Effective Implementation In Practice

Integrating Public Policy and Management

Jodi Sandfort, Stephanie Moulton

• Publisher: Jossey-Bass
• Year: 2014
• ISBN:
  9781118986158
• Edition: 1
• Topic: Politics & International Relations
• Subtopic: Public Affairs & Administration
• Index: Politics & International Relations

A unique approach to policy implementation with essential guidance and useful tools

Effective Implementation in Practice: Integrating Public Policy and Managemen t presents an instrumental approach to implementation analysis. By spanningpolicy fields, organizations, and frontline conditions in implementation systems, this book provides a robust foundation for policy makers, public and nonprofit managers and leaders. Detailed case studies enable readers to identify key intervention points, become more strategic, and improve outcomes. The engaging style and specific examples provide a bridge to practice, while diagrams, worksheets, and other tools included in the appendix help managers apply these ideas to team meetings, operational planning, and program assessment and refinement.

Policy and program implementation is fraught with challenges as public and nonprofit leaders juggle organizational missions and stakeholder expectations while managing policy and program impact and effectiveness. Using their own experience in practice, teaching, and research, the authors empower policy and program implementers to recognize their essential roles within the workplace and help them cultivate the analytical and social skills necessary to change.

• Understand how program or policy technology constitutes the core of implementation
• Study a conceptual framework encompassing power dynamics, culture, relationships in the field and the rules that are operating during program and policy implementation
• Discover a multilevel approach that identifies key points of strategic action at various levels and settings of the implementation system and assesses implementation success

The integration of policy and management mindsets gives readers an insightful yet accessible understanding of implementation, allowing them to achieve the potent results desired by the public. For those in senior positions at federal agencies to local staff at nonprofit organizations, Effective Implementation in Practice: Integrating Public Policy and Management provides an invaluable one-stop resource.

Part One

The Implementation Landscape

Reformers are institutional gardeners more than architects and engineers. They reinterpret codes of behavior, impact causal and normative beliefs, foster civic and democratic identities and engagement, develop organized capabilities, and improve adaptability.¹

The great thing about [gardening] is the way something new is always happening . . . Each year there are new varieties to discover in the annual crop of seed catalogs, new trends to dabble with and new planting schemes to explore. And apart from the dazzling variety of the plants themselves, there are the imponderables of pests, problems and weather that combine to make each season a new gardening adventure. But some things never change—the basic skills of sowing, planting, and cultivation.²

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

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

Finally, in chapter 3, we apply the concept of strategic action fields to the implementation system as a way to suggest a systematic way to explain what happens in implementation systems. By doing this, we emphasize that these systems are complex, not merely complicated. They cannot be neatly reduced to a set of factors or variables that predict success, but rather must be viewed as dynamic, living social systems. Each level in the implementation system is a strategic action field with a unique social structure and dynamics that shape the core program. The core program is what distinguishes implementation from other change initiatives—it involves establishing viable options, using a logic of change, and selecting a means for activity coordination. This is a new way of thinking about the implementation system. And like any other new idea, it may take some time to digest the concepts. We continue to weave the concepts presented in this chapter throughout the rest of the book. By its end, we believe this new way of thinking can become second nature and improve your own endeavors as implementation practitioners.

Notes

¹ Johan P. Olsen, “Understanding Institutions and Logics of Appropriateness: Introductory Essay” (ARENA working paper 13, no. 07, Centre for European Studies, 2007), 10. ² Sue Phillips, introduction to The Practical Gardening Encyclopedia (Surrey: Colour Library Direct, 1997).

Chapter One
Framing Implementation

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

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Box 1.1 Overview of National Health Care Reform

Lauded by some as the most significant social welfare law passed in the United States for half a century, the signing of the Patient Protection and Affordable Care Act by President Obama in March 2010 set into motion a complex series of events. Termed “Obamacare” by political adversaries, the law's goals focused on increasing the quality and affordability of health insurance, decreasing the number of uninsured Americans, and reducing health care costs. Implementation of some features began immediately, but political controversy and legal challenges created initial uncertainty for states as they considered how to craft their own health care policy in relation to federal action. When the Supreme Court ruled the act constitutional in June 2012, states began deciding which of the many options offered in the act they would pursue. For example, states had the option of expanding the Medicaid program to provide more affordable insurance for low-income people, creating health care marketplaces or exchanges to help individuals and small employers purchase private insurance, or making changes to existing state-based health programs. Other states chose to let the federal default options take effect.

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

The need for health care reform in Colorado was high. Compared to other states, a large number of uninsured children and adults either had no health care or paid high out-of-pocket expenses.² In 2011, the governor had signed into law the state's policy authorizing Medicaid expansion³ and the development of the insurance exchange. As in other states, eligibility for support was tied to income eligibility: the lowest-income citizens accessed health insurance through expansions in Medicaid, another group was eligible for tax credits to decrease out-of-pocket costs, and others could now access insurance through an unsubsidized marketplace benefiting from group-negotiated insurance terms. But in May 2013, following the lead of the Colorado Health Foundation, the governor also declared a goal of making the state the healthiest in the nation, raising the urgency and political salience of the issue in the state. Over the previous year, there had been an unprecedented number of public-private initiatives focused on the governor's goals of promoting prevention and wellness, improving service coordination, and making operational changes in payment and information technology. And while sometimes tensions had erupted between state leaders about the pace and consequence of the changes, the network between major organizations had held together.

The Colorado Department of Health Care Policy and Financing played an important role in the state as the agency that authorized many of the public programs. The department's managers, such as Maurice Brown, entered into the contracts with the ten insurance plans advertising on the Connect with Health Colorado website. Accountable to the federal Department of Health and Human Services, ACA activities were significantly influenced by the department's years of experience administering Medicaid, Medicare, and the Children's Health Insurance Program. The new policy also fit solidly into the organization's new articulated mission of improving health care access and outcomes for citizens while demonstrating sound stewardship of financial resources. Managers had developed six organizational goals, including strategies to improve services and align communication, technology, and staffing. The overarching intent was to transform the health care system...