Organization The Division of Health Care Quality (DHCQ), a division of the Massachusetts Department of Public Health, oversees the enforcement of both federal and state regulations and licensing procedures for over 6,000 heath care facilities. Its mission statement is as follows: “The Mission of the Division of Health Care Quality is to promote, protect and preserve the health and safety of everyone in the Commonwealth across all settings.” Currently the Surveyor staff is divided into two main groups: Licensing & Recertification and Complaint Investigation, both of which are divided into 4 manager pools. The Licensing & Recertification manager groups are divided by state regions (north, south, west, metro), while the Complaint unit is divided by two specialty focuses (Hospital and Abuse groups) and two long term care (LTC) groups. The Licensing & Recertification section has approximately 60 surveyors, and the Complaints section has approximately 25 surveyors. In the last year, the division has had a change of director (who has since resigned), has lost the assistant director in charge of Licensing & Recertification, and has lost a manager of one of the complaint surveyor pools.

Research Initiative The primary focus of this study is to look at the two largest work groups of the DHCQ that both primarily do investigation/survey work for the state and federal government. We will identify the strategic constructs, and focus on recommendations that will lead to improved efficiencies and that will save the division and the state time and money. Data Collection Despite the fact that our group was unable to administer a division wide survey, we were able to conduct informal, off-the-record interviews and surveys with a few members of the staff at different levels of the organization. The people we interviewed included a surveyor from both the complaint unit and the license and recertification unit. Also interviewed were a management consultant and a complaint department manager. By having discussions with people from different levels in the organization, we feel as though we were able to attain a more complete outlook of the organization. These discussions, along with the insights of Keith, were the main data used in forming the basis for our political, strategic and cultural analysis, as well as our recommendations. Another source of data collection that we used involved the comparison of the DHCQ’s website with the websites of similar

organizations in other states. This data was a small aspect of our strategic analysis. A final source of data collection was some internal documents that Keith provided to the group. These documents, mostly used for background purposes, included a Long Term Care Hospital validation survey, the fiscal year 2011 mission and priority document, and the fiscal year 2010 budgeted survey workload. Political Lens Organizations are often examples of political systems. The DCHQ is a perfect example where cultural, strategically and political factors are interconnected. It is a very complex organization that has faced several issues in the past years. It is in urgent need for a change. Problems within the organization threaten the workload not to be completed. From

interpersonal issues to political agendas, all of these factors hinder the successful running of the organization. After doing our research on the organization, we have found that one of the biggest issues is that everybody seems to have different agendas and different ways to get things done. Some people are there just to do the job and see it as a stepping stone to the next career move. Another group of

people has been there for 30+ years and are not flexible to change, even if it involves maximizing productivity. The stakeholders in the Department of Public Health are all the inhabitants of the Commonwealth of Massachusetts and to a greater extent the organization of the healthcare system in general. Due to the progressive policies of Massachusetts, many other states look to us as the leading example in many aspects of regulation and policy. While doing our research we have come across different challenges within the organization. While we have an “insider”, it was hard to get different opinions from other workers. We could not do a formal, divisionwide survey and interviews where done on a limited basis. In the middle of our project, another big hurdle presented itself when we found out that the director was resigning. She received an offer for a higher position with the federal government. The commissioner of the department is responsible for finding a replacement and as of the now they have not identified anyone for the position. Past performance and track record matter differently to different people, and when it comes to power at the DHCQ, it does not matter. This is due in part to the union environment. It is incredibly difficult to punish anyone for poor performance. From what information we could gather, past

performance and track record only mattered if you also have a higher political partner trying to promote you, otherwise your only reward for good work is more work. Currently there are 2 directors at the DHCQ that seem as though would be better suited for a different line of work. One is the Assistant Director and the other is the Director of Policy and Planning. Together, their almost flagrant narcissism is hurting the division. The former has been with the division for an extended period of time and has gone against any system change, even if it is helpful to his unit. A glaring example of this occurred when his group of managers noticed that the website was not detailed enough, and citizens filing a complaint needed more guidance. They drafted a form based on one used in another state and requested that it be placed on the website. He denied the request because the Center of Medicare and Medicaid Services were in discussion about the possibility of standardizing an intake form. It has been eight months since the form has been completed with no change in sight from the federal overseers. This example shows how this director uses his formal position as a source of power. He gets the final word and uses this as a source of pride. The second director, the Director of Policy and Planning, was an appointee by the Commissioner of the Department. The position did not

exist prior to her working for the department. Her unit is made up of a few people that have very little in common with each other and their hiring appears to be only a case of nepotism, not job fit. One of the workers reporting to her was responsible for the quality control for the federal databases. This employee, who was unethically hired by a friend, never actually did this job function, and the entire division became threatened with fiscal trouble due to non-compliance with the federal government. This employee was never reprimanded, nor has anyone ever challenged the director as to why he was not doing his job, mainly out of fear. This is another example of how a formal position is used as a source of power. Someone with great power, has given power to someone else, and the rest of the work place has to respect that or face the consequences. The best example of an informal network position of power is our group member Keith. Keith started as a data entry clerk but quickly learned the systems and branched out in his spare time helping out and learning other workers’ job functions. Due to this, there came a time when Keith was the only one in the building who knew how to approach a federal database problem that managers and directors had neglected. Thus, Keith was

promoted, directly reporting to the Director of the bureau as a systems expert, and put in charge of a system redesign task force. This is a great

example of network position as a source of power, as although Keith has no one directly reporting to him, he is a source of knowledge that no one else has in the organization. In addition to this, since he branched out of his original work space, he had exposure to groups that in the past had never communicated with each other. This allowed him to put his knowledge and relationships with his co-workers into a position of power that doubles with the “scarce and valued expertise” section. Strategic Lens “By viewing an organization through the strategic lens, one can see how the flow of tasks and information is designed, how people are sorted into roles, how these roles are related, and how the organization can be rationally optimized to achieve its goals.” (Ancona, Kochan, Scully, Van Maanen, & Westney, 1999) There are three main strategic design processes that are relevant at every level of the organization. These are strategic grouping, strategic linking, and alignment. By analyzing these three

processes in regard to the DHCQ, we feel that we can determine the most efficient ways to divide the surveyor resources. Strategic grouping involves the differentiation of groups of activities, positions, and individual into work units. Grouping decisions dictate the basic framework within which all other organizational design decisions are

made. Strategic grouping focuses on how to group tasks and activities. As noted, the DHCQ is comprised of two main groups: Licensing and Recertification and Complaint Investigation. Despite being within the same organization, the two units are grouped differently. The Licensing and

Recertification unit is grouped by market, while the Complaint Investigation unit is grouped function or expertise. The License and Recertification unit is comprised of four groups (North, West, South and Metro), all of which represent a different geographical part of the state. The strength of grouping by market, or geographically, is that allows for deeper customer knowledge and close customer relationships. In this scenario, the “customers” are the different health care units that are being licensed and recertified. By having the same people cover a certain geographical territory it allows them to gain familiarity with these health care units, obtaining knowledge of their strengths and weaknesses. This familiarity allows for expediting licensing and recertifications more effectively and efficiently. The downside to

grouping geographically is that it allows for the erosion of deep technical expertise. A stellar employee who works in one geographic region may be better utilized in another region that has more complex assignments or that would better utilize his or her strengths. Another potential downside to

grouping geographically, is the chance that a conflict of interest could develop. By reviewing the same health care unit consistently, the workers may develop a friendship with health care unit staff, potentially leading to a less than thorough license and recertification process. The Complaint Investigation unit is also comprised of four groups, however, these are divided by two specialty focuses (Hospital and Abuse groups) and two Long Term Care groups (LTC). Grouping by function brings together individuals who share similar functions, disciplines, skills, and work processes. It also allows for the development of deep functional expertise and a high degree of specialization of knowledge within each function. Finally, grouping by function makes it easier to transfer resources across activities within functions. In contrast to grouping by region, this functional grouping allows Complaint Investigation members to use their knowledge and expertise wherever it is needed. Although they may not be investigating a health care unit they are familiar with, they are able to use their expertise to handle situations. The downside of grouping by functions is that individuals in this type of organization tend to develop narrower perspectives, often having difficulty solving problems that require teaming with other groups. Also, the levels of management in each function expand over time which can inhibit the efficiency of the organization.

“Strategic linking involves designing formal and informal structures and processes to connect and coordinate organizational units whose tasks are interdependent but that have been separated by grouping decisions.” (Ancona, et al., 1999) Some linking mechanisms include formal reporting structures, liaison roles, cross-unit groups, information technology systems, and planning processes. In looking at the organizational chart of the DHCQ, there is a definitive formal reporting structure in place. Also, in the day and age, information technology systems play a pivotal role in any organization. The organizational chart of the DHCQ is a map showing who must keep whom informed and who has the responsibility for linking which activities. The DHCQ has a lead director, who has 4 directors under her, who have a group of managers under them, who have a group of staff under them. This type of hierarchy is a very prevalent linking mechanism, but is not always ideal. Often times, the managers or directors can become

overloaded with complex issues, which can lead to delayed decisions and/or missed deadlines. The DHCQ is a prime example of this type of negative reaction to the formal reporting structure and hierarchy. Invariably, as the DHCQ reaches its fiscal year-end, the managers are back loaded in their review process, and have significant difficulty reaching their quotas for licensing and recertification. This scramble often involves working a

tremendous amount of overtime, along with members of different groups being asked to perform tasks out of their expertise. This clearly is not the most efficient or effective way for the DHCQ to reach its goals. Information technology systems have increased the linking to organizations, influencing the way companies organize and manage work. The DHCQ appears to be lacking in its information technology systems, in particular in regard to how complaints are initiated and moved through the organization. On its website, the DHCQ has a complaints section that lacks detail and information. It only states that to file a complaint that you need to write a letter or call a hotline, with no real guidelines. In contrast, the state of Rhode Island’s Division of Health Services website has a detailed complaint section covering such aspects as what is considered

unprofessional conduct, how a complaint is filed, how complaints are reviewed, and complaint form instructions. Speaking to this last detail, on the website there is a detailed, complaint form that is to be filled out with complaint. The DHCQ’s lack of detail and ways of communicating

complaints, especially in regard to the hotline, could cause some pertinent information to be left off of a complaint. Alignment ensures that the units and individuals assigned tasks and activities by the grouping and linking patterns have the resources and the

motivation to carry them out effectively.

Two important aspects of

alignment that are important in looking at the DHCQ are resource allocation and human resource development. Resource allocation refers to the

organization having the resources it needs to achieve its goals. The DHCQ, as stated earlier, has issues meeting its annual goals, which creates a consistently stressful environment as each year end approaches. In this case, it would appear that resource allocation goes hand-in-hand with the concept of human resource development, which is the assignment of people to positions, jobs and tasks. There is clearly a need for the organization to review its job assignments in a way that would allow the organization reach its annual goals. Culture The cultural side of the DHCQ is incredibly complex, and is formed in conjunction with the political and structural influences. Since this is a state government organization, there are two very important aspects to consider. There are political appointments made to positions, and, for the most part, it is a union environment. This is a problem on the structural end as most political appointments do not want to get their hands dirty when dealing with accountability, and even if they so desired, the unions are

strong enough to defend against firing employees, which can be dragged out over the course of years. The culture of the DHCQ can be summed up in one word: mistrust. A great deal of the division is paranoid and untrusting due to a complete lack of accountability. The question is: why is this? It is a hard question to answer, but by looking at recent history, there are clear signs as to why this has occurred. By specifically focusing on the two surveyor pools, it becomes evidence that the two parts of the division were literally divided from one another. There were two separate directors, on two separate floors, with very similar functioning, all running off one pool of resources. The physical distance between the groups made it difficult for the two to get along, as it was easy to just project blame for anything on the other side. In addition, the two directors had conflicting personalities which caused them to have differences of opinion, leading to a lack of collaboration. These personal problems trickled down to the staff, as a powerful rumor mill would deflect any wrong doing as many of the mid and upper level management saw fit. As childish as all of this was, most of it was passive aggressive, causing the director of the bureau to choose not to take corrective measures. The directors’ personalities seemed invested in

personal power, not on actual goals and management. This led to a domino effect that trickled down to the lowest level. Since no direction was given, most mid level managers felt that there was minimal, if any, support for them to take action. Three years ago, due to incredibly low morale, a consultant was brought in to try to help raise the division’s spirits. A survey and workshop followed to give everyone an outlet to voice their problems. According to the Human Resources manager, the results of the survey found that almost all employees respected and got along with their director supervisor. Further questioning resulted in the finding that mid management did not feel that upper management gave them proper support, leaving them feeling unappreciated. Many hoped that this would bring about the change that was so sorely needed; however as one can imagine from a state government point of view, nothing changed. Why? Because the report clearly stating that upper management was the problem was given to none other than upper management! This led to two important end points. First, nothing was done, wasting tens of thousands of tax dollars. Secondly, employee morale hit an all time low. This is just one of many examples of a complete lack of accountability.

There are positive symbols to be seen in the division of health care quality, but sadly most are seen as incomplete and lip service. The best example of this is the division’s mission statement. It is important to point out that it is not the mission statement itself that is the problem, but how it was created, and by whom. When the new director of the bureau arrived, she thought it was a good idea to create a mission statement that encompassed the mission of everyone in the bureau and included everyone’s input. The problem occurred in that the small task force that spearheaded the writing of the mission statement was lead by an appointed official that many people in the building thought was a political joke. Due to this very few people even attempted to get involved. This back fired for the bureau again, as there was very little buy-in from the main workforce. They

perceived an apparent favoritism of a person appointed to a position, who cared little for anyone’s input but her own. This effect reared itself in other areas. The director tried hard to include everyone in organizational building exercises that included a lunch time outing to the Boston Common. However, many workers who were still seeing very little change in the actual organization continued to see these acts as paying lip service to team work and accountability. What came out of this was a group that was seen as “drinking the kool-aid” vs. a group that

had alienated itself from the rest of the workplace. This continued to lower morale. Other events occurring in parallel to those discussed above involved a scandalous disrespect of the rules by one of the directors who was believed to have a questionable attitude by all. His part of the division was not following a federal guideline which could have cost the division a huge portion of its federal funding. Due to negligence by this director and a member of quality control, people would lose their jobs if this malfeasance was not fixed. In order to fix the problem by fiscal year’s end, a task force was created that consisted of people that were well respected and had a superior work ethic. Meanwhile, both the director and the other employee (that just so happened to work for the political appointed worker mentioned above) were not held accountable, and were not expected to do anything to rectify the issue. To this day, neither of these people has properly

investigated the cause of this error. Events like this not only make workers disenchanted by the lack of accountability, but it also tires out the workers that actually care and try. This is obviously problematic, as it unfairly places the burden of work on those who do the best, no who is ultimately responsible for the work. Overall this has created a culture in which people can be divided into three

groups: people that see the job as a paycheck, people who once cared, but are now burnt out, and people who care, but understand that the organization is toxic, only viewing the job as a stepping stone. Potential Recommendations We researched the following three possible recommendations: keeping DHCQ’s organization structure as is, reorganizing DHCQ by region, and reorganizing DHCQ by specialty. As we mentioned above, DHCQ’s staff is currently divided into two main groups: Licensing & Recertification and Complaint Investigation, both of which are divided into 4 manager pools. The Licensing & Recertification manager groups are divided by state regions while the Complaint unit is divided by two specialty focuses and two long term care (LTC) groups. By keeping DHCQ’s current structure in tact, all team members will continue to perform their jobs without any changes. However, DHCQ is not efficient enough with the current structure. It has difficulty meeting its goal by the end of the fiscal year, which has a negative impact to its reputation and next year’s budget. The second recommendation is to restructure DHCQ by state region, and divide the whole DHCQ into 4 large manager pools (north, south, west, and metro). Each pool is divided into two subgroups focusing on licensing &

recertification and complaints. The greatest advantage of this solution is it reduces travel costs significantly. It also saves surveyors a great deal of time, allowing them to manage their tasks better. By applying this solution,

DHCQ could function much more effectively and efficiently. Conversely, DHCQ might experience a chaotic adjustment at the beginning of the restructure. It would be a challenge to both DHCQ’s management team, as well as the surveyors. Finally, the third recommendation is to restructure DHCQ by specialty, by dividing DHCQ into 2 large manager pools (Licensing & Recertification and Complaint). The advantage of this solution is that each pool could concentrate on its specialty, developing a familiarity with the health care institutes that they survey or investigate. The downside of this solution is that each pool manager would accumulate a much heavier workload. Additionally, this solution does not taking into consideration cost efficiency. Recommendation & Implications According to the data we collected from first person sources, as well as the descriptive functionality of the DHCQ, it is our team’s recommendation that all surveyor teams should be under one power group. In addition, it is imperative that a communication protocol be written and followed to ensure that the two groups are effectively working together. The

primary faults we found with the old structure were not only strategic in nature, but it created an environment that was counterproductive to the mission of the division. These included a lack of trust in upper management, as well as mistrust between peers in other workgroups across the division. These silos generated duplicate work as well as confusion to not only workers who were exposed to multiple groups, but most importantly, to the public, who have a hard time getting hold of the correct parties they need to interact with. Our proposed solution strategically puts all surveyors under one assistant director instead of the two compared to the old system. Survey Operations and the Complaints Unit will still be divided by their survey function; however, their support staff will be pooled, and their direct managers will have the responsibility of communicating to the other groups, as well as having accountability to the assistant director. The function of the Complaint manager is to oversee the intake group to make sure cases are appropriately assigned and that report findings are written in correct standards with the federal and state guidelines, as well as timely delivery to the support staff. The function of the Forecasting & Enforcement Manager is to oversee the scheduling of the yearly survey material as written in the CMS priority

document, doing so in a manner to prevent any unforeseen circumstances. This person should also be directly involved with all enforcement actions, involving surveys (both complaint and standard), to ensure proper timeliness according to CMS guidelines. Finally we have the System Coordinator and Communications Liaison. All support staff involved in surveys will be under his/her Like the other two managers, their main job function is However, for this area it involves post-survey work and

supervision. timeliness.

uploading the data to the federal server on the computer systems within the CMS guidelines. This manager is to make sure that their support staff is getting all of their work completed with enough time to process communications to the facility, or to CMS via computer system, before the survey cycle is closed (currently 70 days) to avoid penalties from CMS. In addition, this manager is responsible for keeping the entire workgroup up to date on any system changes and provide training sessions for anyone in need. This manager is the primary liaison between CMS and the division for anything involving the systems side of any survey. Together, these three managers can keep a close eye on the survey cycles and deadlines mandated by CMS and effectively work as a team to meet any obstacle that comes their way.

For survey purposes, the supervisors were divided into region for Survey Ops and into focus groups for the Complaint Unit. A problem for the complaint supervisors sometimes involved sending a surveyor across the entire state simply because that was the case that was given to them. At times, supervisors would “trade” with other supervisors, but there needed to be a better way. Originally, we were going to change the Complaint Unit group to reflect the region system that worked quite well for Survey Ops, but the Hospital group in the Complaint Unit could not be ignored. Under the accreditation system used for hospitals by CMS, re-accreditation is done by a third party organization contracted by CMS and state survey teams cannot survey hospitals without pre-approval from CMS. Due to this unique set of guidelines, as well as the system implications involved with these cases, we felt that the hospital focus group was necessary. Due to the loss of a complaint supervisor caused by cut backs, it only made sense from a strategic point of view, to have the other two supervisors take on 2 regions a piece. The director in charge of this work group would need little involvement in day to day operations and could have his/her time involved in legal/media requests and hearings, higher scope of severity cases (i.e. jeopardy), and any other pressing matters deemed fit by the bureau director.

It is also important to note that due to feedback and the history of the culture at the DHCQ, that the work group director be a leader that supports the decisions of the workgroup and act as a supportive guide, rather than a suppressive bureaucrat. What the group needs more than anything is someone that cares. REFERENCES
Ancona, D., Kochan, T., Scully, M., Van Maanen, J. & Westney, D.E. 1999. Managing for the future: Organizational behavior and processes (2nd ed.). Cincinnati: South-Western College Publishing.

APPENDIX Original Organizational Chart New Organizational Chart after Recommendations Four Informal Surveys from DHCQ staff Website link

Division of Health Care Quality
Friendly URL: http://www.mass.gov/dph/dhcq Use the link above to return directly to this page in the future.

Mission Statement
The Mission of the Division of Health Care Quality is to promote, protect and preserve the health and safety of everyone in the Commonwealth across all settings.