Sm. Sri. & Med.. Vol. IO. pp
317 to 322. Pergamon
Press 1976. Printed
in Great Britatn.
ORGANIZATIONAL INFLUENCES TO HEALTH CARE*
ON ACCESS
JAMESR. GREJWLEY University of Wisconsin. Madison, Wisconsin, U.S.A. and STUARTKIRK University of Kentucky, Lexington, Kentucky, U.S.A. Ahstrac-This
paper argues that organization-environment relations in health and related fields have a significant impact on patterns of referral and rejection. Two separate areas of research. i.e. basic research on organization-environment relations and research on two aspects of access to health care (referrals and rejections) are reviewed and integrated. Within an exchange framework propositions are developed concerning organizational resources, autonomy, and domain consensus. Finally, it is suggested that organization-environment relations and organizational structures influence the production of treated rates of various personal problems, rates which are often used in research as well _ as in program and policy decisions. INTRODUCIION
It is increasingly recognized that some problems with medical care services are not failures of the service technology but of the organization of the delivery system. A major concern in this area has beeh with the access patients have to care. A review of available research shows that over 50 per cent of people who approach health and social agencies for service fail to receive services or are ineffectively referred elsewhere for help [l]. Concern about this apparent inaccessibility of services has been expressed in discussions of continuity of care [2], coordination of service [3], lack of an “open door” [4], matching the multi-problemed individual to the right service, overlapping and duplicating services [S], lack of accountability and responsibility [6], and gaps in service [7]. Physicians and other professionals report difficulties in referring patients out [S] and have been observed to be reluctant to make good evaluations and referrals [9]. As a result the most difficult cases often get referred to those organizations with the fewest resources and least expertise to deal with them [lo]. Improving access by minimizing the number of applicants who fail to receive service and the number of inappropriate referrals has been a goal of several innovative programs. Some of these programs have suffered because they presupposed that applicants are referred or rejected solely on the basis of their characteristics and how these characteristics related to the service supplied. However, organizational characteristics, apart from the characteristics of their applicants, probably have a major and. systematic impact on rejection and referral patterns.
*This project was funded in part by the Graduate School Research Committee. University of Wisconsin, Madison. The authors wish to thank Jerald Hage, Michael Aiken, Richard Schoenherr. and Sianley Wenocur for helpful comments on earlier drafts of this paper. A version of this paper was presented at the annual meeting of The Society for the Study of Social Problems in San Francisco, August. 1975. 317
The available research on this point is fragmented and not conceptually integrated with basic research in organizational behavior. Our purpose is to advance such an integration in order to generate new ideas and propositions, to facilitate linking diverse literatures in the general medical, psychiatric, rehabilitation, and other health related areas, to develop understandings which span various types of service delivery organizations such as outpatient clinics, general hospitals, sheltered workshops, and related social service agencies, and to suggest strategies which health care planners and administrators can use to think about and act on access problems. We wish furthermore, to stimulate research on how organizational factors may influence access to services through providing new theoretical propositions. Thus this paper will first place referrals and rejections witbin existing conceptualizations of organization-environment relations. Second, it will use existing knowledge in medical, psychiatric, rehabilitation, counseling and associatedareas to develop some propositions about applicant rejection and referral patterns. Finally, a model of referral flow among agencies will be briefly described CONCEPTUALIZING THE ORGANIZATIONENVIRONMENT SYSI-EM
In order to understand the support for and limitations of the propositions developed below, we must carefully review conceptualizations of referrals and rejections as organization phenomena. Increasingly organizations are conceptualized as open rather than closed systems and interest has consequently turned toward the relationship of an organization and its environment [ll] where much of the concern has been with organizational coordination, joint programs, and mergers. Yet while patient referrals are among the most numerous of all organization-environment transactions in the health field, and while referrals and rejections have the most direct impact on the patient. referrals and rejections have rarely
318
JAMESR. GREENLEY and STUARTKIRK
been studied from the organizational perspective, except for pioneering studies by Levine and White [12] and by Hasenfeld [13]. This has occurred because practitioners in the health and welfare area, in an attempt to explain rejections and referrals, have traditionally focused on the social and psychological characteristics of patients rather than on organizational characteristics. Only a few studies such as those by Cumming [14] and Levine and White [lS] adopt the organization as the unit of analysis. Referrals and rejections can be usefully conceptualized within an exchange framework. Many students of organization-environment relationships employ an exchange mode& viewing organizations as importconversiorrexport systems exchanging inputs and outputs with their environments [ 161. Organizations are linked to their environments, especially to other organizations, through various mechanisms of exchange. They can exchange money, personneZ volunteer services, equipment, social roles, and information [17]. Applicants to organizations can be the objects exchanged when an applicant is referred from one service to another [lS] or applicants can themselves exchange objects, such as money, with a provider giving them service [19]. Exchange theory as developed by Blau [20], Homans [21], and Thibaut and Kelley [22] con&s general assumptions which are adopted in this conIn particular, interactions or ceptualization. exchanges between groups and/or individuals are seen as more likely to occur when the outcome of the interaction, rewards minus costs of the interaction, are experienced as more positive in light of the particivalues, and alternatives. pant’s expectations, Exchange theory accepts that organizations as well as individuals may be the units interacting, even though organizations, like individuals, cannot always be assumed to be consistent, rational, or purposeful. While exchange theory has admittedly drawn considerable criticism, it provides a question around which a diverse literature can be organized: what organizational conditions result in referrals and rejections being experienced as positive outcomes and therefore being repeated? Exchanges of applicants may usefully be distinguished from other organizational exchanges in terms of intensity, level, and type. Several levels of intensity of organization-environment involvement have been suggested by Johns and DeMarche, ranging from informal exchange of information to organizational merger [23]. Typically, merger, joint programs, and other interactions which involve commitments of personnel or space, are felt to be intense forms of interaction, having a relatively great impact on the organization [24]. Although applicant populations are of major importance to health and social service organizations, the exchange of applicants through referral is usually considered an organizational involvement of less intensity [25]. Possibly the most important difference between referrals or rejections and some other types of organization-environment relationships concerns the level in the organizational structure at which the organization is interacting with its environment. Of the many levels in a complex organization, two have been dealt with repeatedly, i.e. the administrative (executive and
managerial level) and the operative (point of direct contact with the public) levels. Most of the relevant organization-environment literature concerns interorganizational activities at the administrative level while referrals and rejections typically occur at the operative level, although influenced by administrative decisions. Hence application of much of the existing organizational literature to referrals and rejections will have to be made cautiously. Various types of organization-environment relationships have been noted, suggesting differentiations along other dimensions. Guetzkow distinguishes interaction at the organizational boundary from interpenetration of that boundary and from relationships through a superorganization [26]. The degree of agency freedom to choose a certain relationship is emphasized in Warren’s continuum of relationships ranging from purely voluntary (‘social choice’) to involuntary (‘unitary’) [27]. Competition, bargaining, cooperation, and coalition are four types of relationships described by Thompson and McEwen [ZS]. In terms of the above distinctions, referrals and rejections have been generally described as voluntary [29], cooperative [30], and occurring at organizational boundaries [31]. In sum, agencies are viewed here as open systems engaging in an exchange process with their environments. Organizational exchanges around applicants seeking help are clearly one subset of all possible organization-environment interactions. Referrals and rejections, as organization-environment phenomena, can be generally distinguished as moderately intense. largely voluntary, of a cooperative nature, at the organization’s boundaries, and at the operative level.
REJECTION
OR ACCEPTANCE
The organizational literature suggests that organizations interact and exchange more frequently with their environments when this is likely to increase their resources. Organizations may refuse to cooperate when they perceive cooperation threatening their ability to obtain resources [32]. Patients are themselves resources which health care organizations need [33]. As Levine et al. observe, patients and clients also “help to demonstrate to board members, the general community, and other legitimizing bodies the value and demand for the services of the agency. In bargaining for support to expand its domain or add specialized personnel to its roster, an agency’s case is strengthened if it can point to an impressive waiting list” [34]. Patients and clients are thus recognized as sources of a range of needed resources. as has also beerr observed in a variety of service organizations including alcoholic treatment centers [35], blindness agencies [36], agencies serving the elderly [37], and family planning organizations [38]. At times patients are rejected because they may cost the organization more resources than they represent. In serving patients, physicians and other professionals clearly use up time, occupy facilities, and often expend other resources. Furthermore, certain types of patients can drain staff morale and threaten the organization’s image on which its prestige, legitimacy, and even funding may depend. Scott. for
Organizational
influences on access to health care
describes how blindness agencies “search for and retain clients who fit the public image of the blindness population” as young and employable because the agencies’ successful fund-raising campaigns depend on guilt inducing stereotypes of the rehabilitatable blind and suffer when the agencies’ clientele come to be viewed as old, unemployable, and ineducable [39]. Similarly, an official state rehabilitation organization is described as frustrating other community agencies by its refusal to accept referrals of certain difficult-to-rehabilitate clients. The state agency responsible for funding the rehabilitation organization evaluates its effort largely in terms of the number of successfully rehabilitated clients, so the rehabilitation organization is “reluctant to commit its limited personnel and resources to the lengthy and time-consuming task of attempting the rehabilitation of what seems to be very poor risks” [40]. Thus applicants or patients may also be rejected if they are not viewed as “good risks” for recovery or rehabilitation, and thus are less promising sources of future staff, facilitieg or money. The above observations lead us to predict that the more the organization’s members view patients as resources the greater proportion of patients they will accept for service (see Fig. 1 for a summary of the propositions). A number of factors may be used as indicators of the value of patients to the organization: the degree to which organizational funding or growth is or is perceived to be dependent on the numbers of patients served (patients as sources of financial sup port); the degree to which primary service staff desire new patients; and the extent to which recruiting of new personnel is believed to be dependent on obtaining more patients (patients as sources of non-financial resources). In general, members of organizations act to maximize their organization’s autonomy [41], and this desire for organizational autonomy is often identified example
1.
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Fig. 1. Summary of propositions.
agree-
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the
319
as a major impediment to interorganizational cooperation [42]. Elling, for example describes how a community hospital withdrew from participation in a community-wide hospital improvement plan because the hospital’s board of directors did not wish to sacrifice the hospital’s identity and autonomy in a proposed merger with two other hospitals [43]. This type of organizational behavior is also documented in studies of a community coordinating council [44] and community-wide hospital planning committees [45]. These are largely cases of reluctance to surrender any of the organization’s authority to a council or committee, to supraorganization~ or through cooperation with another agency. Autonomy is inadequately defined in each of these studies but it appears to mean freedom of the organization to make relatively major decisions on its own. In certain circumstances agencies may fear losing autonomy directly to applicants it services (or refuses to service), if, for example, these patients, clients, and others are organized under the banner of “consumer power” or community control. Also, agencies may stand to lose autonomy to other groups or formal organizations by accepting or rejecting certain types of applicants. For example, non-professional blindness agency workers have been observed to favor accepting more compliant and dependent clients in an attempt to preserve their agency’s autonomy and thus shield themselves from forces advocating the professionalization of blindness workers [46]. Defined slightly differently, organizational autonomy may be even a more important variable in explaining acceptance or rejection of applicants. Autonomy may be seen as the ability of the organization to function internally without concern for changes in its external environment Organizations buffer, level, forecast and then ration in attempts to deal with environmental fluctuations [47]. These maneuvers resemble a health service varying its acceptance rates to conform with available personnel. For example, in two university psychiatric clinics known to the authors, the probability of an applicant being accepted for service is high in summer when student applicants are scarce and new psychiatric residents are seeking patients, while in spring under opposite conditions the same applicant would be less likely to receive service. This suggests that applicants will be accepted or rejected at rates most likely to enhance. the organization’s independence from its environment. The second proposition (see Fig. l), therefore, is that the more patients are a source of autonomy to an organization the more likely patients will be accepted for service. The impact of the acceptance of certain numbers and types of applicants on the internal functioning of the organization is felt directly and immediately by the primary service staff of most health and social service organizations. An organization’s members are often quite well informed about effects applicant acceptance patterns can have on the organization’s future. For example, state and federal guidelines often require that certain types of patients or clients defined by age, income status, problem type and so forth be the preferred targets for services. Failure to service such patients may not only jeopardize future resources, but could result in reduced
JAMESR. GREENLEYand STUART KIRK
320
autonomy if external agencies are required to closely monitor the service organization. REFERRALS
A referral is an exchange between an organization and a. patient as well as an interorganizational exchange. Referrals can be usefully examined both as organization-patient and interorganizational exchanges. Referrals as organization-patient exchange
The literature reviewed above on organizationenvironment relationships is probably as applicable to referral decisions as to decisions to give and withhold service. This literature suggests that organizations may be more likely to refer when this gains them the most resources or causes them to lose the least (see Proposition No. 3, Fig. 1). A referral’s value may be measured in financial terms (including the costs of space and staff time) and in terms of staff perceptions of the value of referrals as compared to other organizational services. In some organizations. referrals are generally seen as an inevitable by-product of the applicant screening process. In other organizations, such as the “referral” or “coordination” Senior Citizens Center described by Chin and O’Brien [48], referrals may be defined as one of the major services the organization supplies, if not the core service itself. In these latter organizations, the perceived if not actual costs of referral may be lower. Primary service staff may not feel referrals to be a burden or diversion from “the real work” of the organization, possibly because the organization contains job definitions or “boundary roles” which institutionalize a system of formal and informal rewards for the performance of referrals. The referring professionals in these organizations are also more likely to have developed personal or professional ties with members of potential receiving agencies, making referrals less costly in terms of time, effort and probability of failure. Suggested indicators of the costs of referrals to an organization thus might include: financial drain (actual costs of referring plus the lost resources which would have occurred from performing other functions); loss of staff morale and satisfaction; and lack of organizational recognition of referral as a high priority function. Referrals us interorganizational exchange
Organizations are thought to interact in exchange relationships when this can effectively increase their resources. Cooperation on referral is one way organizations may pool and therefore increase available resources [49]. A referral can be the means by which an agency can divest itself of a patient who is an uncompensated drain on its resources, and through exchange may obtain patients of more value to it than those referred away. While conflict over scarce resources may undermine ,cooperation [SO]. applicants to health and welfare agencies are usually not a scarce resource, and thus interorganizational referral does not parallel conventional competition over government grants or “Community Chest” charity funds. The need for patients probably results in conflict less frequently
than it does in modes of cooperation, such as referral. designed to deal with excess or inappropriate applicants. Proposition No. 4 suggests that organizations will be more likely to make referrals to those organizations which view patients as a resource. since these are the organizations more likely to accept the referral (Proposition No. 1). thereby minimizing the costs of referral for the referring organization. Organizational desire for autonomy, defined as the organization’s freedom to make relatively major decisions without the consent of other organizations, is often viewed as an impediment .to interorganizational cooperation, but no careful research links it to the referral of applicants. More important for referrals is an organization’s degree of autonomy cis-&cis applicant demands relative to the autonomy of other organizations. An organization may be under laws, regulations, or other constraints which force it to accept certain clients and reject others, i.e. the organization has less autonomy in this area. Applicants referred to that organization, providing they meet certain criteria, must be accepted even when other factors, e.g. very poor prognosis, suggest that acceptance may create difficulties for the organization. As a consequence, in an outpatient psychiatric clinic observed by the authors, intake personnel preferred to refer certain difficult applicants to a state psychiatric agency which was required to accept them. By referring to this agency, the job of referral was made considerably easier and the overall costs to the referring organization were minimized. Thus, Proposition No. 5 predicts that organizations will be more likely to make referrals to organizations which have less autonomy relative to other possible referral targets. Exchange between organizations has been seen as dependent on the knowledge of and agreement on organizational missions. Levine and White argue that agreement on populations served, diseases covered, and services rendered, i.e. “domain consensus”, is a voluntary exchange [S]. prerequisite to any Researchers in the area of delinquency prevention [52], organizational behavior in disasters [53] and cotinnunity nursing services [54] have described organizations which failed to refer to each other because they lacked understanding of or agreement on the other organization’s job. Knowledge of the existence of other organizations in the health and welfare network has been found to be surprisingly limited; leaders of organizations in one community knew of only 40-50 per cent of the other organizations [SS]. This suggests that knowledge of or agreement on organizational missions is likely to be an important variable in explaining referral patterns. Proposition No. 6 concerns the agreement which organizations have concerning the populations they serve, the diseases (or problems) covered and the services rendered. It suggests that this agreement, called “domain consensus” by Levine and White [56], is positively associated with the successful exchange of applicants. Unlike Levine and White’s contention, our proposition does not assert that domain consensus is necessary for exchange to occur, but only that consensus facilitates exchanges. Certainly some referrals may occur even when there are low levels of knowledge and consensus among organizations. For example. the authors have reported “mental hospital
Organizational
influences on access to health care
staff members entirely misunderstanding the domain of a ‘homemakers’ service, but nevertheless referring applicants there. And the staff of the homemakers service, after talking to the applicant, sometimes offered their help to the applicant for problems not even perceived by the personnel at the hospital” [57]. Yet the proportion of such referrals accepted at the target organization may be relatively low since many of the referrals are likely to be inappropriate and rejected. Domain consensus may be measured in terms of the degree of an organization’s members’ awareness of the existence and functions of another organization. The less knowledge and agreement about functions that is expressed, the less would be the domain consensus, and the fewer the successful referrals. A MODEL
OF REFERRAL
FLOW
Propositions Nos. l-5 suggest the presence of an overall model of referral patterns. The flow of referrals will tend to be from organizations which place less value on patients to organizations which place more value on patients (Proposition No. 1 implies that organizations which do not value patients will tend to reject and’refer a greater proportion of applicants, and Proposition No. 4 suggests the destination of these referrals). At the same time, referrals will tend to flow toward organizations with little autonomy (Proposition No. 5). Thus organizations placing little value on patients and who are relatively autonomous will refer more applicants than they receive through referral channels. Organizations with little autonomy which highly value patients will become good targets for referrals. The less autonomous organization which does not value patients will direct referrals to organizations which value patients more. Organizations with little autonomy in terms of acceptance criteria but which highly value patients may nevertheless have to make some referrals to more autonomous organizations which value patients. Finally, organizations which place little value on patients, but which have relatively little autonomy, may find themselves the recipients of referrals. Proposition No. 6 suggests a further refinement which could be made within this basic pattern. DISCUSSION
Access to health and related human services has become a major issue among program planners and Autonomy
of
the Oraontzotion
Value of Client 0s Resource to the Oraonizotion Hiah
Low
lrml ‘U
Low ‘Major Minor
Flow Potterns Flow Patterns
-
Fig. 2. Joint effect of organizational autonomy and patients as resources on overall flow of referrals”.
321
administrators and numerous attempts have been made to address access problems. Nevertheless, access problems have not been well understood or effectively remedied. Research on referral and rejection patterns has been limited and fragmented by the lack of theoretical propositions to guide such inquiry. Particularly neglected has been the role of organizational factors in generating differential patterns of service accessibility. This paper has reviewed and organized existing research and theory on this topic to illuminate the possible interaction of several selected organization variables. In our derivation of propositions, it has not been possible to develop several complex issues. The systemic features of the health and related services have been largely neglected, the significance of patient characteristics under certain circumstances, e.g. life and death emergencies, has been largely ignored, and the handling of multi-problemed patients and simultaneous multi-organization involvement with one patient has not been treated. Nevertheless, the framework which has been developed may provide suggestions for the treatment of these additional problems. Perhaps the major implication of this analysis concerns the utilization patterns of health and social services. Such patterns are often used to determine community health needs and the extent of public knowledge concerning a given health probfem and are thus influential in the development of new programs or the expansion of existing ones. Sometimes utilization rates are used as indicators of the true incidence or true prevalence rates of particular problems. Rates based on utilization patterns are incorporated into etiological theories, are often the bases for funding requests, and are the rates of most concern to state and federal budget makers. Yet, these treated incidence and prevalence rates are, in part, products of organizational factors rather than indicators of any true rates of a particular problem in the community. For example, if an alcoholic treatment center finds that patients become of greater value to the center (e.g. when the government increases its per case financial support), the center may respond by soliciting and servicing more applicants. This change would be reflected in the treated rates of alcoholism in that community. Scott, for instance, implies that the rate of blindness in the United States is artificially inflated because blindness agencies place a high value on getting clients [SS]. Changing the utilization patterns for health services’may require altering the manner in which service organizations view applicants and interact with other agencies. REFERENCES 1.
Kirk S. A. and Greenley J. R. Denying or delivering
service? Social Work 19, 439. 1974. 2. Black B. J. and Krause H. M. Inter-agency cooperation in rehabilitation and mental health. Sot. Set-rice Rec. 37, 26. 1963. 3. Barth E. A. The causes and consequences of interagency conflict. Social. 1nquir.l 33, 51. 1963. 4. Cumming E. The issues affecting partnerships among mental health agencies. Hospital & Communir~ Ps_vchiar. 22, 33. 1971. 5. Wilensky H. and Lebeaux C. N. Indusrrial Society and Social We&-e. The Free Press. New York, 1958.
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6. Kahn A. J. Planning Communit! Set-Dicesfor Children in Trouble. Columbia University Press, New York, 1963. 7. Strantz I. H. and Miller W. R. Development of interagency coordination in a program of-comprehensive medical care. Am. J. oubl. HIth 56. 785. 1966. 8. Levine S., White P. ‘E. and Paul ‘B. b. Community interorganizational problems in providing medical care and social services. Am. J. publ. Hlth 53, 1183, 1963. 9. Kahn A. J. op. cit. 10. Cumming E. Allocation of care to the mentally ill, American style. In Organizing for Communiry W&are (Edited by Zald M. N.) pp. 109-159. Quadrangle Books, Chicago, 1967. 11. Gouldner A. W. Organizational analysis. In Sociology Todav (Edited bv Merton R. K.. Broom L. and Cottrell L. S.-J;.) pp. 4db-428. Basic Books, New York, 1959. 12. Levine S. and White P. E. Exchange as a conceptual framework for the study of interorganizatibal relationships. Admin. Sci. Q. 5, 583, 1961. 13. Hasenfeld Y. People processing organizations: an exchange approach. Am. Social. Rev. 37, 256, 1972. 14. Cumming E. Systems of Social Regulation. Atherton, New York, 1968. 15. Levine S. and White P. E. op. cit. 16. Thompson J. D. Organizations and output transactions. Am. J. Social. 68, 309, 1962. 17. Thompson J. D. and Hawkes R. W. Disaster, community organization and administrative process. 1~ Man and Society in Disaster (Edited by Baker G. W. and Chapman D. W.) pp. 268-3000. Basic Books, New York, 1962; Levine S. and White P. E. op. cit. 18. Hasenfeld Y. op. cit. 19. Thompson J. fi. op. cit. 20. Blau P. M. Exchunoe and Power in Social Life. Wilev. _. New York, 1964. ” 21. Homans G. Social behavior as exchange. Am. J. Social. 63, 597, 1958. 22. Thibaut J. W. and Kelley H. H. The Social Psychology of Groups. Wiley, New York, 1959. 23. Johns R. and DeMarche D. F. Community Organization and Agency Responsibility. Association Press, New York, 1951. 24. White P. E. and Vlasak G. J. Interorganizational Research in Health. U.S. Department of Health, Education and Welfare, Washington, D.C., 1970. 25. Johns R. and DeMarche D. F. op. cit. 26. Guetzkow H. Relations among organizations. In Studies on Behavior in Organizations (Edited by Bowers R. V.) pp. 13-44. University of Georgia Press, Athens, Georgia, 1966. 27. Warren R. L. The interorganizational field as a focus for investigation. Admin. &i. Q. 12, 396. 1967. 28. Thompson J. D. and McEwen W. J. Organizational goals and environments: goal-setting as an interaction process. Am Social. Rev. 23, 23, 1958.
29. Levine S. and White P. E. op. cit. 30. Black B. J. and Krause H. M. op. cit.; Johns R. and DeMarche D. F. op. cit. 31. Thompson J. D. op. cit. 32. Thompson J. D., and Hawkes R. W. op. cir. pp. 294-296. 33. Levine S. and White P. E. op. cit. 34. Levine S., White P. D. and Paul 8. D. op. cir. p. 1189. 35. Rubington E. Organizational strains and key roles. Admin. Sci. Q. 9, 350, 1965.
36. Scott R. A. The Making of Blind Men: A Study of Adult Socialization. Russell Sage Foundation, New York, 1969. 37. Morris R. and Randall 0. A. Planning and organization of community services for the elderly. Social Work 10, 96, 1965. 38. Fisher B. M. Claims and credibility: a discussion of occupational identity and the agent-client relationship. Sot. Probl. 16, 423, 1969. 39. Scott R. A. op. cit. p. 97. 40. Levine S., White P. E. and Paul B. D. op. cit. p. 1184. 41. Gouldner A. W. op. cit. 42. Barth E. A. op. cit. 43. Elling R. H. The hospital support game in urban center. In The Hospital in Modern Society (Edited by Freidson, E.) pp. 87-88. Free Press of Glencoe. London, 1963. 44. Mott B. J. F. Anatomy of a Coordinating Council. liniversity of Pittsburgh Press. Pittsburgh, Pennsylvania, 1968. 45. Wilkie C. V. and Notkin H. Community organization for health: a case study. In Patients, Physicians and Illness (Edited by Jaco E. G.) pp. 148-159. Free Press, Glencoe, Illinois, 1958. 46. Scott R. A. op. cit., pp. 101-104. 47. Thompson J. D. op. cir. 48. Chin R..and O’Brien G. M. St. L. General intersystem theory. In Systems and Medical Care (Edited by Sheldon A., Baker F. and McLaughlin C. P.) pp. 207-229. MlT Press, Cambridge, Massachusetts, 1970. 49. Black B. J. and Krause H. M. op. cit. 50. Barth E. A. op. cit. 51. Levine S. and White P. E. op. cit. 52. Hollister C. D. Interorganizational conflict: the case of policy youth bureaus and the juvenile court. Unpublished, 1970. 53. Barton A. H. Communities in Disaster. Doubleday, New York, 1969. 54. Ahla A. M. M. Refit-red by Visiting Nurse. Western Reserve University-Press. Cleveland, 1950. 55. Levine S.. White P. E. and Paul B. D. OD.cit. 56. Levine S.‘and White P. E. op. cit. ’ 57. Greenley J. R. and Kirk S. A. Organizational characteristics of agencies and the distribution of services to applicants. J. HIth & Sot. Behau. 14, 73. 1973. 58. Scott R. A. op. cit.
317 to 322. Pergamon
Press 1976. Printed
in Great Britatn.
ORGANIZATIONAL INFLUENCES TO HEALTH CARE*
ON ACCESS
JAMESR. GREJWLEY University of Wisconsin. Madison, Wisconsin, U.S.A. and STUARTKIRK University of Kentucky, Lexington, Kentucky, U.S.A. Ahstrac-This
paper argues that organization-environment relations in health and related fields have a significant impact on patterns of referral and rejection. Two separate areas of research. i.e. basic research on organization-environment relations and research on two aspects of access to health care (referrals and rejections) are reviewed and integrated. Within an exchange framework propositions are developed concerning organizational resources, autonomy, and domain consensus. Finally, it is suggested that organization-environment relations and organizational structures influence the production of treated rates of various personal problems, rates which are often used in research as well _ as in program and policy decisions. INTRODUCIION
It is increasingly recognized that some problems with medical care services are not failures of the service technology but of the organization of the delivery system. A major concern in this area has beeh with the access patients have to care. A review of available research shows that over 50 per cent of people who approach health and social agencies for service fail to receive services or are ineffectively referred elsewhere for help [l]. Concern about this apparent inaccessibility of services has been expressed in discussions of continuity of care [2], coordination of service [3], lack of an “open door” [4], matching the multi-problemed individual to the right service, overlapping and duplicating services [S], lack of accountability and responsibility [6], and gaps in service [7]. Physicians and other professionals report difficulties in referring patients out [S] and have been observed to be reluctant to make good evaluations and referrals [9]. As a result the most difficult cases often get referred to those organizations with the fewest resources and least expertise to deal with them [lo]. Improving access by minimizing the number of applicants who fail to receive service and the number of inappropriate referrals has been a goal of several innovative programs. Some of these programs have suffered because they presupposed that applicants are referred or rejected solely on the basis of their characteristics and how these characteristics related to the service supplied. However, organizational characteristics, apart from the characteristics of their applicants, probably have a major and. systematic impact on rejection and referral patterns.
*This project was funded in part by the Graduate School Research Committee. University of Wisconsin, Madison. The authors wish to thank Jerald Hage, Michael Aiken, Richard Schoenherr. and Sianley Wenocur for helpful comments on earlier drafts of this paper. A version of this paper was presented at the annual meeting of The Society for the Study of Social Problems in San Francisco, August. 1975. 317
The available research on this point is fragmented and not conceptually integrated with basic research in organizational behavior. Our purpose is to advance such an integration in order to generate new ideas and propositions, to facilitate linking diverse literatures in the general medical, psychiatric, rehabilitation, and other health related areas, to develop understandings which span various types of service delivery organizations such as outpatient clinics, general hospitals, sheltered workshops, and related social service agencies, and to suggest strategies which health care planners and administrators can use to think about and act on access problems. We wish furthermore, to stimulate research on how organizational factors may influence access to services through providing new theoretical propositions. Thus this paper will first place referrals and rejections witbin existing conceptualizations of organization-environment relations. Second, it will use existing knowledge in medical, psychiatric, rehabilitation, counseling and associatedareas to develop some propositions about applicant rejection and referral patterns. Finally, a model of referral flow among agencies will be briefly described CONCEPTUALIZING THE ORGANIZATIONENVIRONMENT SYSI-EM
In order to understand the support for and limitations of the propositions developed below, we must carefully review conceptualizations of referrals and rejections as organization phenomena. Increasingly organizations are conceptualized as open rather than closed systems and interest has consequently turned toward the relationship of an organization and its environment [ll] where much of the concern has been with organizational coordination, joint programs, and mergers. Yet while patient referrals are among the most numerous of all organization-environment transactions in the health field, and while referrals and rejections have the most direct impact on the patient. referrals and rejections have rarely
318
JAMESR. GREENLEY and STUARTKIRK
been studied from the organizational perspective, except for pioneering studies by Levine and White [12] and by Hasenfeld [13]. This has occurred because practitioners in the health and welfare area, in an attempt to explain rejections and referrals, have traditionally focused on the social and psychological characteristics of patients rather than on organizational characteristics. Only a few studies such as those by Cumming [14] and Levine and White [lS] adopt the organization as the unit of analysis. Referrals and rejections can be usefully conceptualized within an exchange framework. Many students of organization-environment relationships employ an exchange mode& viewing organizations as importconversiorrexport systems exchanging inputs and outputs with their environments [ 161. Organizations are linked to their environments, especially to other organizations, through various mechanisms of exchange. They can exchange money, personneZ volunteer services, equipment, social roles, and information [17]. Applicants to organizations can be the objects exchanged when an applicant is referred from one service to another [lS] or applicants can themselves exchange objects, such as money, with a provider giving them service [19]. Exchange theory as developed by Blau [20], Homans [21], and Thibaut and Kelley [22] con&s general assumptions which are adopted in this conIn particular, interactions or ceptualization. exchanges between groups and/or individuals are seen as more likely to occur when the outcome of the interaction, rewards minus costs of the interaction, are experienced as more positive in light of the particivalues, and alternatives. pant’s expectations, Exchange theory accepts that organizations as well as individuals may be the units interacting, even though organizations, like individuals, cannot always be assumed to be consistent, rational, or purposeful. While exchange theory has admittedly drawn considerable criticism, it provides a question around which a diverse literature can be organized: what organizational conditions result in referrals and rejections being experienced as positive outcomes and therefore being repeated? Exchanges of applicants may usefully be distinguished from other organizational exchanges in terms of intensity, level, and type. Several levels of intensity of organization-environment involvement have been suggested by Johns and DeMarche, ranging from informal exchange of information to organizational merger [23]. Typically, merger, joint programs, and other interactions which involve commitments of personnel or space, are felt to be intense forms of interaction, having a relatively great impact on the organization [24]. Although applicant populations are of major importance to health and social service organizations, the exchange of applicants through referral is usually considered an organizational involvement of less intensity [25]. Possibly the most important difference between referrals or rejections and some other types of organization-environment relationships concerns the level in the organizational structure at which the organization is interacting with its environment. Of the many levels in a complex organization, two have been dealt with repeatedly, i.e. the administrative (executive and
managerial level) and the operative (point of direct contact with the public) levels. Most of the relevant organization-environment literature concerns interorganizational activities at the administrative level while referrals and rejections typically occur at the operative level, although influenced by administrative decisions. Hence application of much of the existing organizational literature to referrals and rejections will have to be made cautiously. Various types of organization-environment relationships have been noted, suggesting differentiations along other dimensions. Guetzkow distinguishes interaction at the organizational boundary from interpenetration of that boundary and from relationships through a superorganization [26]. The degree of agency freedom to choose a certain relationship is emphasized in Warren’s continuum of relationships ranging from purely voluntary (‘social choice’) to involuntary (‘unitary’) [27]. Competition, bargaining, cooperation, and coalition are four types of relationships described by Thompson and McEwen [ZS]. In terms of the above distinctions, referrals and rejections have been generally described as voluntary [29], cooperative [30], and occurring at organizational boundaries [31]. In sum, agencies are viewed here as open systems engaging in an exchange process with their environments. Organizational exchanges around applicants seeking help are clearly one subset of all possible organization-environment interactions. Referrals and rejections, as organization-environment phenomena, can be generally distinguished as moderately intense. largely voluntary, of a cooperative nature, at the organization’s boundaries, and at the operative level.
REJECTION
OR ACCEPTANCE
The organizational literature suggests that organizations interact and exchange more frequently with their environments when this is likely to increase their resources. Organizations may refuse to cooperate when they perceive cooperation threatening their ability to obtain resources [32]. Patients are themselves resources which health care organizations need [33]. As Levine et al. observe, patients and clients also “help to demonstrate to board members, the general community, and other legitimizing bodies the value and demand for the services of the agency. In bargaining for support to expand its domain or add specialized personnel to its roster, an agency’s case is strengthened if it can point to an impressive waiting list” [34]. Patients and clients are thus recognized as sources of a range of needed resources. as has also beerr observed in a variety of service organizations including alcoholic treatment centers [35], blindness agencies [36], agencies serving the elderly [37], and family planning organizations [38]. At times patients are rejected because they may cost the organization more resources than they represent. In serving patients, physicians and other professionals clearly use up time, occupy facilities, and often expend other resources. Furthermore, certain types of patients can drain staff morale and threaten the organization’s image on which its prestige, legitimacy, and even funding may depend. Scott. for
Organizational
influences on access to health care
describes how blindness agencies “search for and retain clients who fit the public image of the blindness population” as young and employable because the agencies’ successful fund-raising campaigns depend on guilt inducing stereotypes of the rehabilitatable blind and suffer when the agencies’ clientele come to be viewed as old, unemployable, and ineducable [39]. Similarly, an official state rehabilitation organization is described as frustrating other community agencies by its refusal to accept referrals of certain difficult-to-rehabilitate clients. The state agency responsible for funding the rehabilitation organization evaluates its effort largely in terms of the number of successfully rehabilitated clients, so the rehabilitation organization is “reluctant to commit its limited personnel and resources to the lengthy and time-consuming task of attempting the rehabilitation of what seems to be very poor risks” [40]. Thus applicants or patients may also be rejected if they are not viewed as “good risks” for recovery or rehabilitation, and thus are less promising sources of future staff, facilitieg or money. The above observations lead us to predict that the more the organization’s members view patients as resources the greater proportion of patients they will accept for service (see Fig. 1 for a summary of the propositions). A number of factors may be used as indicators of the value of patients to the organization: the degree to which organizational funding or growth is or is perceived to be dependent on the numbers of patients served (patients as sources of financial sup port); the degree to which primary service staff desire new patients; and the extent to which recruiting of new personnel is believed to be dependent on obtaining more patients (patients as sources of non-financial resources). In general, members of organizations act to maximize their organization’s autonomy [41], and this desire for organizational autonomy is often identified example
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319
as a major impediment to interorganizational cooperation [42]. Elling, for example describes how a community hospital withdrew from participation in a community-wide hospital improvement plan because the hospital’s board of directors did not wish to sacrifice the hospital’s identity and autonomy in a proposed merger with two other hospitals [43]. This type of organizational behavior is also documented in studies of a community coordinating council [44] and community-wide hospital planning committees [45]. These are largely cases of reluctance to surrender any of the organization’s authority to a council or committee, to supraorganization~ or through cooperation with another agency. Autonomy is inadequately defined in each of these studies but it appears to mean freedom of the organization to make relatively major decisions on its own. In certain circumstances agencies may fear losing autonomy directly to applicants it services (or refuses to service), if, for example, these patients, clients, and others are organized under the banner of “consumer power” or community control. Also, agencies may stand to lose autonomy to other groups or formal organizations by accepting or rejecting certain types of applicants. For example, non-professional blindness agency workers have been observed to favor accepting more compliant and dependent clients in an attempt to preserve their agency’s autonomy and thus shield themselves from forces advocating the professionalization of blindness workers [46]. Defined slightly differently, organizational autonomy may be even a more important variable in explaining acceptance or rejection of applicants. Autonomy may be seen as the ability of the organization to function internally without concern for changes in its external environment Organizations buffer, level, forecast and then ration in attempts to deal with environmental fluctuations [47]. These maneuvers resemble a health service varying its acceptance rates to conform with available personnel. For example, in two university psychiatric clinics known to the authors, the probability of an applicant being accepted for service is high in summer when student applicants are scarce and new psychiatric residents are seeking patients, while in spring under opposite conditions the same applicant would be less likely to receive service. This suggests that applicants will be accepted or rejected at rates most likely to enhance. the organization’s independence from its environment. The second proposition (see Fig. l), therefore, is that the more patients are a source of autonomy to an organization the more likely patients will be accepted for service. The impact of the acceptance of certain numbers and types of applicants on the internal functioning of the organization is felt directly and immediately by the primary service staff of most health and social service organizations. An organization’s members are often quite well informed about effects applicant acceptance patterns can have on the organization’s future. For example, state and federal guidelines often require that certain types of patients or clients defined by age, income status, problem type and so forth be the preferred targets for services. Failure to service such patients may not only jeopardize future resources, but could result in reduced
JAMESR. GREENLEYand STUART KIRK
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autonomy if external agencies are required to closely monitor the service organization. REFERRALS
A referral is an exchange between an organization and a. patient as well as an interorganizational exchange. Referrals can be usefully examined both as organization-patient and interorganizational exchanges. Referrals as organization-patient exchange
The literature reviewed above on organizationenvironment relationships is probably as applicable to referral decisions as to decisions to give and withhold service. This literature suggests that organizations may be more likely to refer when this gains them the most resources or causes them to lose the least (see Proposition No. 3, Fig. 1). A referral’s value may be measured in financial terms (including the costs of space and staff time) and in terms of staff perceptions of the value of referrals as compared to other organizational services. In some organizations. referrals are generally seen as an inevitable by-product of the applicant screening process. In other organizations, such as the “referral” or “coordination” Senior Citizens Center described by Chin and O’Brien [48], referrals may be defined as one of the major services the organization supplies, if not the core service itself. In these latter organizations, the perceived if not actual costs of referral may be lower. Primary service staff may not feel referrals to be a burden or diversion from “the real work” of the organization, possibly because the organization contains job definitions or “boundary roles” which institutionalize a system of formal and informal rewards for the performance of referrals. The referring professionals in these organizations are also more likely to have developed personal or professional ties with members of potential receiving agencies, making referrals less costly in terms of time, effort and probability of failure. Suggested indicators of the costs of referrals to an organization thus might include: financial drain (actual costs of referring plus the lost resources which would have occurred from performing other functions); loss of staff morale and satisfaction; and lack of organizational recognition of referral as a high priority function. Referrals us interorganizational exchange
Organizations are thought to interact in exchange relationships when this can effectively increase their resources. Cooperation on referral is one way organizations may pool and therefore increase available resources [49]. A referral can be the means by which an agency can divest itself of a patient who is an uncompensated drain on its resources, and through exchange may obtain patients of more value to it than those referred away. While conflict over scarce resources may undermine ,cooperation [SO]. applicants to health and welfare agencies are usually not a scarce resource, and thus interorganizational referral does not parallel conventional competition over government grants or “Community Chest” charity funds. The need for patients probably results in conflict less frequently
than it does in modes of cooperation, such as referral. designed to deal with excess or inappropriate applicants. Proposition No. 4 suggests that organizations will be more likely to make referrals to those organizations which view patients as a resource. since these are the organizations more likely to accept the referral (Proposition No. 1). thereby minimizing the costs of referral for the referring organization. Organizational desire for autonomy, defined as the organization’s freedom to make relatively major decisions without the consent of other organizations, is often viewed as an impediment .to interorganizational cooperation, but no careful research links it to the referral of applicants. More important for referrals is an organization’s degree of autonomy cis-&cis applicant demands relative to the autonomy of other organizations. An organization may be under laws, regulations, or other constraints which force it to accept certain clients and reject others, i.e. the organization has less autonomy in this area. Applicants referred to that organization, providing they meet certain criteria, must be accepted even when other factors, e.g. very poor prognosis, suggest that acceptance may create difficulties for the organization. As a consequence, in an outpatient psychiatric clinic observed by the authors, intake personnel preferred to refer certain difficult applicants to a state psychiatric agency which was required to accept them. By referring to this agency, the job of referral was made considerably easier and the overall costs to the referring organization were minimized. Thus, Proposition No. 5 predicts that organizations will be more likely to make referrals to organizations which have less autonomy relative to other possible referral targets. Exchange between organizations has been seen as dependent on the knowledge of and agreement on organizational missions. Levine and White argue that agreement on populations served, diseases covered, and services rendered, i.e. “domain consensus”, is a voluntary exchange [S]. prerequisite to any Researchers in the area of delinquency prevention [52], organizational behavior in disasters [53] and cotinnunity nursing services [54] have described organizations which failed to refer to each other because they lacked understanding of or agreement on the other organization’s job. Knowledge of the existence of other organizations in the health and welfare network has been found to be surprisingly limited; leaders of organizations in one community knew of only 40-50 per cent of the other organizations [SS]. This suggests that knowledge of or agreement on organizational missions is likely to be an important variable in explaining referral patterns. Proposition No. 6 concerns the agreement which organizations have concerning the populations they serve, the diseases (or problems) covered and the services rendered. It suggests that this agreement, called “domain consensus” by Levine and White [56], is positively associated with the successful exchange of applicants. Unlike Levine and White’s contention, our proposition does not assert that domain consensus is necessary for exchange to occur, but only that consensus facilitates exchanges. Certainly some referrals may occur even when there are low levels of knowledge and consensus among organizations. For example. the authors have reported “mental hospital
Organizational
influences on access to health care
staff members entirely misunderstanding the domain of a ‘homemakers’ service, but nevertheless referring applicants there. And the staff of the homemakers service, after talking to the applicant, sometimes offered their help to the applicant for problems not even perceived by the personnel at the hospital” [57]. Yet the proportion of such referrals accepted at the target organization may be relatively low since many of the referrals are likely to be inappropriate and rejected. Domain consensus may be measured in terms of the degree of an organization’s members’ awareness of the existence and functions of another organization. The less knowledge and agreement about functions that is expressed, the less would be the domain consensus, and the fewer the successful referrals. A MODEL
OF REFERRAL
FLOW
Propositions Nos. l-5 suggest the presence of an overall model of referral patterns. The flow of referrals will tend to be from organizations which place less value on patients to organizations which place more value on patients (Proposition No. 1 implies that organizations which do not value patients will tend to reject and’refer a greater proportion of applicants, and Proposition No. 4 suggests the destination of these referrals). At the same time, referrals will tend to flow toward organizations with little autonomy (Proposition No. 5). Thus organizations placing little value on patients and who are relatively autonomous will refer more applicants than they receive through referral channels. Organizations with little autonomy which highly value patients will become good targets for referrals. The less autonomous organization which does not value patients will direct referrals to organizations which value patients more. Organizations with little autonomy in terms of acceptance criteria but which highly value patients may nevertheless have to make some referrals to more autonomous organizations which value patients. Finally, organizations which place little value on patients, but which have relatively little autonomy, may find themselves the recipients of referrals. Proposition No. 6 suggests a further refinement which could be made within this basic pattern. DISCUSSION
Access to health and related human services has become a major issue among program planners and Autonomy
of
the Oraontzotion
Value of Client 0s Resource to the Oraonizotion Hiah
Low
lrml ‘U
Low ‘Major Minor
Flow Potterns Flow Patterns
-
Fig. 2. Joint effect of organizational autonomy and patients as resources on overall flow of referrals”.
321
administrators and numerous attempts have been made to address access problems. Nevertheless, access problems have not been well understood or effectively remedied. Research on referral and rejection patterns has been limited and fragmented by the lack of theoretical propositions to guide such inquiry. Particularly neglected has been the role of organizational factors in generating differential patterns of service accessibility. This paper has reviewed and organized existing research and theory on this topic to illuminate the possible interaction of several selected organization variables. In our derivation of propositions, it has not been possible to develop several complex issues. The systemic features of the health and related services have been largely neglected, the significance of patient characteristics under certain circumstances, e.g. life and death emergencies, has been largely ignored, and the handling of multi-problemed patients and simultaneous multi-organization involvement with one patient has not been treated. Nevertheless, the framework which has been developed may provide suggestions for the treatment of these additional problems. Perhaps the major implication of this analysis concerns the utilization patterns of health and social services. Such patterns are often used to determine community health needs and the extent of public knowledge concerning a given health probfem and are thus influential in the development of new programs or the expansion of existing ones. Sometimes utilization rates are used as indicators of the true incidence or true prevalence rates of particular problems. Rates based on utilization patterns are incorporated into etiological theories, are often the bases for funding requests, and are the rates of most concern to state and federal budget makers. Yet, these treated incidence and prevalence rates are, in part, products of organizational factors rather than indicators of any true rates of a particular problem in the community. For example, if an alcoholic treatment center finds that patients become of greater value to the center (e.g. when the government increases its per case financial support), the center may respond by soliciting and servicing more applicants. This change would be reflected in the treated rates of alcoholism in that community. Scott, for instance, implies that the rate of blindness in the United States is artificially inflated because blindness agencies place a high value on getting clients [SS]. Changing the utilization patterns for health services’may require altering the manner in which service organizations view applicants and interact with other agencies. REFERENCES 1.
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