Health Program Management From Development Through

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HEALTH PROGRAM
MANAGEMENT
FROM DEVELOPMENT THROUGH EVALUATION
Second Edition

Beaufort B. Longest, Jr.

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Copyright  2015 by Beaufort B. Longest, Jr. All rights reserved.

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Library of Congress Cataloging-in-Publication Data

Longest, Beaufort B., Jr., author.

[Managing health programs and projects]
Health program management: from development through evaluation/Beaufort B. Longest,
Jr. – Second edition.
p.; cm.
Preceded by Managing health programs and projects/Beaufort B. Longest Jr. 1st ed. c2004.
Includes bibliographical references and index.
ISBN 978-1-118-83470-1 (pbk.) – ISBN 978-1-118-83463-3 (pdf) –
ISBN 978-1-118-83476-3 (epub)
I. Title.
[DNLM: 1. Health Planning–methods. 2. Health Services Administration. 3. Organizational Innovation.
4. Program Evaluation. 5. Total Quality Management. W 84.1]
RA427
610.68 ´5–dc23
2014015932

Printed in the United States of America

SECOND EDITION

PB Printing
10 9 8 7 6 5 4 3 2 1
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CONTENTS

List of Figures, Tables, and Exhibits . . . . . . . . . . . . . xi

Preface . . . . . . . . . . . . . . . . . . . . . . . . . xv
Acknowledgments . . . . . . . . . . . . . . . . . . . . xxi
The Author . . . . . . . . . . . . . . . . . . . . . . xxiii

Chapter 1 The Work of Managers in Health Programs . . . . . . . 1

Key Definitions . . . . . . . . . . . . . . . . . . . . . . .2
The Work of Program Managers in Terms of Core and Facilitative
Activities . . . . . . . . . . . . . . . . . . . . . . . . .7
Core Activities in Program Management Work . . . . . . . . .7
Facilitative Activities in Program Management Work . . . . . . 12
Roles Played by Program Managers: The Mintzberg Model . . . 17
Competencies That Underpin Program Management Work . . . 20
Managing Health Programs Ethically . . . . . . . . . . . . . 24
Managers and the Success of Programs . . . . . . . . . . . . 29

Appendix A: Example of a Health Program: The Global Health

Program of The Bill and Melinda Gates Foundation . . . . . . . 35

Appendix B: Example of a Health Project: The Mass General Care

Management Project . . . . . . . . . . . . . . . . . . . . 37

Chapter 2 Developing/Strategizing the Future . . . . . . . . . 39

Developing the Underlying Theory of a Program . . . . . . . . 40
Using Program Theory and Logic Models in Establishing and
Maintaining Effective Stakeholder Relationships . . . . . . . 42
Developing/Strategizing Activity . . . . . . . . . . . . . . . 44
Situational Analysis: Determining a Program’s Current Situation . 45
Reconsidering and Revising a Program’s Current Situation . . . . 54
Assessing and Controlling Performance to Achieve
Desired Results . . . . . . . . . . . . . . . . . . . . . 59
The Link between Developing/Strategizing and the Performance
of Programs . . . . . . . . . . . . . . . . . . . . . . . 66
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viii CONTENTS

Writing a Business Plan . . . . . . . . . . . . . . . . . . 67

Planning for Interventions Undertaken by Programs . . . . . . 69

Chapter 3 Designing For Effectiveness . . . . . . . . . . . . 81

Creating Organization Designs . . . . . . . . . . . . . . . 82
Key Concepts in Formal Organization Design . . . . . . . . . 83
Application of the Key Organization Design Concepts . . . . . 99
Informal Aspects of Organization Designs . . . . . . . . . . 102
Designing Program Logic Models . . . . . . . . . . . . . . 107
The Staffing Process in Health Programs . . . . . . . . . . . 109

Chapter 4 Leading to Accomplish Desired Results . . . . . . . 119

Leading Defined . . . . . . . . . . . . . . . . . . . . . 120
Influence and Leading; Interpersonal Power and Influence . . . . 121
Motivation as a Basis for Leading Effectively . . . . . . . . . . 123
The Ongoing Search to Understand Effective Leading . . . . . . 139
Toward an Integrative Approach to Effective Leading
in Health Programs . . . . . . . . . . . . . . . . . . . 151

Chapter 5 Making Good Management Decisions . . . . . . . . 161

Decision Making Defined . . . . . . . . . . . . . . . . . . 162
Involving Other Program Participants in Decision
Making . . . . . . . . . . . . . . . . . . . . . . . . . 163
Key Characteristics of Management Decisions and Decision
Making in Programs . . . . . . . . . . . . . . . . . . . 166
The Decision-Making Process . . . . . . . . . . . . . . . . 168

Chapter 6 Communicating for Understanding . . . . . . . . . 203

Communicating: Key to Effective Stakeholder Relations . . . . . 204
A Model of the Communication Process . . . . . . . . . . . 208
Barriers to Communicating Effectively . . . . . . . . . . . . 211
Communicating within Programs . . . . . . . . . . . . . . 217
Communicating with External Stakeholders . . . . . . . . . . 222
Communicating When Something Goes Wrong . . . . . . . . 226

Chapter 7 Managing Quality—Totally . . . . . . . . . . . . . 237

Quality Defined . . . . . . . . . . . . . . . . . . . . . . 239
Measuring Quality . . . . . . . . . . . . . . . . . . . . 241
Managing Quality . . . . . . . . . . . . . . . . . . . . . 242
A Total Quality Approach to Managing Quality . . . . . . . . 243
Patient/Customer Focus . . . . . . . . . . . . . . . . . . 244
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CONTENTS ix

Continuous Improvement . . . . . . . . . . . . . . . . . 245

Teamwork . . . . . . . . . . . . . . . . . . . . . . . . 254

Chapter 8 Commercial and Social Marketing . . . . . . . . . . 269

Commercial Marketing . . . . . . . . . . . . . . . . . . 270
Social Marketing . . . . . . . . . . . . . . . . . . . . . 270
Commercial Marketing in Health Programs . . . . . . . . . . 271
The Five Ps of Commercial Marketing . . . . . . . . . . . . 276
Social Marketing in Health Programs . . . . . . . . . . . . . 288
Conducting Social Marketing Initiatives in Health Programs . . . 289
Ensuring the Success of Social Marketing Initiatives . . . . . . 294
Ethics Considerations in Commercial and Social Marketing
Strategies . . . . . . . . . . . . . . . . . . . . . . . . 295

Appendix C: A Step-by-Step Social Marketing Process . . . . . . 303

Chapter 9 Evaluating . . . . . . . . . . . . . . . . . . . . 309

Program Evaluation Defined . . . . . . . . . . . . . . . . 310
What Do Program Managers Evaluate? . . . . . . . . . . . . 311
Program Theory and Logic Models . . . . . . . . . . . . . 312
Types of Program Evaluations . . . . . . . . . . . . . . . . 316
The CDC Framework for Conducting Program Evaluations . . . 318
Standards in the CDC Evaluation Framework . . . . . . . . . 319
Steps in the CDC Evaluation Framework . . . . . . . . . . . 320

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . 341
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LIST OF FIGURES, TABLES, AND EXHIBITS

Figures
Figure 1.1 An Organization Design Depicting a Program
Embedded in a Host Health Services Organization . . 4
Figure 1.2 A Project’s Life Cycle . . . . . . . . . . . . . 5
Figure 1.3 Model of the Core Activities in Program
Management Work . . . . . . . . . . . . . . 8
Figure 1.4 Model of the Core and Facilitative Activities in
Program Management Work . . . . . . . . . . 13
Figure 1.5 The Manager’s Roles . . . . . . . . . . . . . 18
Figure 1.6 Relative Mixes of Competencies Needed for Effective
Management Work in a Large Program . . . . . . 24
Figure 2.1 Logic Model of a Program . . . . . . . . . . . 41
Figure 2.2 Control of Performance in an HIV Screening
Program’s Laboratory . . . . . . . . . . . . . 60
Figure 2.3 Model of Interventional Planning . . . . . . . . 71
Figure 3.1 Hierarchy of Organization Design . . . . . . . . 82
Figure 3.2 Contrasting Spans of Control . . . . . . . . . . 92
Figure 3.3 Simplified Organization Design of a Functionally
Organized Health Services Organization . . . . . . 99
Figure 3.4 Simplified Organization Design of a Functionally
Organized Program . . . . . . . . . . . . . 100
Figure 3.5 Programmized Organization Design . . . . . . 101
Figure 3.6 Matrix Organization Design . . . . . . . . . . 101
Figure 3.7 A Contact Chart . . . . . . . . . . . . . . 103
Figure 3.8 Informal Group Structure . . . . . . . . . . 105
Figure 3.9 The Staffing Process . . . . . . . . . . . . . 110
Figure 4.1 The Motivation Process for an Individual . . . . 125
Figure 4.2 Comparison of the Content and Process
Perspectives on Motivation . . . . . . . . . . 127
Figure 4.3 Maslow’s Hierarchy of Needs . . . . . . . . . 128
Figure 4.4 Basic Model of Expectancy Theory . . . . . . . 133
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xii LIST OF FIGURES, TABLES, AND EXHIBITS

Figure 4.5 Comparing Three Approaches to Understanding

Effective Leading . . . . . . . . . . . . . . 140
Figure 5.1 Vroom’s Decision Model . . . . . . . . . . . 165
Figure 5.2 The Decision-Making Process . . . . . . . . . 169
Figure 5.3 Fishbone Diagram of Possible Causes of
Nosocomial Pneumonia . . . . . . . . . . . 172
Figure 5.4 Pareto Chart of Causes of Nosocomial Pneumonia . 173
Figure 5.5 Decision Grid for the Possible Addition of a
Satellite Clinic in a Program . . . . . . . . . 179
Figure 5.6 Payoff Table for Ordering Syringes . . . . . . . 180
Figure 5.7 Decision Tree for Automation or Overtime Pay . . 182
Figure 5.8 PERT Network for the Development of an
Open-Heart Surgery Program . . . . . . . . . 186
Figure 5.9 Beta Curve for Optimistic, Most Likely, and
Pessimistic Time Estimates for Activities in
Developing the Open-Heart Surgery Program . . . 187
Figure 5.10 Conceptual Model of a Decision Support
System . . . . . . . . . . . . . . . . . . 189
Figure 5.11 Lewin’s Three Steps in Implementing
Changes Resulting from a Decision . . . . . . . 197
Figure 6.1 Prototype of an External Stakeholder Map
for Health Programs . . . . . . . . . . . . . 205
Figure 6.2 Typical Relationships between a Program
and Its Stakeholders . . . . . . . . . . . . . 205
Figure 6.3 A Model of the Communication Process . . . . 209
Figure 6.4 Communication Flows in a Program . . . . . . 218
Figure 6.5 Common Types of Communication Networks in
Programs . . . . . . . . . . . . . . . . . 220
Figure 6.6 “A” Frame for Advocacy . . . . . . . . . . . 227
Figure 6.7 Types of Errors in Clinical Settings . . . . . . . 228
Figure 6.8 Continuum of Management Responses When
Something Goes Wrong . . . . . . . . . . . 231
Figure 7.1 What Patients/Customers Should Expect of Health
Services . . . . . . . . . . . . . . . . . . 238
Figure 7.2 Components of a TQ Approach to Managing
Quality . . . . . . . . . . . . . . . . . . 243
Figure 7.3 FOCUS-PDCA Model . . . . . . . . . . . . 248
Figure 7.4 Pre-Intervention Flowchart of the Patient
Care Process. . . . . . . . . . . . . . . . 251
Figure 7.5 Generalized Cause-and-Effect (Fishbone)
Diagram . . . . . . . . . . . . . . . . . 253
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LIST OF FIGURES, TABLES, AND EXHIBITS xiii

Figure 7.6 Run Chart of an Intervention to Shorten

Wait Times . . . . . . . . . . . . . . . . 254
Figure 7.7 Key Determinants of Team Effectiveness . . . . 256
Figure 7.8 Model of the Problem-Solving Process for
Improvement Teams . . . . . . . . . . . . 260
Figure 8.1 Elements of a Commercial Marketing Strategy . . 277
Figure 8.2 Phases of the Social Marketing Assessment
and Response Tool . . . . . . . . . . . . . 290
Figure 8.3 Main Components of a Social Marketing Plan . . 291
Figure 9.1 Evaluating Walk a Mile for Health without
a Program Theory . . . . . . . . . . . . . 313
Figure 9.2 Evaluating Walk a Mile for Health with a
Program Theory . . . . . . . . . . . . . . 314
Figure 9.3 CDC Framework for Program Evaluation . . . . 319
Figure 9.4 Checklist for Gathering Credible Evidence . . . . 331
Figure 9.5 Justifying Conclusions and Making
Recommendations in a Program Evaluation . . . 331
Figure 9.6 Outline of a Program Evaluation Report . . . . . 336

Tables
Table 8.1 Examples of Patient/Customer Market Segments . 274
Table 9.1 Options for Evaluating Commercial or
Social Marketing Activities in Programs . . . . . 328

Exhibits
Exhibit 2.1 A Program’s Operating Budget for Year X . . . . . 63
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PREFACE

T his book is about managing health programs. Effective management of

programs is important because these are mechanisms through which a
great many health services are organized and provided in both the public
health and health care sectors. I provide information drawn from manage-
ment research to assist you in developing a comprehensive approach to the
practice of management in health programs. A focused reader will take away
a solid overview of the current best practices in management that apply to
managing health programs.
Health programs target any of the determinants of health. They can
focus on some aspect of the physical environments in which people live and
work, on human behavior, on biology, on the social factors that affect
people, or on the health services offered to them. There is therefore a broad
array of health programs. For example, at the prevention end of the health
services spectrum, people receive information about safe sex practices or
how to eat healthier in the context of health education programs. At the
advanced acute care end of the spectrum of services, people receive kidney
transplants within the context of transplant programs.
A persistent, decades-long trend has created ever larger and more
elaborate structures that organize, deliver, and finance health services
throughout the industrialized world. Current manifestations of this phe-
nomenon can be seen in major public health agencies, such as the
California Department of Public Health (www.cdph.ca.gov), or large
health services organizations, such as the Massachusetts General Hospital
(www.massgeneral.org). Within these large and complex structures, how-
ever, health services are provided directly through relatively small units
called programs.
A substantial literature exists pertaining to the management of large
and complex public- and private-sector health agencies, organizations, and
systems. I have contributed to this literature myself. Nevertheless, there is a
relative paucity of literature about managing at the level of health programs,
where so much of the direct delivery of health services occurs. With this
book, I seek to partially address this imbalance.

xv
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xvi PREFACE

The intended audience for this book includes students in public health,
in health services management, and in a wide variety of health professions
who want to prepare themselves for the challenges of managing health
programs. Even those who aspire to leadership positions in large agencies,
organizations, and systems may begin their management career at the level
of programs. The book will also be useful for those who already occupy a
program management position, because it comprehensively and systemati-
cally presents current information about management.
Programs are defined in this book as organizational units intended to
accomplish one or more objectives through a plan of action that describes
what work is to be done, by whom, when, and how, as well as what resources
will be used. Programs are embedded in organizations and should be of
benefit to the larger host organization. Program management is defined as
the activities through which the mission and objectives of a program are
established and pursued by means of various processes using human and
other resources.
As a way of organizing the discussion of program management, and to
give a sense of the structure of the book itself, I present in Chapter 1 a model of
the activities managers engage in as they manage programs. These activities
are divided into two sets: core activities and facilitative activities. All health
program managers engage in three core activities as they perform manage-
ment work: developing/strategizing, designing, and leading. In addition,
managers also engage in other activities that facilitate and support the
accomplishment of a program’s mission and objectives. Program managers
engage extensively in such facilitative activities as decision making and
communicating as they carry out their management work. Increasingly,
they also engage in managing quality, marketing, and evaluating. Individual
chapters of the book are devoted to each of these activities, presenting in-
depth information about each of them. A brief précis of each chapter follows.
Chapter 1, “The Work of Managers in Health Programs,” contains key
definitions and a background discussion of programs and program man-
agement. The work of managers is considered in terms of the core activities
in which all managers engage as they do management work: developing/
strategizing, designing, and leading. Consideration of this work is extended
to include managers’ facilitative activities: decision making, communicating,
managing quality, marketing, and evaluating. The entire set of core and
facilitative activities in management work is modeled graphically in Fig-
ure 1.4. This figure is the chapter’s centerpiece, depicting the core and
facilitative activities of management work as an integrated and interactive
set of activities. There is also a discussion of the roles played by managers
and the competencies necessary to manage health programs well.