some system administrators appear more committed to preserving the status quo, whether this be the historical prerogatives of the local professionals or the institutional strength of places like the county hospital. Others see it as an
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opportunity for change, but this may mean increasing the size of their bureaucracy, promoting a more narrow medical or social service model, or even paring services down to save county money. Managers of these new systems structures, however innovative and well conceived the systems are, will have difficulty improving patient care without clear goals and a commitment to do so. An innovative system structure is only facilitative. In this regard, it is important to recognize that administrators and politicians who gain control of such systems often pursue administrative and political goals. These include financial control, bureaucratic rationalization, and personal aggrandizement. It may be that the goals common to mental health professionals, such as psychiatrists, may be more in tune with the needs of patients because of the professional socialization and selection that leaves most professionals with a deep commitment to patient welfare. Possibly mental health professional staff should have a greater role in formulating policies in such systems because of their commitment to patient oriented goals? Alternatively, mental health professional staff who enter administrative roles themselves come to face pressures and incentives which steer them toward serving organizational goals over those of the individual clients. While there are many suggestions for goal development, a general principle may be to involve a broad range of professionals in planning and goal setting, as well as others from social services, rehabilitation, housing, government financing, consumers, and families of consumers (Stein et al. 1990). The principle of involving various constituents in planning and goal development is a cornerstone of PL 99-660, which guides states to establish plans and goals. As such PL 99-660 can be a useful tool in goal setting, recognizing that this law mandates state level goals that may not be the same as the goals chosen by local mental health authorities.
Monitoring and Feedback Effective organizations need to be able to monitor the quality of their products. It is difficult to imagine a successful automobile company whose leadership could not tell whether a particular car coming off its lines could run or not. While it may be substantially more difficult to tell whether a particular patient's care is appropriate or successful, there must be some standards to give direction to the system. Mental health system leadership must be able to tell whether a particular patient's care is consistent with overall system goals, and vice versa.
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However, all too often innovative systems are built (to say nothing of traditional systems) in which the mechanisms for such monitoring are neglected. In one system I know, such monitoring goes on though the direct contact of an administrative agent with the clients, clients' families, and front-line staff. This person is open to family and client questions and complaints, and may work with or through other monitoring mechanisms that sometimes exist, such as consumer rights or quality assurance programs. He or she seeks out information on clients who show up as having undesirable service histories, such as a revolving door pattern of hospital admissions. My experience is that one person can monitor 500 to 1000 patients, but not much more. Also for management purposes, this monitoring does not have to reach into the realm of questioning professional judgment, such as on medications or such. Rather it needs to watch for solutions and work in partnership with the professionals. Adequate system monitoring is sometimes eschewed out of neglect or ignorance. Yet there are system-relevant reasons also. First, administrators, especially those in larger systems, are often non-clinicians. As non-clinicians, they often feel inadequate to assess the work of clinicians, and professionals usually agree with and promote this perception. Thus administrators concentrate on what they feel adequate to monitor, things such as financial records and patient flows. Yet such monitoring, however necessary, gives only the aggregate amount spent, accumulated patient service information, and so forth. It does not tell whether for a particular patient the funds were available for the correct care response or whether the patient's pattern of service was appropriate. This can only be done at the patient level. While the individual clinician can do this, the individual clinician is usually not in a position to observe the whole system response to even a single patient. The individual patient must also be observed at the system level. Even the patient with a case manager must have organizational leadership that can evaluate the adequacy of the case management. Second, systems tend to be so big in numbers of clients and professionals that administrators feel helpless to observe all but the grossest indicators of success. This may be common to large urban service areas. In such circumstances, administrators may tend to focus on where funds are spent and units of service given, rather than whether care is working for individual clients. Yet manufacturers routinely monitor products coming off multiple lines in multiple plants, even in different
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countries. Computer manufacturing executives may not be able adequately to assess even a single computer, but they can find someone who can and put them where the output is visible. Mental health system administrators, whether they themselves have the ability to assess quality care, need a similar ability to monitor. This may mean breaking down the system into small enough parts to allow observation of quality to occur. In these necessarily oversimplified analogies to computer and automobile manufacturing, it is important to recognize the difficulty of often assessing whether a particular treatment is most appropriate, and also to admit the existence of honest professional differences about the goals and methods of treatment. Nevertheless, the fact remains that for the mental health authorities to be successful, they must place more effort into monitoring in order to assess success and to adjust and refine their interventions. Appropriate feedback needs to accompany monitoring. The purpose of monitoring is to allow feedback to the organization's members so that they can adjust their behaviors and practices to more nearly achieve the organization's goals (Shortell et al. 1976; Schulz et al. 1983). Feedback is necessary if the information gathered in monitoring is to be used to steer the organization in the desired direction. Also, monitoring without feedback can be destructive to morale and have other negative consequences for organizational members.
Promoting Desirable Interorganizational Cultures A final neglected issue is related to the issues of goals, monitoring, and the acceptance of authority, but is also much broader t h a n even these. It concerns the knowledge and commitment that personnel in the system have, not only to a set of goals but also to the methods of achieving these goals, as well as the understandings people have about how they will work with others. Successful administrators must communicate an organizational mission. They must communicate acceptable means to these ends. They must get organizational participants to adopt these goals and methods as their own. They need to promote a sense of community with some trust and respect. They need to transfer their power into legitimately accepted authority. In short, they need to pay attention to what are aspects of the culture of an organization.
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An organizational culture is a set of attitudes, beliefs, and other shared sentiments which are shared by members of an organization (Ott 1989). The popular and professional management literature has stressed the importance of organizational culture in recent years, stemming from attributions of culture to success of Japanese industries, and findings of Peters and Waterman's In Search of Excellence (1982). To the extent that a local mental health system is conceived as a collection of organizations, we may speak of an interorganizational culture or system culture (Mount and Greenley 1989). Administrators must promote strong, appropriate and consistent system or interorganizational cultures, in the same way that managers of individual organizations need to be concerned about their organization's cultures. Interorganizational cultures may be very difficult to influence and manage. The new system innovations, being large supra organizations themselves, are made up of diverse organizations in which are embedded various professions, each with their own unique attitudes and experiences. For these systems to work effectively, system administrators must attend to the communication of goals, methods, and commitment to them. In order to promote a desirable interorganizational culture, managers may need to develop mechanisms to allow informal interaction and reinforcement of attitudes and commitments. People from diverse parts of the system may be presented with opportunities to interact in ways that develop common understandings and trust. This might involve bringing people together across organizational boundaries and also levels in the interorganizational structure. For example, system managers and front-line providers could be brought together to voice their problems and perspectives and listen to each other. Interorganizational system culture should not be neglected.
SUMMARY The implementation of innovative mental health systems opens a variety of great opportunities to overcome traditionally resistant problems in the care of the seriously mentally ill. Yet managers and others in these systems need to pay attention to issues of setting goals, monitoring care, giving feedback, and promoting desirable interorganizational cultures.
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