Accountability in the Home and Community Care Sector in Ontario

Accountability in the Home and Community Care Sector in Ontario by Carolyn Alice Steele Gray A thesis submitted in conformity with the requirements for the degree of Doctor of Philosophy Institute of Health Policy, Management and Evaluation University of Toronto © Copyright by Carolyn Alice Steele Gray (2013) Accountability in the Home and Community Care Sector in Ontario Carolyn Alice Steele Gray Doctor of Philosophy Institute of Health Policy, Management and Evaluation University of Toronto 2013 Abstract This research seeks to identify what accountability frameworks were in place for the home and community care sector in the Canadian province of Ontario, how home and community care agencies in Ontario responded to accountability demands attached to government service funding (specifically through Community Care Access Centre (CCAC) contracts and Local Health Integration Network (LHIN) Multi-Service Accountability Agreements (MSAAs) and what, if any, effect accountability frameworks had on service delivery. This study uses a multi-phase parallel mixed methods approach. First, an environmental scan and document analysis was conducted to identify accountability frameworks and identify key characteristics of accountability demands. Next, 114 home and community care agencies in Ontario were surveyed and 20 key informant interviews were conducted with executives from 13 home and community care agencies, two CCACs and two LHINs. Data from these different methods were combined in the analysis phase. Home and community care agencies face multiple accountability requirements from a variety of stakeholders. We found that government agencies relied most heavily on regulatory and expenditure policy instruments to hold home and community care organizations to account. ii Organizational size and financial dependence were significantly related to organizational compliance to accountability demands attached to CCAC contracts and MSAAs. In addition to the theorized potential organizational responses to external demands (compliance, compromise, avoidance and defiance), this study found that organizations engaged in internal modification where internal practices are changed to meet accountability requirements. Smaller, more poorly resourced organizations that were highly dependent on LHINs or CCACs were more likely to internally modify organizational practice to meet accountability demands. Although MSAAs and CCAC contracts supported a quality culture amongst organizations, internal organizational changes, such as redirecting time towards reporting requirements and away from care, and cutting innovative practices and programs, were reported to have a negative impact on the quality of service delivery. Government reliance on contract-based accountability for funded home and community care services, while politically advantageous, has the potential to seriously and negatively affect the quality of home and community services delivered. Policy makers need to carefully consider the potential impact on quality of service delivery when developing and implementing accountability policy. iii Acknowledgments This dissertation could not have been completed without a tremendous amount of help from colleagues, mentors, friends and family who provided expertise, guidance, and moral support. I would like to thank the following individuals to whom I am exceedingly grateful: My supervisor, Dr. Raisa Deber, always had an open door and provided thoughtful guidance, a supportive environment, and opportunities for development as a student and researcher. I would also like to thank Dr. Deber for her research funding made possible through the Ministry of Health and Long-Term Care grant and through the CIHR-PHSI (PHE-101967). Dr. Janet Lum, a member of my thesis committee, my Master’s supervisor, and, in many ways, my mentor, who provided impressively thorough feedback on my thesis, gave open and honest advice, and has provided me with many professional opportunities. My third committee member, Dr. Whitney Berta, was generous with her time and feedback on the thesis, and whose positive attitude helped me through some of the biggest challenges I faced. Extra thanks to Dr. Berta for double coding many tediously long documents to validate the coding scheme. I would like to add a special thanks to my supervisor and committee for their patience, encouragement and support after the birth of my son in the last year of my thesis work. Their extreme generosity with their time and willingness to work around a sometimes challenging childcare schedule was outstanding. Mr. Kanecy Onate, research assistant to Dr. Deber, provided endless help and support with statistical questions, administrative requirements, and last minute crisis situations. His ability to provide help at any hour with good humour and a smile was a continuous inspiration. Mr. Alvin Ying, research assistant to Dr. Janet Lum, was an excellent support through this thesis. Whether providing useful links, articles, or quick administrative help, Alvin always came through when we I needed help. Ms. Stephanie Ma provided excellent support as a volunteer research assistant; we hope you gained the experience you were looking for. iv Ms. Lee Vernich, Director of the Research Services Unit at the Dalla Lana School of Public Health and Mr. Kevin McCurley, research assistant, provided excellent assistance gathering missing data from survey respondents. It was a pleasure working with these researchers. I would like to thank the team of transcriptionists who transcribed all interviews. To my colleagues and dear friends Seija Kromm, Jessica Bytautas and Renata Axler for sharing ideas, laughs and kind ears. Additional thanks to Seija and Jessica for double coding interviews and mission statements, and for being my partners in all aspects of accountability. Special mention to Seija for reading over this thesis to provide feedback and for being the best conference buddy anyone could ask for. Thanks to the six individuals who acted as pilot sites for my survey whose feedback was incredibly valuable. I greatly appreciate your time, and the care you showed in providing feedback. To my key informants, Anne Wojtak, Bill Manson, Debra Bell, Shaneena Mukhi, and Angele Albert-Ritchie for taking the time to provide me with background information and for sharing documents. I would like to thank all the survey respondents and interview participants for their time. I would like to acknowledge the financial support of the Canadian Institute for Health Research ICS Travel grant for making it possible to present findings at scientific conferences. I would also like to thank my Nan and Grandad Rowe for contributing to my tuition, and thanks to Diane Rowe for making that possible. It was a very special gift I will never forget. To my dear friends who always believed in my abilities, especially when I did not. For providing much needed escape through dinners, cottage weekends, and softball; for enduring me through the tumults of thesis work; for reminding me of why this work is important to me; for all this and more I thank and love you Ashley, Chad, Eric, Sally, Slater and Vanessa. My family, Mum and Dad, sisters Sarah and Jamy, and in-laws Christine, Owen, Elizabeth and James who never once questioned this choice and for their understanding when work resulted in my absence from family events. Your love and support were often just what I needed v to get by. I cannot thank Christine Crombie enough for the countless days and hours of childcare in the final year of my thesis. A very special thanks to Elizabeth for generously offering her time to edit this work; her brilliant editorial skills were a tremendous help in the final stages of my thesis. And finally, to my husband Ian Gray, our son Henry Gray, and our wonderful dog Fenris, I cannot describe how important you all are to me. I am thankful this work gave me the chance to spend so much of Henry’s first 17 months at home with him; his sweetness, curiosity, and smiles could turn around even the darkest days. And to my husband Ian, whose love, understanding, respect, and patience are unmatched. For being my inspiration, sounding board, running partner, grammar robot, softball coach, housekeeper, and very best friend, I will be forever thankful. vi Table of Contents Acknowledgments.......................................................................................................................... iv Table of Contents .......................................................................................................................... vii List of Tables .................................................................................................................................. x List of Figures ............................................................................................................................... xii List of Appendices ....................................................................................................................... xiii Acronyms and glossary ................................................................................................................ xiv Chapter 1 Introduction .................................................................................................................... 1 1 Introduction .............................................................................................................................. 1 1.1 Background: The home and community care sector ......................................................... 2 1.2 Focusing on Ontario .......................................................................................................... 9 1.3 Thesis outline ................................................................................................................... 10 Chapter 2 Literature review and theoretical framework ............................................................... 12 2 Introduction ............................................................................................................................ 12 2.1 Accountability theory ...................................................................................................... 13 2.2 History of accountability and new public management................................................... 19 2.3 Organizational behavior, responses and characteristics .................................................. 22 2.4 Intended and unintended consequences, perverse outcomes and the affect on quality ... 37 2.5 Literature review summary .............................................................................................. 43 Chapter 3 Methods ........................................................................................................................ 45 3 Introduction ............................................................................................................................ 45 3.1 Unit of analysis ................................................................................................................ 46 3.2 Ethics ............................................................................................................................... 47 3.3 Environmental scan: Identifying the sampling frame ...................................................... 47 3.4 Phase one: Document analysis and survey ...................................................................... 48 3.5 Phase two: Key informant interviews .............................................................................. 53 3.6 Mixed-methods analysis and interpretation ..................................................................... 56 vii Chapter 4 Document analysis ....................................................................................................... 57 4 Introduction ............................................................................................................................ 57 4.1 To whom: Accountability frameworks in place .............................................................. 57 4.2 Breaking down the “for what” ......................................................................................... 75 4.3 MSAAs and CCAC contracts “at what cost”: Answerability and sanctions ................. 102 4.4 Multiple accountabilities for the HCC sector: Document analysis summary ................ 109 Chapter 5 Quantitative findings: Survey results ......................................................................... 110 5 Introduction .......................................................................................................................... 110 5.1 Survey response rates: Challenges associated with organizational surveys .................. 110 5.2 Descriptive analysis of the survey ................................................................................. 112 5.3 Survey sample characteristics ........................................................................................ 114 5.4 Organizational responses to accountability requirements ............................................. 116 5.5 Summary of survey findings .......................................................................................... 134 Chapter 6 Qualitative findings .................................................................................................... 136 6 Introduction .......................................................................................................................... 136 6.1 Descriptive information of interview participants ......................................................... 136 6.2 Organizational responses as reported by interviewees .................................................. 137 6.3 Organizational factors that affect organizational responses .......................................... 148 6.4 The problem with indicators .......................................................................................... 176 6.5 Unintended consequences .............................................................................................. 178 6.6 Summary of qualitative findings ................................................................................... 179 Chapter 7 Analysis, discussion and conclusions......................................................................... 182 7 Introduction .......................................................................................................................... 182 7.1 Accountability frameworks in place: Research question 1 analysis .............................. 183 7.2 Organizational responses to accountability requirements: Research question 2 analysis 186 7.3 Organizational factors that affect responsiveness: Research question 3 analysis ......... 191 7.4 Unintended consequences and potential effects of accountability on home and community care service delivery: Research question 4 analysis ............................................ 200 7.5 Discussion ...................................................................................................................... 204 viii 7.6 Practical implications..................................................................................................... 207 7.7 Limitations ..................................................................................................................... 209 7.8 Strengths and contribution ............................................................................................. 209 7.9 Future research............................................................................................................... 210 7.10 Conclusion ................................................................................................................... 211 References ................................................................................................................................... 212 ix List of Tables Table 2-1: Potential organizational responses to institutional pressure ........................................ 27! Table 2-2: Strategies to support integrated care. .......................................................................... 42! Table 3-1: Coded LHIN MSAA and CCAC documents .............................................................. 49! Table 4-1: Summary of accountability frameworks ..................................................................... 58! Table 4-2: Components of accountability frameworks ................................................................. 75! Table 4-3: Financial accountability in LHIN MSAAs and CCAC contracts................................ 85! Table 4-4: Performance accountability in the LHIN MSAAs and CCAC contracts .................... 93! Table 4-5: Political/democratic accountability in the LHIN MSAAs and CCAC contracts ........ 96! Table 5-1: Operationalized dependent variables......................................................................... 117! Table 5-2: Number of organizations in the survey that demonstrate different responses........... 117! Table 5-3: Dependent and explanatory variable definitions - quantitative data ......................... 119! Table 5-4: Explanatory variable correlation matrix .................................................................... 120! Table 5-5: Three factor solution, factor analysis VARIMAX rotation ....................................... 121! Table 5-6: Logistic regression analysis of 48 organizations compliance response to LHIN MSAA in relation to their size................................................................................................................. 124! Table 5-7: Logistic regression analysis of 49 organizations compliance response to CCAC contracts in relation to their size. ................................................................................................ 125! Table 5-8: Logistic regression analysis of 53 organizations compliance response to LHIN MSAAs in relation to the percent of funding received from the LHINs. ................................... 126! Table 5-9: Logistic regression analysis of 47 organizations compliance response to CCAC contracts in relation to the percent funding received from CCACs. ........................................... 127! Table 5-10: Logistic regression analysis of 63 organizations compliance response to LHIN MSAAs in relation to the number of stakeholder and accreditation relationships held. ............ 129! Table 5-11: Logistic regression analysis of 36 organizations compromise response to LHIN MSAAs in relation to the number of stakeholder and accreditation relationships held. ............ 130! Table 5-12: Logistic regression analysis of 59 organizations compliance response to CCAC contracts in relation to the number of stakeholder and accreditation relationships held. ........... 131! x Table 5-13: Logistic regression analysis of 54 organizations compliance response to LHIN MSAAs in relation to the organizations size and human resource distribution. ......................... 132! Table 5-14: Logistic regression analysis of 47 organizations compliance response to CCAC contacts in relation to the organizations size, human resource distribution, and status.............. 133! Table 5-15: Summary of survey findings ................................................................................... 134! Table 6-1: Interview participants' organizational responses to LHIN MSAAs and CCAC contracts ...................................................................................................................................... 147! Table 6-2: Dependent and explanatory variable definitions, qualitative data............................. 149! Table 6-3: Financial dependence and stakeholder conflict affect on organizational responsiveness to MSAAs and CCAC contracts. ................................................................................................ 155! Table 6-4: Perceived inevitability and organizational autonomy affect on organizational responsiveness to MSAAs and CCAC contracts. ....................................................................... 161! Table 6-5: Perceived strictness and role clarity affect on organizational responsiveness to MSAAs and CCAC contracts. .................................................................................................... 167! Table 6-6: Organizational characteristics associated with responses to MSAAs and CCAC contracts. ..................................................................................................................................... 175! Table 6-7: Summary of findings with regard to propositions. .................................................... 179! xi List of Figures Figure 6-1: Interview sample organizations' stakeholders as identified by interview participants. Presented by number of organizations that identified each stakeholder. .................................... 152! Figure 6-2: Number of organizational stakeholders identified by interview participants. ......... 153! Figure 7-1: Model of HCC organizational responses to LHIN MSAA and CCAC contracts. ... 190! Figure 7-2: Organizational characteristics associated with responses to LHIN MSAAs and CCAC contracts. ..................................................................................................................................... 199! xii List of Appendices Appendix 3-A: Documents and their sources ............................................................................. 227 Appendix 3-B: Survey version, pre-piloting ............................................................................... 231 Appendix 3-C: Survey feedback forms for pilots ....................................................................... 238 Appendix 3-D: Pilot feedback .................................................................................................... 241 Appendix 3-E: Introductory letter ............................................................................................... 242 Appendix 3-F: Interview guides with introductory letter and consent forms ............................. 245 Appendix 3-G: Final survey (written version of the online survey) ........................................... 263 Appendix 4-A: Accreditation Canada, required organizational practices and CARF and ISO accreditation processes................................................................................................................ 274 Appendix 4-B: MSAA indicator framework .............................................................................. 276 Appendix 5-A: Tables and figures .............................................................................................. 277 Survey sample bias tables ....................................................................................................... 277 Survey descriptive statistics tables.......................................................................................... 279 Relationships between independent variables – factor analysis findings ............................... 285 Appendix 5-B: Organizational size operationalization ............................................................... 288 Appendix 5-C: Additional tables ................................................................................................ 290 Comparing respondents and non-respondents ........................................................................ 290 Additional descriptive statistics tables .................................................................................... 292 Appendix 6-A: Qualitative descriptive and data tables .............................................................. 296 Appendix 6-B: Role/ involvement descriptions .......................................................................... 306 Appendix 6-C: Descriptions of organizational goals .................................................................. 307 xiii Acronyms and glossary Acronyms ADP: Adult Day Program BOC: Balance of Care CAPS: Community accountability planning submission CARF: Commission on Accreditation of Rehabilitation Facilities CCAC: Community Care Access Centre CEO: Chief Executive Officer CHA: Canadian Healthcare Association CNAP: Community Navigation and Access Program CSS agency: Community Support Service agency. FP: For-profit HCS agency: Home care service agency. HRSDC: Human Resources and Skills Development Canada HQO: Health Quality Ontario HSP: Health service provider HSAA: Hospital Service Accountability Agreements IADLs: Instrumental Activities of Daily Living ISO: Standards Council of Canada LHIN: Local Health Integration Network LHSIA: Local Health System Integration Act LSAA: Long-Term Care Home Service Accountability Agreements MLPH: Ministry-LHIN Performance Agreement MOHLTC: The Ministry of Health and Long-term Care MSAA: Multi-sector service accountability agreement xiv NFP: Not-for-profit NPM: New Public Management OACCAC: Ontario Association of Community Care Access Centres OCSA: Ontario Community Support Association OECD: Organization for Economic Co-operation and Development OHCA: Ontario Home Care Association OHQC: Ontario Health Quality Council OHRS: Ontario Health Reporting System OHRS/MIS: Ontario Healthcare Reporting Standards OT: Occupational Therapy PT: Physical Therapy or Physiotherapy TDHC: Toronto District Health Council RFP: Request for proposal WERS: Web Enabled Reporting System Glossary Accountability: A relationship between two parties that includes three components: accountability “to whom” (between which parties is the accountability relationship), accountability “for what” (the activities for which parties in the relationship are responsible), and accountability “at what cost” (the sanctions associated with failure to meet responsibilities) “the relationship that exists when one accepts responsibility that has been conferred and the duty to report back to the person or body that conferred it” Accountability webs: complex set of accountability relationships between multiple individuals or organizations. Accountors: Those holding other individuals or organizations to account for their actions. Accountees: Those individuals or organizations being held to account for their actions. Answerability: the obligation to respond to questions relating to decisions and/or actions taken. Community Support Service (CSS) Agency: An organization that delivers community care services. xv Complementarity: When quantitative and qualitative data examined overlapping but distinct facets in a mixed methods study. The intention is to use one method to enhance, illustrate or clarify results from the other. Contestability: Level of resistance to entry and exit from a market. Financial accountability: using auditing, budgeting and accounting tools to track and reporting on the use of financial resources. Home and community care: An array of services that allow individuals who suffer some mental or physical incapacity to live at home and receive the care they need. Home Care Services (HCS) Agency: An organization that delivers home care services. Isomorphism: the constraining processes that force organizations within the same environment to become similar. Includes three forms: coercive, mimetic and normative. Measurability: How precisely produce or service inputs, processes, outputs and outcomes can be measured. Mixed methods research: Research that combines qualitative and quantitative methods. Multiplicity: The degree of conflict between multiple constituent expectations inflicted on an organization. Nonresponse error: Instances where those who respond to a survey differ from those who do not respond along variables which are important to the study. Observability: Whether services or products an be directly observable by managers. Parallel mixed analysis: A mixed methods research technique which involves combining separately analysed qualitative and quantitative in the interpretation and write up of a study. Performance accountability: asks organizations and agencies to account for their performance with an emphasis on services, outputs and results. Political/democratic accountability: focuses on how government fulfills public trust, represents citizens’ interests and responds to the needs of society. Policy instruments: the means and methods that governments use to shape policies toward defined goals Sanctions: mechanisms used to enforce accountability. xvi 1 Chapter 1 Introduction 1 Introduction Accountability in health care has become a topic of great interest to academics, public servants, and the broader public, particularly in light of recent health care reform efforts and increased calls for greater accountability in the public sector. Although a topic of great interest, accountability is often a vague and poorly understood concept that has multiple, sometimes disparate, definitions. The accountability literature suggests that accountability is best understood in terms of three components: accountability “to whom” (between which parties is the accountability relationship), accountability “for what” (the activities for which parties in the relationship are responsible), and accountability “at what cost” (the sanctions associated with failure to meet responsibilities) (Bergsteiner & Avery, 2009; Brinkerhoff, 2003; Thomas, 1998). Accountability policy instruments commonly used in the health care sector may include: financial incentives, information systems (often in the form of annual reports which may include performance measurement tools), regulations, and professionalism/stewardship models. Accountability is important as a means to ensure public trust (CHA 2001), of promoting continuous improvement in the use of resources and public authority (Aucoin and Jarvis, 2005), and as an opportunity to incent performance improvement (CHA, 2001). Given the growing concerns regarding both rising costs of health care and quality of care, accountability practices that are associated with health system effectiveness in planning, delivery and evaluation of health services (Leo, 2006), makes accountability an attractive policy approach to improving the health system. Unfortunately, there is evidence to suggest that some accountability tools, such as performance measurement, can also result in unintended and perverse organizational outcomes (Baranek, Deber, & Williams, 2004; Clark & Swain, 2005; De Bruijn, 2007). Some studies have shown that accountability requirements may lead to less desirable individual level behaviours rather than promoting more positive organizational environments (Beu & Buckley, 2001). Given the increased interest in accountability and its potential for improving health care system sustainability and quality, it is paramount that policy makers know whether organizations are 2 responding to accountability demands as expected, or whether accountability results in unintended organizational responses that may negatively impact on how health services are delivered. In this work, four research questions will be addressed in order to gain a better understanding of how health care organizations respond to accountability requirements in the home and community care sector: Research Question #1: What accountability frameworks are currently in place for home and community care agencies in Ontario and how do the characteristics of these frameworks vary? Research Question #2: What is the array of realized organizational responses to accountability requirements? Research Question #3: How do responses vary as a function of organizational factors? Research Question #4: What are the potential impacts of accountability frameworks on home care service delivery? 1.1 Background: The home and community care sector While there is no single definition of home care, the Romanow Report (2002) states that at the least it is a term used for an array of services that allow individuals who suffer some mental or physical incapacity to live at home and receive the care they need. Home and community care can be understood in terms of the services being delivered and the location where those services are delivered. Home and community care services serve three functions: 1. Acute care substitution: home and community care services that meet the needs of individuals who would otherwise have to enter or remain in an acute care facility 2. Long-term care substitution: home and community care services that meet the needs of individuals who would otherwise need to be institutionalized, and 3. Maintenance and prevention: home and community care services that help individuals to stay independent in their current living environments. In many cases these services can help to prevent functional and health breakdowns and premature institutionalization (Anderson & Parent, 2000; CHA, 2009; Baranek et al., 2004; Dumont-Lemasson, Donovan, & Wylie, 1999; Hollander & Walker, 1998). Home and community care services include both professional and non-professional services. Home care services are primarily professional services and may include nursing, physiotherapy, occupational therapy, speech therapy, social work, and dietetic services. Home care services also 3 include non-professional services such as personal care (bathing, dressing, and feeding), homemaking, and respite services (Health Canada, 2010). Community care services are nonprofessional services and can include day programs, meals on wheels, and friendly visitor programs (Ibid). Other community services can include transportation, foot care, security checks, recreation/social programs, lawn and home services, and respite care. Home and community care services may serve a variety of populations including seniors, children with special care needs, or individuals with physical or mental health challenges. The types of services and the methods by which these services are delivered may differ for each of these populations. In order to simplify the analysis and allow for more straightforward comparisons among organizations, only organizations that provide services to seniors (including the frail elderly) are examined in this analysis. The health needs of this growing population have become a central concern to policy makers, healthcare professionals and the general public. Concerns are rising because of the rising population of seniors in Canada and internationally which are resulting in increasing healthcare expenditures, and because public expectations are shifting regarding the rights of seniors to remain in their homes for as long as possible (Williams, Challis, Deber, Watkins, Kuluski, Lum, & Daub, 2009a) 1.1.1 Financing and delivering home and community care services in a Canadian context In Canada, health care is financed and delivered using what the Organization for Economic Cooperation and Development (OECD) calls a public-contracting model in which there is public financing for a sub-set of care, with care being delivered by both not-for-profit and for-profit private providers (Docteur and Oxley, 2003). The Canada Health Act, 1985 is federal legislation that sets out five criteria that must be met by provinces and territories in order to receive Federal government funding (Health Canada, 2002). The Act only requires that provinces and territories cover “medically necessary” physician and hospital services; as a result, it is up to the discretion of each province to determine how and if home and community care services will be provided or funded by the government. Most provinces have private for-profit and not-for-profit home and community care services available and some will have services publicly available, although public availability varies across the country with regard to the terms and conditions of the services (Marchildon, 2013). 4 1.1.1.1 Determining ‘make or buy’ based on production characteristics Preker, Harding, and Travis (2000) suggest that a product or service’s level of contestability and measurability (whether high, medium or low) indicates whether a government should “make or buy” the product or service. This model of decision-making, which Preker et al. have termed a “make or buy” decision grid, provides an alternative approach to the neoclassical economic theory of using consumption characteristics, which are argued not to be applicable to health care products and services (Preker et al., 2000; Preker & Harding, 2000). This “make or buy” model can help government policy planners determine what approach to service delivery is the most appropriate based on the characteristics of the home and community care sector. A perfectly contestable market is one in which “firms can enter it freely (without any resistance from other firms) and subsequently leave it without losing any investments, while having equal access to technology” (Preker et al., 2000, p. 782). Highly contestable goods are goods that experience low barriers of entry and exit to the market. Increased barriers to entry in the market can be caused by high investment, or “sunk,” costs, high technical specifications, high product differentiation, copyright protection, and high asset specificity (which also represents a sunk cost) (Ibid). Measurability can be defined as “the precision with which inputs, processes, outputs and outcomes of particular goods or services can be measured” (Preker et al., 2000, p.782). Observability is related to measurability, in that the level of observability (how directly observable is the service/product by a manager) will affect the level of measurability of the service. For instance a service with high-observability may be easier to measure than one with low-observability. Home and community care is an example of a low-observability service, in that it has characteristics that Lipsky (1980) identified as a “street-level bureaucracy.” Streetlevel bureaucracies are public service agencies that employ a significant number of street-level bureaucrats as a proportion of their workforce. Street-level bureaucrats can be defined as public service workers (or more broadly for non-government workers) who interact directly with citizens/clients through the course of their jobs. Street-level bureaucrats will tend to have substantial discretion in determining the nature, amount and quality of work provided to clients. Street-level bureaucrats may experience minimal supervisory scrutiny, and may also be expected to exercise discretion without direct managerial oversight. 5 Home and community care services generally represent a highly contestable service, and moderately measurable service and so are conducive to competitive contract purchase models according to Preker et al’s “make or buy” model. However, this model also points to the need for additional accountability tools such as the use of regulations to deal with the low to moderate measurability. Furthermore, the relative discretion at the point of interaction between street-level bureaucrats and clients supports the need for regulations and additional accountability frameworks for the home and community care sector. Assuming that Preker et al’s “make or buy” model is appropriate, then it can be argued that using contracts to procure services and to hold contractees accountable is an appropriate accountability framework for this sector. 1.1.2 Home and community care in Ontario In Ontario, home and community care services are available to clients through a variety of different access points and eligibility requirements (Williams et al., 2009a). The costs of services and funding mechanisms also vary widely across the home and community care sector (Ibid). Both home care and community care services can be purchased from providers on an as needed basis from a wide array of home and/or community care service providers. The Ontario Ministry of Health and Long-Term Care (MOHLTC) funds some home and community care services for Ontarians through Local Health Integration Networks or LHINs. In 2006, the MOHLTC divided the province into 14 geographically based LHINs covered under the Local Health System Integration Act, 2006. The intention of regionalizing the health care system in this way was to increase the responsiveness of the health system to the needs of local communities by planning, funding and integrating services at a regional level (Ontario’s LHINs, 2013). The LHINs receive funding from the MOHLTC to allocate to local health services such as acute care hospitals, long-term care, mental health and addictions services, Community Health Centers, Community Care Access Centres (CCACs) and community support services. The latter two services are the focus of this study. 1.1.2.1 Home care service delivery and financing in Ontario: CCACs CCACs, which are funded by the LHINs, are obligated to provide assessment, but are not necessarily obligated to pay for services to clients. Home care services are purchased by CCACs on a competitive basis from both for-profit and not-for-profit private Home Care Services (HCS) 6 agencies under capped budgets set by the province. Services are then allocated to individuals but there is a ceiling on the amount or units of publicly-funded services an individual may receive (Williams et al, 2009a). CCACs were first introduced in 1996 by Mike Harris’ Progressive Conservative government as a means to simplify access, preserve existing organizations, and reduce administration (Baranek et al., 2004). Originally 43 CCACs were created to serve different geographic areas across Ontario, this later became 42, when two were consolidated, and was consolidated further to 14 that match up geographically with their corresponding LHIN. Ontario’s CCACs act as both purchasers of and connectors to home and community care services for their clients. CCACs can purchase professional services (including nursing services, physical therapy, occupational therapy, speech and language therapy, social work services and dietetic services), non-professional services (including personal support and home making services), and medical supplies for clients who are assessed as eligible. Eligible clients are assigned case managers who link them to all the services that they may require. CCACs will also connect clients to long-term care options as well as other community services such as meals-on-wheels, transportation, caregiver relief and adult day programs. Some of these community services may be funded by LHINs directly through Multi-Service Accountability Agreements (MSAAs) (discussed below), while others are paid for privately. CCACs purchase home care services from health service providers (HSPs) through a competitive procurement process (Caplan, 2005). This competitive process has undergone two moratoria, the second beginning in 2008 after two non-profit agencies that had delivered service in the Hamilton region for many years became disqualified from competing for contracts in December of 2007 (Kushner, Baranek, & Dewar, 2008). This moratorium continues to this day with the exception of requests for proposals (RFPs) for medical equipment agreements, meaning that organizations holding contracts will continue to do so unless contracts are terminated (see Chapter 4 for a discussion of grounds for termination) and agencies not currently holding contracts cannot bid for new contracts. New contract templates, funding/payment models and performance indicators that will move home care delivery towards an outcome-based care model are currently under development for CCACs. Under this model contracts will be performance based and renewable with payment based on outcomes and confirmed delivery of best practices. It was expected that by April 2013 7 the new outcomes-based reimbursement model would be put in place for HSPs currently on contract with CCACs. The new model is expected to be a combination of the existing contracts and the new outcomes-based care model that was piloted. By 2014 the model will be reexamined and “re-freshed” (OACCAC, 2013a). As of July 2013, the model was being piloted for wound care and palliative care services (OACCAC, 2013b&c). The focus of this thesis is on contract models from 2011. Although the precise model reviewed is undergoing change, there will likely be many similarities in the accountability requirements of organizations under contract in jurisdictions other than Ontario; therefore there is still value in examining the effect of those accountability requirements on HSPs. 1.1.2.2 Community care service delivery and financing in Ontario: MSAAs In Ontario, community care services are provided by a mixture of for-profit and not-for-profit volunteer driven Community Support Service (CSS) agencies. Services provided by not-forprofits can be funded through provincial, municipal and charitable sources; provincial funding for community care services is not extended to for-profit providers. CSS agencies will often charge user fees for services, sometimes on a sliding scale to accommodate different incomes, and may provide single services or a basket of services in settings such as supportive housing sites or adult day centres (Williams et al., 2009a). Services can also be purchased from not-forprofit or for-profit providers by individuals and paid for out-of-pocket or through private insurance. The MOHLTC provides funding for community care services through Multi-Service Accountability Agreements (MSAAs). These agreements are based on the foundation of the LHSIA as well on the Ministry-LHIN Performance Agreement (MLPA). The LHSIA and MLPA require the LHINs enter into service accountability agreements with HSPs. There are three types of service accountability agreements: Hospital Service Accountability Agreements (HSAAs); Long-Term Care Home Service Accountability Agreements (LSAAs) and Multi-Sector Service Accountability Agreements (MSAAs). Both CCACs and community service agencies (included in the Community Support Sector) are covered under the MSAA. The MSAA (like the HSAA and LSAA) constitute a multi-year agreement for service delivery between LHINs and HSPs (LHIN Collaborative, 2013a). 8 There have been two versions of the MSAA since its inception, the most recent covering the period from 2011-2014. This research focuses on this more recent version of the MSAA. The MSAAs are negotiated between the LHINs and sectors covered under the MSAA. The MSAA covers the accountability requirements and performance expectations the LHIN has of HSPs who receive funding from the LHIN for services (LHIN Collaborative, 2013b). Prior to signing an MSAA, an HSP must submit a Community Accountability Planning Submission (CAPS) that covers service planning, measurement and evaluation, and organizational performance (Ibid). 1.1.3 Need for study As noted above, Ontario uses a ‘public-contracting’ model for most health care, whereby it ‘buys’ services from private providers (both for-profit and not-for-profit), rather than ‘makes them by using public sector employees. The Ontario government has opted to “buy” home and community care services for eligible Ontarians through contract-based competitive procurement and agreement models. Research question one will provide a comprehensive overview of existing accountability frameworks in place for the home and community care sector. This comprehensive overview will pay particular attention to regulation for the sector since regulation has been identified as necessary in instances where governments opt to “buy” services (Preker et al., 2000). Research questions #2, #3 and #4 are particularly timely given the recent changes to accountability requirements for HSPs under MSAAs and the recent restructuring of the CCAC contracts. This research provides insight into how organizations have responded to accountability tools and how these responses are influenced by both organizational factors and characteristics of accountability demands. Few studies have examined accountability from an organizational perspective; this study provides new research evidence from which policy makers can draw while reworking accountability frameworks at the LHIN and CCAC levels. Additionally, this study highlights both intended and unintended consequences of accountability frameworks and further distinguishes between positive and negative consequences. Findings from this study will help to support the development of accountability policies that benefit both governments and the organizations being held to account. Finally, this study contributes to the broader academic accountability and organizational behaviour literature. Many studies on responsiveness to accountability frameworks have focused 9 on individual level factors such as ethical behaviour (Beu & Buckley, 2001), interpersonal exchanges (Erdogan, B., Sparrowe, R.T., Liden, R.C., & Dunegan, K.J., 2004). and concepts of personal responsibility and self-management (Dose & Klimoski, 1995). This research explores the intersection between accountability frameworks and organizational behaviour, which has not been extensively studied. 1.2 Focusing on Ontario The home and community care sector in Ontario is an excellent setting within which to explore how and why organizations respond in different ways to accountability requirements. It shares many common features of other home and community care models, including the use of case managers and multidisciplinary teams, the use of a single access point linked to regions through CCACs and LHINs (although it should be noted that clients may be able to access services through other pathways as well), and the use of a mixed funding model with some services being publicly covered while others require user fees. Furthermore, like other models, Ontario relies on a variety of different organizations to deliver home and community care services to clients accessing services through, or outside of, the CCAC and LHIN systems. Additionally, Ontario’s CCAC and LHIN systems provide many of the same home and community care services as other jurisdictions. Finally, like other jurisdictions, Ontario has focused on avoiding unnecessary institutionalized care provided in long-term care settings or acute care settings, particularly emergency rooms and alternate-level care beds in acute care hospitals. The multiple organizations delivering home and community care services in Ontario also possess many of the attributes that are theorized to impact on organizational behaviour and responsiveness. Organizations in this sector vary in size, structure, funding, geographic location and organizational goals, all of which are among the key organizational variables that are expected to affect organizational responsiveness to external demands, including accountability requirements (factors anticipated to impact on responsiveness are discussed in Chapter 2). Additionally, since home and community care organizations will often face multiple, potentially competing, demands from different stakeholders, the presence or absence of conflicting demands is another important variable in organizational responsiveness. While the focus of this research will be on the accountability frameworks used by Ontario’s CCACs and LHINs to hold 10 organizations to account for services provided, accountability demands from other stakeholders will be taken into consideration in the analysis. 1.2.1 Other delimitations and limitations This study will focus only on the home and community care sector in Ontario, with a specific focus on home and community care services delivered to the senior population to have more homogeneity with regards to service needs and population characteristics. This may limit the potential generalizability to home and community care services delivered to other populations with other characteristics. Additionally the ability to generalize findings from this study to other jurisdictions will be dependent upon which models they use to deliver home and community care, and what methods they rely on to hold community service agencies to account. However, given some strong similarities between programs, as identified above, reasonable connections can be made between the findings from this study to other jurisdictions that provide public funding for home and community care. Finally, the key informant interview explore only two geographic areas within Ontario (LHINs and CCACs) and key-informant interview sampling is purposive. This further limits the generalizability of the study to other regions. 1.3 Thesis outline This thesis consists of the following additional six chapters: Chapter 2: Theoretical Framework. This chapter explores the accountability, home and community care and organizational behaviour literature and describes the theoretical framework that guides this research. Chapter 3: Methods. This chapter describes the methods used to gather data and conduct analysis in support of this research. Chapter 4: Document Analysis Findings. This chapter presents findings related to research question #1: What accountability frameworks are currently in place for home and community care agencies in Ontario and how do the characteristics of these frameworks vary? Results of the environmental scan of existing accountability frameworks and document analysis of two accountability frameworks in place for home and community care organizations in Ontario are covered in this chapter. 11 Chapter 5: Survey Findings. This chapter presents quantitative findings related to research questions #2 and #3: What is the array of realized organizational responses to accountability requirements and how do responses vary as a function of organizational factors? Quantitative findings from the survey and environmental scan are covered in this chapter. Chapter 6: Qualitative findings. In this final findings chapter, qualitative findings from key informant interviews are presented. Results from the interviews are combined with findings from the document analysis presented in chapter 4 in order to explore propositions linked to research questions #2 and #3. This chapter also presents findings in relation to research question #4: What are the potential impacts of accountability frameworks on home care service delivery?. Chapter 7: Discussion and Conclusions. This final chapter provides an analysis and discussion of findings in order to answer the four research questions that guide this research. Two models of organizational responses and organizational factors that impact on responsiveness are presented. This chapter also offers final concluding thoughts and policy implications of the findings. 12 Chapter 2 Literature review and theoretical framework 2 Introduction This chapter introduces the theoretical framework used to guide this research project and provides an overview of relevant organizational behaviour, accountability and health services literatures, which were used to develop the framework and analyse data for this thesis. First, this chapter will explore the accountability literature, beginning with a discussion of the key characteristics of accountability frameworks. This is followed by a brief overview of the history of accountability and an examination of current forms of accountability as influenced by the New Public Management (NPM) movement. The accountability literature is used to explore the first research question: Research question #1: What accountability frameworks are currently in place for home and community care agencies in Ontario and how do the characteristics of these frameworks vary? Next, organizational behaviour theories will be examined in relation to organizational responsiveness to external demands. In particular Oliver’s (1991) theory of organizational responsiveness will be explored in relation to accountability and health services literatures in order to develop a theoretical framework of organizational responsiveness that will be used to explore research questions #2 and #3: Research question #2: What is the array of realized organizational responses to accountability requirements? Research question #3: How do responses vary as a function of organizational factors? Finally, this chapter explores the health services literature regarding best practices in home and community care service delivery, and the political science literature outlining potential unintended consequences of accountability and performance measurement that could affect the quality of care delivery. The secondary literature is used to examine the final research question: Research question #4: What are the potential impacts of accountability frameworks on home care service delivery? 13 2.1 Accountability theory Paul Thomas (1998) suggests that several key terms need to be defined when discussing accountability. Of particular importance is the distinction between accountability and responsibility. Responsibility is a broader term that includes three meanings: • • • Agency: assumes that the actor being held responsible has the power to cause events to happen and the actor feels obligated to act Accountability: “authoritative relationship in which an agent is answerable for performance and is subject to sanctions for failure to meet criteria” (p.352) Moral obligation: an actor’s sense of moral obligation to perform or not perform an action. Specifically Thomas defines accountability as “an obligation to explain and to justify how one discharges responsibilities, the origins of which may be political, constitutional, statutory, hierarchical, or contractual” (p. 352). The Canadian Healthcare Association (CHA) (2001) offers a similar definition of accountability as “the relationship that exists when one accepts responsibility that has been conferred and the duty to report back to the person or body that conferred it” (p. 3). The accountability literature suggests several key components of accountability: 1. The assigning of clear roles and responsibilities (Bergsteiner & Avery, 2009; Thomas, 1998) 2. The obligation to answer questions regarding decisions and/or actions, often termed answerability (Brinkerhoff, 2003; Thomas, 1998) 3. The enforcement of sanctions (or rewards) for poor (or good) performance (Brinkerhoff, 2003; Thomas, 1998). Sanctions can be considered in broad terms to include legal requirements, penalties, professional codes of conduct, incentives, and public exposure or negative publicity. Based on these definitions, identifying accountability relationships should include three components: “to whom” (to whom are you answerable), “for what” (responsibilities), and “at what cost” (sanctions). It is also important to discuss “how” accountability is pursued. 2.1.1 To whom: Complex relationships and accountability webs The question, “To whom is an organization answerable?” is not necessarily as simple as one organization answering to another. A single organization may have multiple accountability relationships with governments, individuals and groups that hold them to account for their actions. Bergsteiner and Avery (2009) suggest that rather than single relationships, it is more 14 likely that organizations are part of a complex set of relationships, known as accountability webs, which can include bi-directional or mutual accountability between parties. The “to whom” aspect of accountability is further complicated by the direction of the accountability relationship. Bergsteiner and Avery (2009) developed a multiple constituency matrix to better understand the complexities of accountability relationships. A key aspect of the matrix is identifying whether accountability relationships are mutual (or bi-directional), unidirectional, or self-based. Organizations may also experience horizontal accountability with peers or equal stakeholders in instances where there are mutual relations between accountors and accountees or where there are instances of networks (Schillemans, 2008). It is likely that home and community care agencies are also part of broad accountability webs and may have multiple varying accountability relationships with many different organizations, groups and individuals. We can also expect that the relationship with multiple stakeholders will vary in terms of the direction of the relationship or may exist horizontally. Horizontal accountability may be particularly prominent in the home and community sector as new service networks of agencies emerge, like the Community Navigation and Access Program (CNAP) in 1 Toronto, Ontario. 2.1.2 For what: Purposes, roles, relationships and citizen engagement The “for what” component of accountability can be examined in terms of three key characteristics: the purposes of accountability, the roles and responsibilities that agents are accountable for, and the role of citizen engagement. 2.1.2.1 Purposes of accountability Brinkerhoff (2003 & 2004) suggests that defining accountability relates to specifying the purpose of accountability. He identifies three types of accountability: financial, performance and political/democratic. First, there is financial accountability that concentrates on procedural compliance using auditing, budgeting and accounting tools to track and report on the use of 1 CNAP is a network of community care agencies that aims to improve the coordination and access of community support services in Toronto through a collaborative of over 30 agencies (see www.cnap.ca for details about this network). 15 financial resources (Brinkerhoff, 2003). The government (often finance and planning ministries) will exercise oversight and control internally over ministries and agencies, but also externally over other agencies’ procurement processes and contracts (Ibid). Government ministries and agencies who are purchasers of services are able to exercise sanctions for financial accountability through their contracting arrangements (Brinkerhoff, 2004). Second is performance accountability that focuses on outcomes. Performance accountability asks organizations and agencies to account for their performance with an emphasis on services, outputs and results. Often parties are held to account to set performance targets (Brinkerhoff, 2003). Performance accountability is intended to “support and promote improved service delivery and management through feedback and learning” (Brinkerhoff, 2004, p.374). Performance accountability is linked to financial accountability in that financial resources used to produce particular goods and services for citizens must be accounted for (Brinkerhoff, 2004). The key difference is that financial accountability focuses on the process of using financial resources to support the provision of goods and services, while performance accountability focuses on the results of providing those goods and services (Ibid). It is important to note that performance is not necessarily equivalent to quality. A significant issue arises when trying to both define and measure performance in a meaningful way. As Thomas (1998) aptly points out: “Not all types of programs are equally amenable to results-based accountability. There are definitional and technical problems with performance measurement, especially when ‘soft’ services are being delivered, and these call into question the validity of such measures” (p. 379). Definitional issues identified by Thomas are particularly complex when considering the multifaceted nature of quality measurement in health care service delivery. Health care quality could include any of the following aspects of quality: input quality, health care process quality, healthcare product quality, health gain, and patient satisfaction (van den Heuvel, Niemeijer, & Does, 2013); however, performance accountability tends to focus primarily on outcomes (Brinkerhoff, 2003). Furthermore, different stakeholders will be interested in different aspects of performance (Thomas & Palfrey, 1996). Thus, determining what is important to measure in terms of performance and quality will differ depending on who is asked. We must therefore be cautious and refrain from equating performance accountability with accountability for quality. 16 Finally, there is political/democratic accountability that focuses on how government fulfills public trust, represents citizens’ interests and responds to the needs of society (Brinkerhoff, 2004, p.374). One of the central concerns of political accountability is equity with regard to fair 2 distribution of services and resources (Brinkerhoff, 2003). Political/democratic accountability is aligned with performance accountability in instances where delivering services is considered to be responding to citizens’ needs (Brinkerhoff, 2004). Of particular importance in political/democratic accountability is “building trust among citizens that government acts in accordance with agreed-upon standards of probity, ethics, integrity and professional responsibility” (Ibid, p. 374). The three different purposes of accountability are used to: 1) control the misuse and abuse of public resources and/or authority; 2) provide assurance that resources are used and authority is exercised according to appropriate legal procedures, professional standards, and societal values; and/or, 3) support and promote improved service delivery and management through feedback and learning (Brinkerhoff, 2004, p. 374). 2.1.2.2 Roles and responsibilities The accountability literature suggests the importance of assigned roles and responsibilities between parties in an accountability relationship. Expectations, norms and obligations that are clearly understood by both parties, along with role clarity will contribute to stronger accountability relationships (Bergsteiner & Avery, 2009; Thomas, 1998). Clearly defined roles that are reinforced through shared norms encourage desired behaviours (Frink & Klimoski, 2004), thus enhancing accountability. 2.1.2.3 Enhancing citizen engagement Abelson and Gauvin (2004) suggest that citizen engagement can serve to enhance accountability by supporting answerability, sanctions, and the building of relationships. Most importantly for Abelson and Gauvin, citizen engagement can support the development of trust between citizens and governments and/or health care service providers, which could in turn encourage 2 While there are multiple definitions of equity, for the purposes of this thesis equity is understood as Brinkerhoff’s concept of equitable distribution of services and resources. 17 relationship building. They consider relationship building to be a strong accountability tool that relies less heavily on sanctions as compared to other tools. Furthermore, relationship building contributes to ensuring decision-making is transparent, and improves direct public accountability. This view acknowledges the possibility of bi-directional accountability relationships enhancing relationship building and trust, instead of unidirectional relationships that are more about control. Accountability frameworks that employ citizen engagement mechanisms can thus be argued to support trust and strengthen accountability relationships. 2.1.3 At what cost: Answerability and sanctions Brinkerhoff suggests that answerability and sanctions are two key aspects of accountability. Answerability involves the “obligation to answer questions regarding decisions and/or actions” (Brinkerhoff, 2003, p.5), and is regarded by Brinkerhoff to be the “essence of accountability” (Brinkerhoff, 2004, p.372). Answerability is associated with two activities: 1) the reporting and monitoring of processes and outputs associated with activities; and 2) providing explanations and justifications for actions taken. Strategies that support answerability may include regulation, oversight, monitoring and reporting (Brinkerhoff, 2003). Answerability alone is not enough ensure strong accountability. Sanctions associated with answerability are what give “teeth” to accountability. Brinkerhoff (2004) argues that health policy sanctions are most often related to regulation related to: 1) licensing and accreditation of health care professionals and frontline workers; 2) health care financing and pay for performance; and 3) quality assurance policies. Sanctions can also include professional codes of conduct, incentives (to encourage and discourage behaviour), and soft sanctions (public exposure and publicity) (Brinkerhoff, 2003 & 2004). Included in incentive structures is the use of market mechanisms, such as privatization and competition, to ensure performance accountability sought through contracts. As discussed above, the use of contracting in health care, and across the public sector, has become more prominent under NPM (defined in Section 2.2.2 in this chapter). Enforcement of sanctions can range from broad legal enforcement to internal agency monitoring systems. 18 2.1.4 How accountability is pursued: Policy instruments Accountability can be pursued and enforced using policy instruments, which are defined as the means and methods that governments use to shape policies toward defined goals (Howlett & Ramesh, 1993). Many authors have sought to classify and define policy instruments used by governments to identify why some instruments are chosen over others. Linder and Peters (1989) identify seven classes of policy instruments: direct provision, subsidy, tax, contract, authority, regulation, and exhortation. The broad policy instrument literature suggests there will be necessary trade-offs that occur when choosing one instrument over another. According to Linder and Peters, the policy instrument literature points to three basic relationships that frame the central trade-offs: “1) the higher the precision of the instrument, the less intrusive it is likely to be; 2) the less intrusive the instrument, the less likely it is to arouse public opposition, but 3) the higher its precision, the more complex and costly the instrument is to administer” (Ibid, p. 46). Linder and Peters suggest that the choice of policy instrument, and the subsequent trade-offs of that decision, will depend on the relative value decision-makers place on the four instrument attributes: resources intensiveness, targeting (precision and selectivity of the tool), political risk (the support and opposition for that tool and the public visibility of the issue), and constraint (the coerciveness of the tool). To determine why certain policy instruments are chosen over others, Howlett and Ramesh put forward a spectrum of substantive policy instruments that exist along a continuum between goods and services delivered by the government to goods and services delivered by private organizations. The choice of instrument along this spectrum is determined by the stated capacity to affect delivery of the good or service and the networks of social actors whom the state must influence. Direct provision of goods and services are theorized to occur in instances when state capacity to do so is high and policy subsystem complexity is low (Howlett, 2000). Doern and Phidd (1992) offer a similar model of policy instruments in which instruments vary by level of coercion. However, in their model the choice of instrument is influenced by both the actual coerciveness of the tool as well as the perception of coerciveness (Doern & Phidd, 1992). Doern and Phidd’s (1992) model suggests five policy instruments, which can be used as both the means and the ends through which political goals are pursued. These include self-regulation (private behaviour), exhortation, expenditure, regulation (including taxation), and public 19 ownership. The choice of instrument is influenced not only on the level of coerciveness of the tool, but also by ideas and values embedded in the policy process (Doern & Phidd, 1992). The ideas around “legitimate coercion involved in governing” and other ideological views held by governing bodies will play an important role in helping governments decide which tools to use (p.97). Doern and Phidd’s model of policy instruments will be used for this analysis to help identify the level of coercion associated with accountability policy while taking into account the role of dominant ideas in selecting policy tools. Coerciveness and impingement on organizational autonomy are theorized to affect organizational responsiveness to external demands. Thus, determining the level of coercion exerted by an accountability tool is an important factor in this study. Furthermore, this model provides insight into the politicized nature of instrument choice, which is particularly important in an NPM era in which accountability policy has been ideologically driven. 2.2 History of accountability and new public management 2.2.1 Traditional accountability Accountability in Canada has traditionally been associated with the constitutional conventions of responsible government and ministerial responsibility (Kernaghan, 2002). Ministerial responsibility has both collective and individual dimensions: collective ministerial responsibility requires the cabinet (consisting of cabinet ministers) to resign in the event of a vote of nonconfidence; individual ministerial responsibility requires ministers to answer to the legislature (who represents the citizenry) for their actions and for the actions of their department, and resign in the event of gross error (Ibid). This form of accountability occurs vertically in that each individual working in the government must answer to a superior, with the “ultimate” authority being the citizens who have the constitutional authority to “pass judgment” on the people they elect. In this way accountability is intended to promote democratic control, compliance, and continuous improvement in the use of resources and public authority (Aucoin & Heintzman, 2000; Aucoin & Jarvis, 2005). In vertical accountability structures, the relationships of importance are between citizens and governments and/or citizens and public institutions (Abelson & Gauvin, 2004). Traditional 20 accountability structures are considered central to representative democracy since they keep citizens in a position of power (Aucoin and Jarvis, 2005). The need for “transparent and timely information on who is responsible to whom for what” is of particular importance (Axworthy, 2004, p.2); clear information is necessary for citizens to be able to hold the government and public institutions to account. The role of the citizen in this relationship is to provide (and potentially withdraw) legitimacy and power to the government by voting; the role of government is to meet their responsibilities and maintain the authority given to them by the public by answering and accounting for their actions. Flood and Sinclair (2003) suggest that traditional forms of accountability provide accountability for the “big picture” only. They argue that more specific forms of accountability are required in order to take into consideration the type of decision-maker and the type of decision or action taken. In health care there have been a number of different accountability models to address these specific contextual factors highlighted by Floor and Sinclair; however, traditional accountability sets the foundation for these specific accountability mechanisms and thus must be considered in any analysis of accountability in Canada. 2.2.2 New public management Between 1985 and 2000, the Canadian public service underwent major changes guided by neoliberal ideas, which held that the private sector, by way of using market principles, could offer a greater choice of more cost-effective services than could governments (Charih & Rouillard, 1997; Dyck, 2008). Christopher Hood retrospectively termed the neoliberal influenced administrative principles implemented in Australia, New Zealand, the UK and Canada as New Public Management (NPM) (Lynn Jr., 2006). NPM claims to improve performance and efficiency in the public service by providing managers with greater decisionmaking autonomy and imposing performance management models. Thomas (1998) suggests that part of the “reinventing government” philosophy of NPM was the assertion that “’steering” (policy determination) should be separated from “rowing” (the operation of programs and the delivery of services)” with the role of the government being to steer rather than row (p. 370). Essentially, NPM is intended to provide managers with more time to manage the big issues instead of micro-managing the small issues (Christensen, Fimreite, & Lægried, 2007). It is 21 important to note that Canada has taken a more cautious and restrained approach to NPM reforms when compared to other countries like the UK and New Zealand (Aucoin, 2002). Bresser-Pereira (2004) suggests that NPM is characterized by a decentralization of resources and power, a move towards contracting out and outsourcing public services; strengthening accountability for agencies and social organizations; strengthening the civil service; increased decision-making autonomy for policy-makers and civil servants; establishing an incentive system (which includes the use of performance evaluation); and, the adoption of information technology. Of note is that NPM increases the focus on accountability as opposed to traditional forms of ministerial responsibility and pays special attention to “technical arguments about how to enhance accountability in government” (Gregory, 2003 p.444). With the rise of NPM, the use of contracting out services rose significantly. This is not surprising given that contracting out is argued to improve efficiency, cut public service costs, reduce the size of the state, and enable governments to manage results (Phillips & Levasseur, 2004) all which are aligned with the ideals of NPM. Thomas (1998) suggests that NPM reforms have had significant implications for how accountability is pursued, particularly under privatization, commercialization, public-private partnerships, contracting out and market testing. With regard to contracting Thomas asserts that: To be successful at contracting out, governments must be willing and capable of stating their policy and program goals with reasonable precision in order to give direction to and to monitor the performance of private contractors. At the administrative level there must be the organizational capability to refine goal statements, negotiate contracts, monitor contracts, and insist upon results in terms of cost savings, service quality, and the integrity of the process (Thomas, 1998, p.377). The influence of NPM reforms on accountability has also occurred in the health care sector. Tuohy (2003) suggests that the NPM movement, along with the development of information technologies required to measure and monitor performance, have resulted in a shift towards contract model accountability in the health care sector. The model was adopted more wholeheartedly by nations who underwent internal market reforms, such as the enhancement of private markets and the importation of market-type instruments in the public sector (Ibid). Strict accountability measures that tend to focus on control and financial accountability with an emphasis on concrete deliverables have come along with contracted services (Phillips & 22 Levasseur, 2004). There has also been a push for performance measurement methods. Clark and Swain (2005) argue, “most management improvement initiatives in the federal government over the last half century have been rooted in some variant of results (or performance) measurement” (p.457). While some have argued that NPM is no longer the dominant ideology guiding governance today (Dunleavy, Margetts, Batow, & Tinkler, 2006) many of the policy tools and structures that were influenced by NPM remain and continue to inform accountability policy. 2.3 Organizational behavior, responses and characteristics The organizational behaviour theory literature provides theoretical grounding from which to answer research questions #2 and #3 that ask: What is the array of realized organizational responses to accountability requirements and how do responses vary as a function of organizational factors? Two bodies of theory from this literature, resource dependence theory and institutional theory, are particularly useful in understanding how organizations respond to external demands, and what factors may be involved in those responses. Resource dependence theory suggests that organizations are “loosely-coupled” to their environment, which offers organizations some flexibility in their responses to environmental stimuli (Pfeffer & Salancik, 1978). From this perspective, organizations are not expected to react to every environmental factor they come in contact with. Rather an “organization’s likelihood of response to any given demand will increase with the importance of the resource provided and the interest group’s level of control over that resource” (Banaszak-Holl, Zinn, & Mor, 1996, p. 99). This theory suggests that organizational effectiveness is an external standard which judges how well an organization is meeting demands and expectations of external groups (Pfeffer & Salancik, 1978). According to resource dependence theory, an organization’s likelihood of compliance to accountability is based on the degree to which it is dependent on the external actor imposing the control. As there are a multitude of vital resources that are likely secured from a variety of different stakeholders including funding, human resources, legitimacy, accreditation and market share, this may lead to multiple dependence relationships. Institutional theory provides another perspective on organizational conformity, which may provide added insight into why an organization will (or will not) comply with accountability demands. Institutional theory and resource dependence theory emphasize that the social environment imposes “constraints on organizations that affect[s] how they look – their structures 23 – and what they [do] – their practices” (Pfeffer & Salancik, 2003, p. xv). However, while resource dependence theory focuses on transactions and exchange of resources, institutional theory emphasizes social rules, expectations, norms and values as the key drivers of organizational conformity (Ibid). DiMaggio and Powell (1983) suggest that isomorphism, the constraining processes that force organizations within the same environment to become similar, is the process which best captures organizational propensity towards homogeneity. Isomorphism can occur through three different mechanisms. Coercive isomorphism: Results from both formal and informal demands placed on target organizations from external organizations upon which the target organization is dependent. It also results from cultural expectations from the society in which the organization resides. Coercive isomorphism can occur as a direct response to government mandate, like accountability requirements. Mimetic isomorphism: Occurs when organizations model themselves against other organizations in their environment during times of uncertainty. Normative isomorphism: Results from normative pressures that stem primarily from professionalization, specifically: 1) The formal education process through which professionals gain their skills and legitimacy; and 2) the growth and elaboration of professional networks. Individuals who share a profession are more likely to operate under the same norms. Normative isomorphism related to professionalism may be particularly important in accountability relationships. Bergsteiner and Avery (2009) suggest that informal norms and selfaccountability (which could be derived through professional norms) are important sources of accountability. Frink and Klimoski (2004) further suggest that individuals are likely to be strongly attached to their perceived roles, in which case, it is important to ensure alignment of external expectations (such as accountability requirements) to internal expectations (that are derived from an individual’s role or profession) in order to avoid work stress in the form of role ambiguity which could lead to cynicism and unpredictable behaviour. The attachment to a perceived role could be extended to the organizational level in that an organization may see itself as playing a role, which will dictate a set of norms to which it adheres. Institutional and resource dependence theories both assume that an organization is driven by its desire for survival. This underlying assumption may be particularly powerful in determining organizational responsiveness to accountability requirements given that, according to the organizational ecology literature, organizations that can readily demonstrate accountability and 24 reliability are favourable and more likely to survive (Hannan & Freeman, 1984). Of concern is that organizations may engage in undesirable behaviours in order to be perceived as accountable. Resource dependence and institutional theories of organizational behaviour can help to identify how an organization will react to external demands, which can help determine whether an organization is likely to comply with demands or engage in activities that give the illusion of compliance. 2.3.1 Organizational responsiveness framework Oliver (1991) suggests that resource dependency and institutional theories can be combined in order to help predict organizational strategic responses to external influences. As noted above, these two theories highlight key aspects of accountability theory and when applied in combination, can be used to determine how organizations respond to accountability requirements imposed from their external environments. Combining insights from institutional and resource dependence theories help to demonstrate how organizational behaviour “may vary from passive conformity to active resistance in response to institutional pressures, depending on the nature and context of the pressures themselves” (Oliver, 1991, p. 146). A particular strength of this approach is that it addresses a major criticism of institutional theory, the overly passive and conforming depiction of organizational response it offers; the inclusion of resource dependence theory incorporates the potential for variation in degree of choice, awareness, proactiveness, influence and self-interest. Additionally, the resource dependence perspective highlights such potential advantages of non-compliance, not dealt with by institutional theories, as: maintaining autonomy over decision-making, flexibility to allow for continuous adaptation, and latitude needed to alter or control the external environment in line with organizational goals and objectives. Oliver suggests there are five predictors of organizational strategic response to external stimuli: cause, constituents, content, control, and context (defined and discussed in greater detail in the following section). Oliver’s model has been previously explored and supported in the literature (Goodstein, 1994; Ingram & Simons, 1995; Proenca, Rosko, & Zinn, 2000; Modell, 2001). Proenca et al. (2000) use this framework to conceptualize community orientation in hospitals as a strategic response to environmental pressures. The findings from this study supports Oliver’s model and concur with Oliver’s contention that: 25 “Organizational responsiveness to environmental pressures is influenced by causal expectations underlying pressures, dependence on constituents who exert the pressures, congruence between environmental demands and organizational goals, exposure to environmental institutions, and the responsiveness of other similar organizations in the area” (Proenca et al., 2000, p. 1025). Another study conducted by Ingram and Simons (1995) uses Oliver’s framework to explain organizational responsiveness to work-family issues. This study also finds strong support for Oliver’s conceptualization of factors that affect organizational responsiveness to external institutional pressures. Given the strong links between resource dependence and institutional theories and accountability issues, Oliver’s framework is used to anticipate organizational responsiveness to accountability requirements. 2.3.1.1 Possible organizational responses Oliver’s framework puts forward a number of possible organizational strategic responses to external pressures that vary from passivity to active resistance. In the analytical framework used for this thesis, responses theorized by Oliver have been collapsed into two categories: compliance and non-compliance. Creating two broad categories of responses helps to operationalize responses but still acknowledges the multiple forms of non-compliance originally theorized. Compliance: This response represents total conformity to external demands. While Oliver’s original conceptualization of acquiescence includes three different forms (habit, imitation and compliance) it is expected that home and community care organizations will be more likely to engage in compliance only as this relates to a conscious obedience to requirements. It is unlikely that an organization will blindly or unconsciously respond to accountability frameworks which are knowingly imposed on them. In the home and community care sector this response may be operationalized as winning contracts/agreements, meeting all reporting requirements stipulated in contracts/agreements, and the perception of strong compliance by managers who oversee contracts/agreements. Non-compliance: Oliver’s framework in combination with the accountability and home and community care literatures suggests three potential forms of organizational non-compliance that may occur in the Ontario home and community care sector. 26 Compromise and Manipulation: When organizations are confronted with conflicting demands from multiple constituents they may attempt to balance, pacify or bargain these demands. Compromise tactics are said to “represent the thin edge of the wedge in organizational resistance to institutional pressures” (Oliver, 1991, p. 153). Oliver suggests that organizations will bargain with government agencies on service standards and accountability requirements. Frink and Klimoski (2004) assert that accountability relationships are often negotiated, and that the negotiation process may influence reactions to accountability. Compromise activities may thus occur before accountability requirements are put in place, which can also lead to other responses (such as compliance) after implementation. Other compromise tactics may include shifting of services delivered and/or populations served, and/or engaging in partnerships/sub-contracts or mergers. Manipulation, while originally set out as a separate organizational response, is related to the negotiation tactics used in setting accountability frameworks. Oliver defines manipulation as “the purposeful and opportunistic attempt to co-opt, influence, or control institutional pressures and evaluations” (Oliver, 1991, p. 157). This response involved the exertion of power to actively change the content of the pressures or expectations. Organizations that are able to exert greater power may be more successful in early negotiation processes over accountability requirements stipulated in contracts. This response can include winning contracts/agreements, engaging in negotiation before the awarding of contracts/agreements, and the subsequent meeting of reporting requirements stipulated in that negotiation process. Avoidance: Oliver defines avoidance as an attempt by organizations to preclude the necessity to conform. Avoidance is achieved through concealment, buffering and escape tactics, and is motivated by the organizations’ desire to circumvent conforming behaviour altogether. This response can be operationalized as organizations who win contracts/get agreements who then do not conform to all requirements; resulting in sanctions or reduced contract volumes. This response can also be operationalized as organizations that stop competing for contracts/agreements after previous successful (or unsuccessful) attempts; this may indicate that an organization is attempting to avoid the accountability requirements attached to contracts. Defiance: Defiance involves an active form of organizational resistance to external pressures. These range from dismissal to challenge to attack. This response represents a full rejection by the 27 organization of the external pressure being enforced and is most likely to occur when organizations perceive the cost of defiance as low. This response may be operationalized as organizations that lose contracts/agreements due to non-compliance with the terms of the contracts. Defiance can also be demonstrated by perverse behaviours organizations engage in to meet accountability demands. These responses are summarized in Table 2-1: Table 2-1: Potential organizational responses to institutional pressure. Source: adapted from Oliver (1991, p.152). Level of Response Description resistance Low Compliance Winning contracts/agreements, meeting all reporting requirements stipulated in contracts/agreements, and through the perception of strong compliance by managers who oversee contracts/agreements. Compromise Winning contracts/agreements, engaging in negotiation & before the awarding of contracts/agreements, and the manipulation subsequent meeting of reporting requirements stipulated in that negotiation process, shifting of services delivered and/or populations served, and/or engaging in partnerships/sub-contracts or mergers. Avoidance Organizations who win contracts/get agreements who then do not conform to all requirements; resulting in sanctions or reduced contract volumes. Organizations who stop competing or applying for contracts/agreements after previous successful (or unsuccessful) attempts. High Defiance Organizations who lose contracts/agreements due to noncompliance with the terms of the contracts. Organizations that engage in perverse behaviours to meet demands. 2.3.1.2 Organizational factors that may affect responsiveness Oliver’s model suggests there are five factors that will influence organizational responses. These factors can be used to identify the organizational elements that are likely to affect how an organization will respond to accountability frameworks. The five predictors are linked to the accountability and home and community care literatures in order to generate a set of hypotheses to be tested in relation to research question #3 which seeks to determine what factors affect organizational responsiveness. Cause. Cause refers to the set of expectations, rationale, or intended objectives that underlie environmental pressures on organizations. Oliver suggests expectations can fall into two 28 categories: social fitness (legitimacy), and economic fitness (efficiency). Social fitness refers to the laws and regulations that affect organizations, while economic fitness refers to financial accountability of organizations to their stakeholders. Oliver proposes that when an organization anticipates that conformity will enhance social or economic fitness an organization will be more likely to comply; essentially, the organization needs to perceive the demand as improving its social legitimacy and/or attainable economic gain. However, if there is skepticism regarding the legitimacy or utility of conformity, organizations will compromise on requirements, avoid certain conditions, or manipulate conditions of conformity. The cause construct suggests that an organization’s response will depend upon the degree to which the organization “agrees with and values the intentions or objectives that stakeholders are attempting to achieve” (Oliver, 1991, p. 162). Looking at accountability in the home and community care sector, pressures that would make an organization more “socially fit” may include meeting accreditation standards or adhering to regulations imposed on frontline workers (either professional or non-professional). High quality of care ratings (either through performance measures or from client satisfaction surveys) could also improve an organization’s social fitness. An accountability framework that requires an organization to adopt certain accounting or business practices could improve its economic fitness. While Oliver suggests perceived utility is the key attribute here, Proenca et al. (2000) indicate an organization’s visibility is essential to its willingness to acquiesce to the demand. Their study found organizational size had a significant positive impact on degree of community orientation in hospitals, supporting their claim that larger organizations are more visible than smaller ones and so will experience additional pressure to conform to external demands to demonstrate legitimacy. It can be hypothesized that large community service agencies will similarly feel additional pressure to conform to accountability frameworks as compared to smaller agencies. Proposition 1. Larger organizations will be more likely to comply with accountability requirements. Alternately, larger organizations will be more likely to have better access to resources (Banaszak-Holl et al., 1996). Better access to, and control over, resources will enhance an organization’s power (Bjoe & Whetten, 1981), which may allow for an organization to avoid or manipulate external influences, like accountability requirements. As this potential exertion of 29 power is closely related to an organization’s access to resources, this variable is captured in the concept of resource dependency addressed by Proposition 2a. What is important to note here is that organizational size and resource dependency are related variables, both of which potentially influence organizational responsiveness. The intersection between these variables will be explored in the final analysis in Chapter 7. Constituents. Organizations will often have relationships with multiple constituents such as the state, professions, interest groups, and the general public. Different constituent groups will impose a variety of regulations, laws, and expectations on organizations which may be conflicting. Oliver argues that organizational compliance is most likely to occur when multiplicity, the degree of conflict between multiple constituent expectations inflicted on an organization, is low. When multiplicity is high, Oliver’s framework proposes that alternative organizational responses are more likely. Multiplicity is an important factor in determining organizational responsiveness to accountability requirements as organizations, particularly health care organizations, will often face a number of differing accountability requirements from multiple stakeholders. As previously stated, accountability demands between organizations may be unidirectional, bidirectional, self-based (Bergsteiner & Avery, 2009), or horizontal (Schillemans, 2008). The resource dependence and institutional perspectives of organizational behaviour highlight how the level of dependency an organization has on its stakeholders will influence organizational responses to external constituent demands. Oliver suggests that higher conformity will be observed in cases where an organization is highly dependent on the stakeholder that is exerting the pressure to conform. Dependency may stem from an external organization’s direct control of needed resources, and also through an external organization’s ability to indirectly control the flow of resources; a process known as influence pathways (Frooman, 1999). Influence pathways are an important factor to consider when identifying strong dependency relationships, as organizations may be dependent on external actors who do not have direct control of needed resources. Furthermore, this demonstrates that multiple constituents may work together to exert influence over a single organization. Carsciaro and Piskorksi (2005) also highlight that dependency may be mutual, which will limit one organization’s ability to exert power over the other. In these instances we may see horizontal accountability frameworks in place. Dependency, 30 particularly for financial support, will play a role in how community service agencies respond to accountability requirements. Proposition 2a: Organizations are more likely to comply with accountability requirements from stakeholders upon whom they are highly dependent for funding. It is often the case that organizations will have relationships with multiple stakeholders (Bergsteiner & Avery, 2009) with whom they have varying dependencies. In cases where an organization has strong dependency relationships on multiple stakeholders with differing expectations, but is unable to adapt goals and values to those relationships and/or does not have strong leadership to align goals, these expectations can lead to shifting levels of compliance to accountability demands. This may occur when organizations lack resources to meet all the demands of their stakeholders, or in instances where the multiple external demands are in conflict with one another. According to Oliver’s framework, this could be viewed as a high multiplicity situation that will lead an organization to engage in compromise, avoidance, defiance, and manipulation tactics. Under conditions of high multiplicity, an organization may respond differently to different accountability requirements. For example, an HCS agency may need to produce detailed quarterly patient status reports and performance indicators to a funder. Alternately, the families of patients may demand that patients receive more average care time per day. Facing limited front-line staff time for both reporting and client care, the HCS agency may comply with the reporting requirement attached to funding, but engage in either defiance or manipulation responses to patients’ families regarding with respect to demands for additional care time. It is expected that the type of responses organizations give to competing demands (i.e. avoidance or defiance) will vary as a function of other organizational factors such as dependency and level of coerciveness of the demand (level of “control”). These relationships between variables will be explored in the analysis to help determine what type of response may be expected. Proposition 2b. Organizations that have multiple dependencies on different stakeholders with differing accountability requirements are less likely to have the same response to all requirements. Proposition 2c. When differing accountability requirements from different stakeholders are not well aligned, organizations are less likely to have the same response to all requirements. 31 Content. Oliver suggests that there are two content dimensions of external pressures that will affect how an organization responds. The first dimension is the consistency of the pressure with organizational goals, and the second is the impact of pressures on organizational decisionmaking autonomy. Organizations are more likely to conform when external pressures align to organizational goals and when these pressures do not constrain substantive organizational decisions. When goal alignment is low and pressures constrain decision-making autonomy, organizations are hypothesized to engage in avoidance and manipulation strategies (Oliver, 1991). As previously discussed, accountability may serve three functions: 1) to ensure financial accountability; 2) to ensure performance accountability; and, 3) to ensure political/democratic accountability (Brinkerhoff, 2003). According to Oliver’s framework, the degree to which these goals of accountability match those of the organization being held to account will determine the level of organizational compliance. Proenca et al. (2000) use for-profit (FP) and not-for-profit (NFP) status to determine level of content congruence, because their work suggests FP or NFP status is a strong indicator of organizational goals and therefore potentially an important variable for accountability. For example, it could be expected that FP health care agencies may be more likely to comply with financial and performance accountability requirements than political/democratic ones, while an NFP organization may be more focused on quality care and equity issues than financial concerns. Furthermore, FP corporate organizations are expected to provide a return on investment to shareholders (Deber, 2004); a relationship which is likely to affect responses to accountability requirements. Examining an organization’s mission and value statements will also provide indicators of organizational goals. Goal incongruence may lead to poorer organizational performance (Scheid & Greenley, 1997) and undefined roles and responsibilities, which may undermine the strength of accountability relationships (Frink & Klimoski, 2004). Furthermore, the use of accountability tools, such as certain performance measures, that organizations do not feel adequately reflect their performance may lead to potentially adverse effects (Clark & Swain, 2005; De Bruijn, 2007; discussed later in this chapter). While goal incongruence may lead to avoidance tactics it could alternately encourage organizations to change their goals and objectives in order to match goals of external demands (compromise tactic). One study found that performance assessments (one type of accountability framework) were used to help clarify community organizational goals and 32 priorities (Leggat, Narine, Lemieux-Charles, Barnsley, Baker, Sicotte, Champagne, & Bilodeau, 1998). In the home and community care sector organizations might shift their objectives, service mix, or population served in order to meet contract requirements. Organizations may also merge together in order to increase their access to resources required to meet contract requirements. These are both examples of compromise tactics. If the goals of the accountability framework and those of the organization are already aligned; however, it can be expected that organizations will comply with requirements. Proposition 3a. Organizations are more likely to comply with accountability requirements if they align with their organizational goals. Proposition 3b. Organizations will engage in compromising responses to accountability tools that are not aligned with organizational goals during the development and implementation stages of accountability requirements. Pressures on organizational decision-making autonomy may also affect organizational responsiveness to accountability. Some theorists contend that maintaining organizational autonomy is of utmost importance to organizations (Cook, Shortell, Conrad, & Morrisey, 1983). Sufficient organizational autonomy (along with sufficient resources and supportive political and social environments) has been found to be a key element to achieving perceived effectiveness in accountability approaches such as state long-term care ombudsman programs (Estes, Zulman, Goldberg, & Ogawa, 2004). Although physician autonomy has been a key driver in the early development of accountability in the health care sector (Tuohy, 2003), a study conducted by Harrison and Dowswell found that English general practice physicians demonstrated little resistance to bureaucratic accountability pressures which undermined their autonomy as they saw these requirements as “inevitable” (Harrison & Dowswell, 2002, p. 221). The authors suggest that when pressures are perceived as inevitable they become generally accepted in the medical discourse. Organizations may also see infringement on their autonomy as inevitable, and so will comply to external demands as occurred with the doctors in Harrison and Dowswell’s study. What may be more important than the desire for autonomy is whether an organization perceives the accountability demand as inevitable, regardless of its impact on organizational autonomy. In the home and community care sector, certain accountability requirements may be perceived as inevitable when an organization 33 is highly dependent on funding in order to survive and if the demand is viewed as inflexible. Links between dependency and autonomy will be explored in the final analysis in Chapter 7. Proposition 3c. Organizations will be less likely to comply with accountability requirements that infringe on their autonomy. Proposition 3d. Organizations will be more likely to comply with accountability requirements that are perceived as inevitable, despite their impact on organizational autonomy. Control. Institutional control describes the means by which external pressures are imposed on target organizations. Oliver suggests there are two distinct processes through which constituents may exert pressures: through legal coercion or through voluntary diffusion. Organizations are hypothesized to more readily comply with pressures when the consequences of nonconformity are highly punitive and strictly enforced. Furthermore, the extent to which pressures have been diffused or spread voluntarily through an organizational population will influence the target organization’s compliance. The accountability literature provides examples of both formal and informal methods to achieve accountability. Formal methods of control may include specific policy instruments (like those used for accountability) that can vary by level of coerciveness (Howlett, 2000). The policy implementation literature suggests more coercive forms of policy may lead to better adherence. In their study of changing sources of formal structure in the civil service, Tolbert and Zucker (1983) found mandated reform to be more rapidly adopted than non-mandated reform. It can thus be expected that accountability requirements that are enacted in law may achieve greater organizational conformity. Another formal tool is the use of sanctions. Abelson and Gauvin (2004) suggest that accountability strength will range from weak to strong depending on the consequences of noncompliance. In this view, strong accountability is associated with strong sanctions such as penalties, negative publicity and public exposure; moderate accountability is associated with answerability (the need to provide a rationale for decisions); and weak accountability is associated with relationship-building tools which promote trust and responsiveness (associated with accountability tools used in stewardship and stakeholder models). Stronger tools that elicit stronger penalties may lead to stronger organizational compliance. 34 However, the existence of coercive policy instruments and strict sanctions alone may not be enough to elicit organizational compliance to accountability frameworks. Strong accountability standards have been criticized for being overly rigid which may discourage innovative practice (Brandsen, Boogers, & Tops, 2006). It could be conceivable, then, that if an organization perceives a strong accountability tool, such as performance measurement or regulations, to be detrimental to organizational performance, it may engage in manipulative or avoidance behaviours towards the accountability requirement. What is important is whether the activities of the organization being held to account can be monitored and measured in a meaningful way. Given the relatively low measurability and observability of the home and community care sector (discussed in chapter 1) the perception of strong sanctions may be more important than the use of coercion and strong sanctions for non-compliance. Brandsen et al.’s (2006) study of soft governance3 approaches to disaster management guidelines in the Netherlands demonstrated that organizations that perceived these soft tools as formal requirements tended to adhere to guidelines strongly rather than partially as was expected. Bergsteiner and Avery (2009) further suggest that a key facet of strong accountability relationships is that individuals (or in this case organizations) believe that they will be held accountable. Proposition 4a. Organizations will be more likely to comply with accountability requirements that are perceived to carry strict penalties for noncompliance. The accountability literature also highlights the importance of informal norms-based accountability derived from professionalism and self-accountability. Informal accountability is aligned with the voluntary diffusion of control discussed in Oliver’s framework. Role theory helps to understand how informal control mechanisms affect organizational behaviour. It emphasizes the importance of relationships, and helps to predict why agents may respond to accountabilities in unexpected ways (Frink & Klimoski, 2004). Frink and Klimoski stress that norms of behaviour developed and enforced through routine work interactions are most likely to impact behaviour. Role theory can also be taken to the organizational level to help describe how organizations are more likely to adhere to organizational norms shared between organizations and enforced through interactions. Role theory would suggest that organizations may be more 3 Soft governance is an approach to accountability that involves providing unofficial guidelines to improve practice rather than hierarchically imposing mandates. 35 likely to adhere to accountability requirements if they are enforced through norms-based organizational interaction. Proposition 4b. Organizations will be more likely to comply with accountability requirements that are enforced through consistent interaction between the target organization and the organization holding it to account. Informal control can also be exerted through reliance on professional norms. As previously discussed, professionalization encourages organizational normative isomorphism which will encourage individuals who share a profession to operate under the same norms (DiMaggio & Powell, 1983). An accountability framework may rely on professionalism by requiring organizations to hire individuals who are members of a professional association, or by requiring organizations to adhere to specific regulations or pieces of legislation that govern professional behaviour (for example the Ontario Physiotherapy Act). Normative isomorphism would suggest that using professionalism in accountability frameworks could lead to organizational compliance. Proposition 4c: Organizations will be more likely to acquiesce to external demands that rely on professional norms (i.e. regulations stipulated by a professional body). Context. The final construct in Oliver’s framework is the environmental context within which external pressures are exerted on target organizations. The key dimensions of this construct are environmental uncertainty and interconnectedness, which are hypothesized to affect organizational conformity to external pressures. The resource dependence and institutional perspectives highlight how multiplicity is likely to exacerbate uncertainty and unpredictability, leading to compliance, compromise or avoidance strategies. In times of uncertainty organizations may engage in mimetic isomorphism. Thus, if an external institutional expectation has been voluntarily diffused through an organizational population it may be expected that the target organization is more likely to comply. High interconnectivity is also expected to lead to organizational conformity as interconnection facilitates the diffusion of norms, values, and shared information. As discussed above, strong interconnectivity that promotes interaction between an organization and the agent holding it to account may lead to stronger adherence to accountability through the enforcing of behavioural norms. Rather than a context construct this fits well with the control construct and is covered by proposition 4b. Regarding uncertainty there is some support in the accountability literature to suggest that when organizations are uncertain of the consequences of non-conformity to accountability 36 requirements, such as guidelines, there may be a propensity towards adherence (Brandsen et al., 2006). However, this concept may also fit into the control construct regarding an organization’s perception of the coerciveness of an accountability requirement (proposition 4a). For the purposes of accountability, interconnectivity and uncertainty fit under the control construct rather than the context construct. The accountability literature points to other contextual factors that may influence organizational responsiveness to accountability tools. While FP or NFP status may have an impact on the content construct as discussed earlier, FP or NFP status may also be an important contextual factor that will affect organizational adherence to accountability requirements. Accountability requirements, especially those in contracts with stringent rules, obligations and procedures, will often result in higher costs in terms of time, money and flexibility (Donahue, 1989). Organizations with greater access to financial and paid human resources (required to put in the time to meet accountability requirements such as writing reports) may be better able to meet accountability requirements. In the home care setting, the costs of accountability requirements have been found to hinder NFP community service agencies that tend to have less access to resources for meeting these requirements when compared to FP agencies (Deber, 2004). NFP/FP status can be used as an indicator of access to resources. Other indicators of access to resources also include organizational size (as previously stated larger organizations will have better access to resources) and ratio of paid to volunteer workers. Proposition 5a. Organizations with better access to resources will be more likely to comply with accountability requirements. Another important organizational factor highlighted by Gelfand, Lim, and Raver (2004) is the importance of taking a cultural perspective on accountability. In their study of cultural effects of accountability Gelfand et al. found that individualist and collectivist cultures will pursue and implement accountability differently. In individualist cultures accountability rests with specific people and is often formalized in explicit symbolic forms such as through manuals, regulations, and job performance analyses. Collectivist cultures see accountability as resting with entire groups and will elicit it in more informal ways such as through roles, duties, and group norms. The cultural context may be important to organizational adherence to accountability requirements. For example, if an organizational culture is collectivist, perceiving their duties as 37 intertwined, then imposing an individualist accountability tool such as performance reporting may not be perceived as legitimate and may not be adhered to. Proposition 5b. Organizations will be more likely to comply with accountability requirements that are aligned with their cultural context. 2.4 Intended and unintended consequences, perverse outcomes and the affect on quality Accountability frameworks have the potential to do more than merely hold parties to account for their actions. Accountability frameworks, and the performance measures often used to support accountability have both positive and negative unintended consequences. Research question #4 that asks “what are the potential impacts of accountability frameworks on home care service delivery” seeks to capture these potential unintended consequences. 2.4.1 Negative unintended consequences of accountability and performance measurement Accountability practices such as audits, monitoring, performance measurement and evaluation may have serious side-effects (De Vries, 2007). A study of modern accountability practices (such as those just listed) in the Netherlands (Ibid) found four negative unintended consequences: 1. Increased costs due to reporting requirements before (ex-ante) and after (ex-post) activities were conducted. 2. Accounts became increasingly inconsequential. 3. Increasing and noticeable bias in the reports; providing primarily positive information. 4. Practices often failed to address questions of responsibility (a key factor in strong accountability practices). It was additionally found that the erosion of traditional accountability practices in favour of these new practices resulted in other problems such as confusion regarding individual accountability, a lack of routinization, and a lack of sanctions. Although there are few studies like De Vries which examine perverse effects of accountability frameworks generally, there is a significant body of literature on the potentially perverse effects of performance measurement, which is a key component of many accountability requirements for home and community care agencies in Ontario. A number of academic papers have put forward seven potential unintended consequences of performance measurement frameworks. 38 Incenting strategic behaviour: Focusing on output measurement can lead to behaviours such as “gaming the numbers” in which outputs are achieved but through unprofessional means (De Bruijn, 2007; Townley, 2005). For example, a long-term care home may have a low rate of hip fracture; however, this may be a result of the facility opting to restrain patients to their beds or wheelchairs to prevent them from walking and thus reduce the rate of falls. Measurement may also encourage “creaming” or “cherry-picking” inputs in order to ensure more beneficial outputs. The example provided by De Bruijn (2007) is a school that excludes students with learning or behavioural problems in order to ensure high academic performance of the school. This could be highly problematic in the case of home and community care providers where low-needs seniors may be preferred over high needs seniors, as organizations may seek to exclude more challenging cases to increase the odds of high performance measures. Veiling actual performance: Aggregating and averaging performance data on a macro level could mask suboptimal performance on a micro level, or even mask or blur the causal (or lack of) connections between actions and performance outputs at the micro level. Furthermore, the average may not be reflective of the individual parts of the program and lead to invalid conclusions regarding a program’s performance. De Bruijn (2007) asserts this problem is also related to the issue of lost performance meaning, which occurs when external evaluators using performance data are distanced from the program. External actors may not understand the causal mechanisms that lead to performance results; leading them to only see output numbers rather than the complete performance story. Tunnel vision: Occurs where organizations focus on performance measures to the exclusion of other operational activities and functions. This may result in goal displacement in which organizations work towards the measure rather than towards good performance (Townley, 2005). Dis-incenting professionalism: Performance measurement may also result in disincentives for professionalism and organizational learning. For example, if professionals view measures as poor, unfair and not dynamic, they may be tempted to act in such a way as to achieve the desired measurable outcome in the short term whether or not those actions are the most appropriate ones. Related to this is an over-reliance on benchmarking which could result in an organization taking on practices from other organizations without taking context into consideration (De Bruijn, 2007). Such negative effects are caused by an over-reliance on output data only. 39 Ossification of practice and decreased flexibility: There is a danger that, once performance measures are established they will constrain behaviour resulting in avoidance of innovative methods that will not be captured by established measures (Townley, 2005). Additionally, set measures may restrain flexibility in practice and could lead to poor performance in other areas. Assuming perfection: Clark and Swain (2005) speak of “utopian management frameworks” which are “divorced from the realities with which public administrators have to deal” (p.455). These frameworks assume perfection in a vastly imperfect system which often must deal with inadequate resources, last-minute deadlines, and continuously changing organizational expectations. Clark and Swain argue that the problem lies in attempting to apply performance measurement techniques originally designed for repetitive industrial activities to unique, creative, or highly discretionary activities that are often causally distant from expected or desired outcomes. This can result in the distortion of a manager’s understanding of good management practices in the public sector as administrators struggle to meet unrealistic demands imposed by unfair performance measurement standards. Decoupling: Townley (2005) suggests performance measures will be underutilized when they are divorced from the everyday activities of the workforce, or carry costs that are perceived to outweigh their benefits. He states that when organizations deem performance measures too intrusive they may engage in decoupling behaviours in which organizational activity continues with limited engagement with those involved in collection and reporting of performance measurement. Decoupling may be viewed as a type of “avoidance” organizational response. As performance measurement is a part of the contract accountability framework used to hold home and community care to account, this response will be included as an avoidance response. 2.4.2 Positive intended and unintended consequences of accountability and performance measurement As previously stated in Chapter 1, accountability can serve to ensure public trust (CHA 2001), promote continuous improvement in the use of resources and public authority (Aucoin & Jarvis, 2005), and can incent performance improvement (CHA, 2001). Accountability can also serve to support citizen engagement in the policy process (Abelson & Gauvin, 2004). In addition to these anticipated positive consequences of accountability, there could be positive unintended consequences. In the U.S. health system some performance measures have been found to support 40 health care organizations in taking a system perspective, by examining a full sequence of care for individuals (Nolan, 2006). In their systematic review Marshall, Shenkelle, Leatherman, and Brook (2000) found that publicly reporting measures of U.S. hospitals’ performance led to the promotion of inter-organizational collaboration, internal monitoring of performance and the use of data for benchmarking across hospitals. Beyond the broad system level effects, accountability could also serve to support best practices in health care service delivery. There are a number of accountability frameworks that look to encourage high quality service delivery and support positive program outcomes. For example, results-based accountability focuses on top-line questions about program effectiveness rather than on bottom-line processes and output information (Wanderson, Imm, Chinman, & Kaftarian, 2000) the emphasis is on using accountability as a tool to improve program performance. Although results-based accountability overtly supports best-practice in health care service delivery, accountability policies can also inadvertently support or hinder best-practices. In relation to research question #4, this thesis will examine whether accountability frameworks facilitate, or create barriers to, the use of best-practices in home and community care service delivery. 2.4.2.1 Best-practices in home and community care A central goal of home and community care programs is to help individuals age-in-place (Health Canada, 2010). The literature points to three factors that play a significant role in helping seniors age-in-place: targeting strategies, integrated care, and supporting caregivers. Identifying whether accountability frameworks support or impede these factors will help determine whether existing accountability frameworks support aging-in-place and thus work towards meeting the central goal of home and community care programs. Furthermore, this literature will help to determine whether performance accountability is capturing key features of quality in home and community care services delivery; which, as previously noted, is not always achieved. 2.4.2.1.1 Targeting strategies: Addressing high-risk groups and appropriate care. The senior population is a heterogeneous group with varying care needs. A minority of high needs seniors tend to be the heaviest users of the healthcare system, and as such it is suggested that this population should be targeted first (Department of Health, 2005). Targeting individuals 41 “at-risk” of institutionalization is a key component of Balance of Care (BoC); a policy planning tool intended to identify the appropriate mix of institutional and community-based resources required to support an aging population, with a particular focus on the proportion of individuals who can be safely and cost-effectively supported in their homes and in the community (Williams, Kuluski, Watkins, Montgomery, Lum, & Ying, 2009b). Targeting strategies can play an integral role in ensuring at-risk individuals age-in-place. As targeting is an important feature of helping seniors age-in-place it will be important to determine the impact of accountability frameworks on targeting activities. Targeting practices that have been used by home and community care programs include assessment tools and strategies that assess need and ability to access care, like those used in Australia (Hales et al., 2006); multi-pronged approaches which include screening, communication and training for individuals working with the senior population; and the use of communication and information system technology (Social Data Research, 2007). Targeting strategies could also involve providing the appropriate care at the appropriate time to support healthy aging in place. In their 2003 report to the Ontario MOHLTC about community support services, the Toronto District Health Council (TDHC) recommended targeting strategies that would “maintain quality of life and independence of the senior and his/her caregiver; prevent and/or delay institutionalization, and reduce and/or eliminate caregiver burden” (Toronto District Health Council, 2003, p. i). The TDHC supports targeting strategies that would provide the most benefit to seniors in their communities rather than only targeting high-risk populations. 2.4.2.1.2 Integrated Care Another factor that is integral to helping seniors age-in-place is the provision of integrated care. Integrated care is particularly important for populations with physical, developmental or cognitive disabilities who tend to have complicated and ongoing needs, experience difficulties in everyday living, require a mix of services, and receive care in different settings (home, community and institutional), such as the frail elderly (Kodner & Spreeuwenberg, 2002). In their study of the role of community support services provided to seniors, Lum, Ruff, and Williams (2005) find that integrated care across the continuum of care, particularly when facilitated by intensive case management, is a key factor to help seniors remain independent. Integrated care 42 has been shown to lower the need for institutionalization and the desire to be institutionalized in the frail elderly population (Touringy, Duran, & Bonin, 2004). According to Kodner and Spreeuwenberg (2002), integrated care strategies should address five domains: funding, administration, organization, service delivery and clinical practice. They suggest the following strategies to support integrated care: Table 2-2: Strategies to support integrated care. Source: adapted from Kodner and Spreeuwenberg (2002, p.4). Strategy Activities Funding Pooling of funds (at various levels) Prepaid capitation (at various levels) Consolidation/decentralisation of responsibilities/functions Inter-sectoral planning Needs assessment/allocation chain Joint purchasing or commissioning Co-location of services Discharge and transfer agreements Inter-agency planning and/or budgeting Service affiliation or contracting Jointly managed programs or services Strategic alliances or care networks Consolidation, common ownership or merger Joint training Centralised information, referral and intake Case/care management Multidisciplinary/interdisciplinary teamwork Around-the-clock (on-call) coverage Integrated information systems Standard diagnostic criteria (e.g. DSM IV) Uniform, comprehensive assessment procedures Joint care planning Shared clinical record(s) Continuous patient monitoring Common decision support tools (i.e. practice guidelines and protocols) Regular patient/family contact and ongoing support Administrative Organizational Service delivery Clinical Williams et al. (2009a) note that integration is a significant problem in the Ontario context given that CCAC case managers only have access to a limited range of home care services and must work under a service ceiling. While CCAC case managers can link individuals to other needed community services, there is no mechanism to coordinate and monitor those services. 43 Community service agencies will face similar problems in that they are only in charge of the services they deliver and may not have the ability to coordinate care with other organizations and health care sectors (Ibid). 2.4.2.1.3 Supporting caregivers The availability of informal care providers is a key factor in determining whether an individual can be cared for in the home or community (Hollander & Chappell, 2002). Informal support provided by family helps recognize and affirm the need for formal assistance to elderly family members and may help facilitate entry into a formal care system and ensure needs are being met as they change (British Columbia Ministry of Health, 2004). Family caregivers of seniors with chronic conditions are vulnerable to negative mental and physical health outcomes, and may exhibit higher levels of loneliness and social isolation (Stewart, Bamfather, & Neufeld, 2006). In order to avoid these health impacts and caregiver burden five strategies have been suggested: 1) providing information and education to caregivers; 2) helping caregivers develop critical thinking skills to make healthy decisions; 3) helping caregivers employ coping strategies to reduce stress; 4) providing resources and social supports; and 5) doing assessments of caregivers and the care situation (Riess-Sherwood, Given, & Given, 2002). Supporting caregivers can also serve to support integrated care (Kodner & Spreeuwenberg, 2002). Stipulations in accountability frameworks may affect professional and non-professional support workers’ ability to provide added support to caregivers. Furthermore, accountability frameworks may include provisions that informal caregivers take on additional tasks such as filling out quality of care surveys or being available for assessments; both of which increase caregiver burden. Given the importance of informal caregivers to ensuring seniors age-in-place, an examination of the potential impacts of accountability frameworks on informal caregivers is warranted. 2.5 Literature review summary This chapter presents a theoretical framework to guide this research. The framework draws on the accountability, organizational behaviour and home and community care literatures to put forward propositions and identify independent and dependent variables to be included in the study. The accountability and political science literature will be used to identify what can be included as an accountability framework in the analysis. Furthermore, it points to key 44 characteristics of accountability tools that are linked to organizational behaviour theories in order to generate hypotheses about organizational responsiveness to accountability policy tools. The organizational responsiveness framework based on Oliver’s (1991) model will be explored in this study. Finally, the performance measurement and home and community care literatures help to identify the potential unintended consequences of accountability frameworks and how accountability potentially affects the quality of care. The literature discussed in this chapter provides guidance on how data are to be operationalized and identified. This literature will also be used to guide analysis of findings and support study conclusions and policy implications presented in Chapter 7. While additional literature that relates to research findings will be presented in Chapter 7 as well, the current literature review provides the groundwork for this study. 45 Chapter 3 Methods 3 Introduction This chapter provides an overview of the methods used to answer the four research questions proposed in this study. A sequential mixed methods approach was employed to answer research questions. Cresswell and Plano Clark (2007) provide a concise definition of mixed-methods research: Mixed methods research is a research design with philosophical assumptions as well as methods of inquiry. As a methodology, it involves philosophical assumptions that guide the direction of the collection and analysis of data and the mixture of qualitative and quantitative approaches in many phases in the research process. As a method; it focuses on collecting, analyzing, and mixing both quantitative and qualitative data in a single study or series of studies. Its central premise is that the use of quantitative and qualitative approaches in combination provides a better understanding of research problems than either approach alone (Cresswell & Plano Clark, 2007, p.5). The premise of this definition is that research problems can be better studied and understood when qualitative and quantitative approaches are combined rather than when they are used on their own (Ibid). Cresswell and Plano Clark attribute the benefits of mixed methods research over other research designs for the following reasons: • • • • • The weaknesses of both quantitative and qualitative research can be offset using a mixed methods design. More comprehensive evidence can be gathered using a mixed methods design. It helps to broaden approaches and collaborations to research inquiry. Mixed methods research encourages researchers to draw on multiple worldviews and explore perspectives that encompass both qualitative and quantitative methods. Mixed methods research is practical in that it allows researchers to use all methods available to them and is more aligned with how individuals tend to solve problems in real life. These many advantages of mixed methods research make it an attractive approach to answer the research questions put forward for this study. Mixed methods research designs can differ from study to study depending on how data are integrated and analyzed (mixing the data), the sequence with which data are gathered, and the 46 weights or priorities assigned to different forms of data (Cresswell, 2003; Cresswell & Plano Clark, 2007; Green, Caracelli, & Graham, 1989; Caracelli & Greene, 1993; Greene, 2007). An important first step in determining the appropriate research design is to identify the purpose for the mixed-methods design. In this case the purpose is complementarity which is “when qualitative and quantitative method are used to measure overlapping, but distinct facets of the phenomenon under investigation. Results from one method type are intended to enhance, illustrate, or clarify results from the other” (Caracelli & Greene, 1993, p.196). This study takes a sequential two-phased explanatory design procedure as defined by Cresswell and Plano Clark (2007). The first phase was a document analysis and survey, followed by a second phase of key informant interviews. Data from the two phases were combined to test propositions (see below for analysis methods). Cresswell (2003) defines this method as a concurrent nested strategy in which data from both quantitative and qualitative sources are needed to answer research questions. This approach allows for multiple perspectives to be considered in the analysis (Ibid). For this study both methods were employed with the emphasis varying by proposition, depending on which method provided the greater amount of evidence. 3.1 Unit of analysis The unit of analysis in this study is organizations that deliver home care services to help seniors age at home in their communities including: professional home care services (nursing, physiotherapy, occupational therapy, speech therapy, social work, and dietetic services) and nonprofessional home and community care services (personal care, homemaking, day programs, meals on wheels, friendly visitor programs, transportation, foot care, security checks, recreation/social programs, lawn and home services, and respite care). Organizations considered do not have to currently or have previously held a contract with any CCAC; nor do they have to currently or have previously held an MSAA with any LHIN. Two geographic regions in Ontario were chosen to be the focus of this study. One is primarily urban and the other is primarily rural. The regions are not identified in order to protect participant confidentiality. Representation from urban and rural settings is important as there can be significant differences in the way services are procured and delivered in these two settings in Ontario (Williams et al, 2009a). It has also been found that urban and rural regions will differ in 47 terms of seniors’ access to informal caregivers who may be pivotal in helping seniors live independently (Williams, Peckham, Kuluski, Montgomery, Morton, & Watkins, 2010). 3.2 Ethics Ethics approval for this research was granted by the Research Ethics Board at the University of Toronto in December of 2010. No other approvals were required to complete this research. 3.3 Environmental scan: Identifying the sampling frame An environmental scan of organizations that deliver home and community care services in the two regions of interest was conducted to identify the sampling frame for the study. Searches for organizations were conducted between October 2010 to May 2011. Searches were conducted using internet sources, beginning with the search engine www.310ccac.ca. This is a search engine run by the Ontario Association of Community Care Access Centres (OACCAC) to help individuals find health, home and community care organizations who deliver services in their region. A search for “home care services” was conducted for both regions of interest; this term produced findings for both home and community care organizations. Additional sites that contained organizations of interest were searched: the Community Navigation and Access Program (www.cnap.com); and, the Canadian business directory (www.canadianbusinessdirectory.ca), a business listing site for the urban centre (using keywords “seniors” and “home support”). Organizations were also searched for based on membership in known home and community care organizations and networks including the Ontario Community Support Association (OCSA), the Ontario Home Care Association (OHCA), specific home and 4 community care networks and programs , registered charity listings (Canadian Revenue Agency website, www.cra-arc.gc.ca) and any organization listed as providing contracted services with LHINs and CCACs in the two regions of this study (listed on LHIN and CCAC websites and through the MOHLTC FIM database, described below). The primary investigator conducted the 4 These networks are not named as they would identify the regions included in the study. Identification of those regions could jeopardize the confidentiality of participants in this study. 48 5 searches for the urban region first and an undergraduate student conducted the search in the rural region using the same methods. These searches provided names, contact information and, where available, websites for the organizations. Each organization was then researched by the primary investigator using the organization’s websites as well as through Google searches. These individual searches provided additional information about each organization including: • • • • • • • • • • • • Services delivered Location served Primary clientele Language/cultures served Partnerships Whether they currently hold, or ever held, any CCAC contracts or LHIN MSAAs in any part of Ontario Number of staff and volunteers Funders and funding sources and financial information. This information for some organizations was gathered from the MOHLTC FIM database6 Not-for-profit/for-profit status Organizational mission, vision and values Accreditation status Annual reports (which provided additional information such as financial information) These individual organization searches also served to exclude any organization that was not in the scope of the analysis. The environmental scan yielded 196 organizations in the urban region, and 54 organizations in the rural region that met inclusion criteria. 3.4 Phase one: Document analysis and survey The first phase of this research study consisted of data collection from two main sources: documents and a survey. In this stage the documents were also analyzed. A preliminary analysis of the survey was also conducted; however, full analysis was completed during the analysis and interpretation phase of the research. 5 This was an unpaid student intern who provided support to the project in order to gain experience in research methods. 6 http://www.mohltcfim.com/cms/client_webmaster/login_a.jsp?sectionID=website. This database lists financial, human resource, and service information reported by most organizations under LHIN MSAAs. Not all organizations under MSAAs, however, are reporting. Financial data from this site is from 2009/2010. 49 3.4.1 Document collection and analysis Online searches for relevant accountability documents were conducted between May 2009 and February 2012. For the most part documents were gathered from websites. In some cases research partners or key informants who provided insight into accountability demands on home and community care organizations in Ontario provided additional documents. See appendix 3-A for a list of documents and their sources. Documents were coded using NVivo 7 software. A sub-sample of four documents was double coded by the primary investigator and by a thesis committee member, Dr. Whitney Berta, to validate the coding scheme. Each coder used the same coding template and findings were compared. For the most part, the two coders agreed on the coding; where there was discrepancy, modifications to the coding tree and/or code descriptions were made until consensus on appropriate coding was reached. This process also identified some additional codes for the coding scheme. Once there was agreement LHIN MSAA and CCAC contract documents were coded for analysis. Documents included in the analysis were overview documents (general conditions and consultation documents), contract and agreement schedules, agreement templates, and instructions and guidelines related to contracts, agreements and/or RFP processes (see Table 3-1 for a list of all coded documents). Table 3-1: Coded LHIN MSAA and CCAC documents Organization holding to account CCAC Type of document Contracts Contract prequalification 7 Coded documents Source General Conditions Contract Schedules 1,2 & 4 Contracts Schedules 3: Nursing, Personal Support Work and Homemaking7 Instructions Prequalification for medical supplies; nursing; OACCAC website: http://www.ccacont.ca/Content.aspx?EnterpriseID =15&LanguageID=1&MenuID=1 073 Retrieved June 13th 2011 OACCAC website: http://www.ccacont.ca/Content.aspx?EnterpriseID There were no significant differences between Schedule 3 for nursing and other professional services (dietetic services, OT services, PT services, and SLP services) beyond the types of services that are included under each profession. As such only the nursing schedule was coded as it is sufficiently representative of all professional services. 50 Organization holding to account Type of document Coded documents Source personal support and homemaking; therapy. RFP process LHIN MSAAs =15&LanguageID=1&MenuID=1 059 Retrieved June 13th 2011 RFP Consultation OACCAC website: RFP Schedules: A, B, C, D http://www.ccac&E ont.ca/Content.aspx?EnterpriseID =15&LanguageID=1&MenuID=1 05 Retrieved June 13th 2011 MSAA Template 2011 TC LHIN website: CSS schedules http://www.torontocentrallhin.on. CAPS guidelines* ca/Page.aspx?id=3960&ekmensel =e2f22c9a_72_262_3960_1 Retrieved June 13th 2011 *CAPS guidelines were provided by a LHIN key informant 3.4.2 Survey development and data collection A survey was conducted to supplement the environmental scan of organizations to gather necessary variables for the study. Dillman, Smyth, and Christian’s (2009) tailored design method was used to guide survey development and distribution. The tailored design method is intended to help reduce total survey error by encouraging survey developers to attend to multiple sources of survey error including coverage, sampling, measurement and nonresponse error. 3.4.2.1 Survey sampling Cluster sampling, a method in which a specific group is sampled (Teddlie & Yu, 2007), was used for this survey. In this case the group of interest (or survey population) were organizations delivering home and community care services in the two selected urban and rural regions (see “unit of analysis” section above). The sampling frame for those regions was gathered through the environmental scan process. While the search for organizations was thorough, it is possible that some organizations in the survey population were not represented in the sampling frame, which could lead to some coverage error. It is also possible that some organizations on the list were beyond the scope of the study as there were a few organizations with limited descriptive information available. For the most part these organizations were missing required contact information and were not surveyed. 51 Surveys that are endorsed by organizations’ social networks tend to yield greater response rates (Cycyota & Harrison, 2006). In order to capitalize on social networks the OCSA (a research partner) was used to distribute surveys. The OCSA represents many of the not-for-profit home and community care organizations in Ontario. Because the OCSA had interest in the survey findings, the survey was distributed to all OCSA members, rather than to just those in the two Ontario regions of interest. Additionally, it was expected that sampling all OCSA members could yield a higher number of responses, which would allow for the use of higher powered statistical tests. Not all of the organizations in the two-region sampling frame are OCSA members; non-members were contacted directly via email or phone. Most organizations had websites and email addresses; this demonstrates that they have adequate access to the internet. Unfortunately not all organizations identified in the sampling frame could be contacted due to missing contact information or phone numbers that were no longer in service. 3.4.2.2 Survey development Another source of potential survey error is “measurement error” which refers to inaccurate or imprecise respondent answers resulting from poorly constructed surveys (Dillman et al., 2009). Following the tailored design model we strove to make the survey clear and understandable, visually easy to follow, salient and relevant to the target audience, and appropriately ordered. The initial survey was first sent to key representatives of the home and community care sector for comment. The CEO’s from OCSA and OHCA kindly provided their time to review the survey and provide feedback either by phone or in person. This process generated a preliminary survey (see Appendix 3-B) that was then entered into a web-based format using Askit.ca. Askit.ca was chosen because it is a Canadian administered website and is held to Canadian privacy laws. The survey was then piloted on six organizations that varied in size, geographic location, services delivered, not-for-profit or for-profit status, and primary clientele. These organizations answered the survey online and completed a feedback form (see Appendix 3-C) regarding their experience taking the survey. Two of the five respondents also contacted the primary investigator over the phone to discuss their experience. Most pilot subjects found the questions to be clear, 52 easy to understand, and indicated that they did not cause any uneasiness. Changes to the survey are outlined in Appendix 3-D. Obtaining feedback from representatives of the sector as well as from individuals who would be part of the target population is strongly recommended by the tailored design method of survey development (Dillman et al., 2009). This pilot study determined the understandability of questions and its feasibility in terms of whether respondents had necessary information and time required to complete it. We did not ask questions regarding ordering of question to pilot respondents as that was discussed with OCSA and OHCA representatives. No experiments were embedded into the pilot study; it was used to provide a “good sense of how the study procedures [would] work in practice” (Ibid, p.228). One key finding was that all survey respondents preferred the online method to receiving a mail survey. Thus the survey was administered online. 3.4.2.3 Follow-up telephone surveys 8 Many surveys were returned partially uncompleted. The most prominent gaps were organizational response variables and organizational financial information. These response gaps significantly limited the ability to run desired statistical tests so the Research Services Unit in the Dalla Lana School of Public Health at the University of Toronto was hired to contact survey respondents over the phone to gather missing data. Contact information for 110 of the organizations was provided to the Research Services Unit. There were five respondents to the survey whose response left it unclear about which organization they represented, and who did not provide contact information on the survey meaning we were unable to determine who to contact. A research assistant called each of the remaining 105 organizational contacts and asked the unanswered questions to the survey over the phone. Data entry was done directly into an excel data spread sheet. Forty-six organizations were successfully contacted and completed their surveys over the phone. Using different data gathering methods may introduce additional measurement error since respondents may answer the same questions differently when asked using different modes (Dillman et al., 2009). The presence of the interviewer over the phone and the use of oral as 8 There was missing data from between 16 and 86 respondents depending on the question. 53 opposed to visual communication can influence how respondents answer questions (Ibid). It is believed that the strengths of gathering the extra data using an additional method outweighed the potential introduction of additional measurement error. 3.4.2.4 Nonresponse error Nonresponse error occurs when those who respond to the survey are different than those who did not respond along variables that are important to the study (Dillman et al., 2009, p.17). In order to reduce nonresponse error the survey was designed to appear worthwhile to potential respondents (Dillman et al., 2009). The cover letter and consent form that were included with the survey (see Appendix 3-E) clearly explained to recipients how participation could potentially benefit them as a way to increase response rates. Another method to help improve web-based (and mail) survey response rates is to use multiple contacts (Dillman et al., 2009). The survey was sent to all members of the OCSA via their listserve of 498 members across Ontario. An email which included an introductory letter (see Appendix 3-E) and a link to the survey was sent three times to the list-serve (June 28th, July 12th, and July 26th 2011). Those who were not OCSA members were emailed directly, and those without email addresses were called on the telephone. Emails were sent July 8th, 18th, and 27th of 2011. Initial calls were made August 22nd 2011 and organizations that could not be reached were called back at least once within a week. 3.5 Phase two: Key informant interviews As noted in Chapter 2, not all variables of interest could be captured quantitatively through a survey and environmental scan. In order to gather data on these additional variables required to test propositions, key informant interviews were conducted with the accountors (the urban and rural CCACs and LHINs of focus) and with the accountees (organizations upon whom accountability requirements are imposed). Interview schedules, introduction letters and consent forms can be found in Appendix 3-F. Purposive sampling was used for both groups to identify participants. Purposive sampling can be defined as “selecting units (e.g., individuals, groups of individuals, institutions) based on specific purposes associated with answering a research study’s questions” (Teddlie & Yu, 2007, p.77). This method is useful in selecting participants that have important characteristics or information that is required of a study (Ibid). 54 For both accountors and accountees purposive sampling was used to achieve comparability (Teddlie & Yu, 2007) and “criterion” sampling was used to identify accountors of interest by “review[ing] and study[ing] all cases that meet some predetermined criterion of importance” (Patton, 2002, p. 238). In this instance the criteria for inclusion was that the individual needed to be from either the LHIN or a CCAC in one of the two regions of interest, and they had to be involved at the managerial and/or director level in administering LHIN MSAAs or CCAC contracts. For each LHIN and CCAC in each region there were only one or two individuals who met the criteria, resulting in four interviews. For accountees the criterion for inclusion was home and community care organizations that had a particular response to accountability requirements associated with LHIN funding and CCAC contracts (see Chapter 2). This sampling was also used to identify one or two unique cases that would be used as part of the comparison. This method could also be considered “theory-based sampling” in which the criterion is based on an existing theory (Patton, 2002); in this instance the criterion was identified from Oliver’s (1991) theory of organizational responsiveness. It was originally hoped that the survey would identify organizations of interest, by identifying organizations that had responded differently to accountability frameworks. Unfortunately there were too few respondents from the urban and rural regions of interest that had the variety of responses that would have been required. Because the survey did not provide enough respondents who responded differently to accountability frameworks, we relied on interviewed accountors to identify organizations who exhibited the characteristics we were looking for. The accountors were asked during their interview to identify organizations in their region that engaged in one or more of the following responses to accountability requirements: • • • • • Full compliance with contracts/agreements over sustained period of time Bargaining or negotiating terms of the contracts/agreement either prior to entering the agreement Changing types of services delivered and/or populations served Merging with other organizations or partnering to deliver contracts/agreements Avoiding MSAAs, possibly after having already had previous contracts/agreements with the LHIN. Key informants provided names of organizations who exhibited responses they were aware of who met the above criteria. In some cases organizations elicited multiple responses. Fourteen 55 potential organizations were identified by key informants of whom 13 were able to be contacted; one organization was undergoing a significant organizational change and a representative was unable to make time for an interview. Four organizations delivered community care services, three delivered home care services, and six delivered both. Of the community care service providers three were from the rural region and one was from the urban region. Of the home care services providers two delivered services in both urban and rural regions and one delivered services in the rural region only. Of the six organizations that delivered both home and community care services one was rural, three were urban, and two delivered services in both urban and rural regions. The organizations included in the sample represent a range of sizes and clientele served; one organization delivers services in French (see Table 6A-1 in Appendix 6-A for a summary of characteristics of each organization. Accountee interviews were conducted with managers, directors, and chief executive officers (CEOs) at identified home and community care organizations. In some instances, organizations carried both CCAC contracts and LHIN MSAAs or had a main office and sub-offices within one or both of the two regions of interest. In these instances multiple interviews were conducted for one organization. Also in some cases there were multiple individuals from an organization who could answer questions, in these cases interviews were conducted with both individuals from the organization. While it is preferable that multiple individuals from a single organization be interviewed in order to capture multiple perspectives, in many cases there was only one individual at an organization that had the experience and position necessary to answer questions and as such only one interview was conducted. A total of 15 interviews were conducted with home and community care organizations and four interviews were conducted with CCAC and LHIN representatives. An interview schedule was prepared and sent to key informants prior to the interview. While the interview schedule was written with relevant indicators in mind, the open-ended nature of the questions was used to leave room for discussion into areas that were relevant but unexpected. Open-ended questions are intended to let the respondent provide their own answer and interpretation (Johonson & Reynolds, 2005), which allowed for the exploration of new and unexpected ideas and issues. Furthermore, in some instances, answers to questions could not be fully anticipated and so setting out a list of potential answers would not have been sufficient. Furthermore, many of the individuals interviewed can be considered “elites” because they 56 occupy senior managerial positions within their organizations. An open-ended, semi-directed structure allowed for the inclusion of elite “insider” information and helped ensure interviewees did not detect the use of standardized questions which may have limited responsiveness (Ibid). Interviews were recorded and transcribed for analysis. Coding was done using NVivo 10 software. A sub-sample of four interviews was double coded by the primary investigator and by a colleague in order to validate the coding scheme. Each coder used the same coding template and findings were compared. For the most part, the two coders agreed on the coding, and where there was discrepancy, modifications to the code description were made and consensus on appropriate coding was reached. This process also identified some additional codes to add to the coding scheme. The double coded documents were recoded using the new coding scheme and it was then applied to the remaining interview transcripts. 3.6 Mixed-methods analysis and interpretation A parallel mixed analysis technique was used to analyse the data. This is an appropriate method for mixed-methods analysis in cases where the purpose of the mixed methods design is triangulation, complementarity, initiation or expansion (Onwuegbuzie & Teddlie, 2003). As the purpose of this study was complementarity a parallel mixed analysis is appropriate. In this approach initial analysis of quantitative and qualitative data occurs separately and then the findings from the two analyses are interpreted and written up in an integrated manner (Ibid). The statistical software package SAS version 9.3 was used to analyse the survey data using logistic regression techniques, and ANOVAs. The specifics regarding which method was used in relation to the analysis of data are defined in Chapter 4 as they relate to the findings presented.9 Qualitative coding of documents and interview transcripts was done iteratively, beginning with a coding structure based on the theoretical framework outlined in Chapter 2. The coding and validation process allowed for the identification of additional codes and themes to emerge. In Chapter 7 quantitative and qualitative analysis findings are interpreted together in relation to research questions and propositions outlined in Chapters 1 and 2 respectively. 9 Including a description of the analysis method alongside findings allows for easier interpretation. 57 Chapter 4 Document analysis 4 Introduction This chapter seeks to answer the first research question posed by this study: What accountability frameworks are currently in place for home and community care agencies in Ontario and how do the characteristics of these frameworks vary? Findings from environmental scan and document analysis (see Chapter 3 for details regarding data gathering and analysis) are used to answer research question #1. Findings related to this research question are focused on the three main components of accountability, previously defined in the literature review (see Chapter 2): “to whom” (to whom are organizations held to account), “for what” (what responsibilities are organizations held to account), and “at what cost” (what are the consequences of noncompliance). Exploring these three aspects of accountability contributes to answering the research question. This chapter examines most of the groups that hold home and community care agencies in Ontario to account (the “to whom” component) and provides general information regarding the “for what” and “at what cost” components. The “to whom” examination provides an answer to the first part of research question #1 about what accountability frameworks are in place. A more in-depth analysis regarding the “for what” and “at what cost” components is conducted for accountability frameworks that are imposed on home and community care agencies that receive funding from Local Health Integration Networks (LHINs) and Community Care Access Centres (CCACs) in Ontario. These are the main focus of the analysis as CCACs and LHINs are the primary sources of government funding for home and community care agencies in Ontario. The “for what” and “at what cost” components capture the key accountability characteristics that can vary among frameworks; an examination of these will answer the second part of the research question. 4.1 To whom: Accountability frameworks in place Like many agencies, home and community care organizations in Ontario are held to account by a number of different bodies and groups, each of which use different frameworks or tools to hold agencies to account for different reasons. Accountability requirements may be mandatory for any 58 home and community care organization to run as an agency in Ontario. Others’ requirements may be voluntary, becoming mandatory when a home and community agency chooses to compete for funding from different agencies, and must hence meet accountability demands associated with funding. Table 4-1 summarizes the mandatory and voluntary accountability frameworks in place for home and community care organizations in Ontario. It also identifies key characteristics under the headings “to whom”, “for what” and “at what cost” and categorizes the type of instrument (the “how” component) used according to Doern and Phidd’s (1992) model of policy instruments. The model was introduced in Chapter 2 and will be elaborated on in this chapter. Table 4-1: Summary of accountability approaches used in Ontario Type of Instrument (How) Regulation Accountability mechanism To whom Government legislation general Regulation/ expenditure Government legislation – linked to funding Regulation/ expenditure Government policies and guidelines – linked to funding Expenditure Expenditure For what At what cost Mandatory/ voluntary Fines and/or imprisonment Mandatory Government grants Government - General and citizens business practices - Running a health care organization Government Availability and citizens and quality of funded services Government Guidelines and citizens for the delivery of services, management of human resources, and management of funds Government Program and citizens outcomes LHIN Government Mainly for - Reduction of Loss of funding Mandatory in order to receive funding Loss of funding Mandatory in order to receive funding Loss of future funding Voluntary to apply – mandatory in order to receive funding Voluntary to 59 Type of Instrument (How) Accountability mechanism To whom (government) agreements for service provision and citizens Expenditure Contracted service delivery for the government CCAC Expenditure/ exhortation Non-government expenditure Exhortation Accountability to other stakeholders Regulatory/ expenditure/ exhortation Accreditation For what performance and financial processes and outcomes. Government Mainly for and citizens performance and financial processes and outcomes. Funders and Mainly for donors financial (sometimes performance) outcomes (i.e. annual reports) Clients and Mainly for their performance families, and service volunteers, delivery the broader community Accreditatio Mainly for n bodies performance processes and outcomes At what cost Mandatory/ voluntary funding - Loss of funding/ agreement apply – mandatory in order to receive funding Voluntary to apply – mandatory in order to receive contract Often mandatory in order to receive funding - Reduction of contract - Loss of funding/ contract. - Loss of funder - Loss of donors - Loss of clients - Loss of volunteers - Loss of community support - Loss of accreditation - In some cases loss of funding Voluntary, but will often be pursued in order to maintain support Voluntary to apply – mandatory in order to receive some funding From Table 4-1, we can see that many accountability requirements imposed on home and community care organizations are voluntary; organizations do not necessarily have to adhere to them to operate. Additionally, very few of these accountability demands are purely drawing on one particular policy instrument; instead they combine a number of policy instruments. Combining policy instruments is commonly used to help shape and guide organizational behaviour (Hood, 1983). Combining tools can help reinforce and strengthen them. For example having funding linked to regulation offers a powerful financial incentive for organizations to 60 adhere to legislation and regulations; if they do not adhere they could lose funding that may be required for the organization to survive. 4.1.1 Regulatory policy instruments: Government legislation As noted, health care in Canada is deemed to be primarily under provincial jurisdiction. The government of Ontario has many laws, regulations and policies in place that seek to control behaviour and actions of home and community care organizations. Some laws broadly to NFP organizations and/or commercial businesses; some apply to health service providers more generally, while others apply specifically to home and community care organizations. These laws and regulations stipulate a series of behaviours and activities that home and community care organizations can and cannot engage in, and have associated penalties for non-compliance. The laws that apply broadly to NFP and or commercial businesses and health care organizations are regulatory policy instruments that are mandatory (see Table 4-1). Regulatory policy instruments are considered to be on the coercive end of the policy instrument spectrum since they affect the financial budgets of companies and individuals who are required to comply with these regulations (Doern & Phidd, 1992). Regulations can be viewed as compulsory or “directive” policy instruments because they are intended to “compel or direct the action of target individuals and firms, who are left with little or no discretion in devising a response” (Howlett & Ramesh, 1995, p. 87). Howlett and Ramesh (1995) further distinguish between economic regulations and social regulations. Economic regulations tend to focus on the market and business practices of an organization, with the intention of correcting perceived imbalances that emerge due to regular market forces. Social regulations, in contrast, tend to apply emphasis on the moral and physical well-being of individuals served by organizations and government bodies and often apply to matters of health, safety and social practices. The mandatory regulations imposed on home and community care organizations are economic regulations. They are designed to ensure that organizations engage in lawful business practices. In general, organizations subject to these laws are accountable to government and by extension to the citizens represented by the government. Penalties for non-compliance are predominantly fines; however, in some cases may include imprisonment. Ontario laws that apply broadly include (but are not limited to): 61 Business Corporations Act (1990): This Act applies to every corporate body with share capital that is incorporated. This Act outlines a number of rules for business corporations including but not limited to how to manage corporate finance (in particular the management and sale of shares), the rights of shareholders, the application of corporate securities, guidelines regarding directors and officers, and financial statements. Offences against the Act can lead to fines or imprisonment. Corporations Act (1990): This Act applies to every corporation that is incorporated and not covered under the Business Corporations Act. Not-for-profit organizations are incorporated under this Act in Ontario. The Act outlines a number of rules for corporations including, but not limited to applying for incorporation, rules for corporations with and without share capital, and specific stipulations for different types of companies (i.e. mining and insurance). Offences against the Act can lead to fines or imprisonment. Auditor General Act (1990): This Act applies to any recipient of a government grant and requires these organizations to provide information regarding powers, duties, activities, financial transactions and methods of business that may be required by the Auditor General. Organizations who contravene access to information can be subject to fines or imprisonment. Occupational Health and Safety Act (1990): This Act applies to employees in the service of any corporation; some sections also apply to self-employed persons. The Act outlines obligations for employers in order to keep their workplaces safe, and provides employees with rights to refuse or stop work where health and safety is an issue. Employers may be subject to inspections and must comply. Offences can lead to fines or imprisonment. Accessibility for Ontarians with Disabilities Act (2005): This Act establishes accessibility standards for information and communications, employment and transportation. Standards apply to all obligated organizations (can be any organization). Offences can lead to fines. Pay Equity Act (1990): This Act applies to all employers in the private sector who employ ten or more employees, and all employers in the public sector. The purpose is to redress systemic gender discrimination in compensation for work performed by employees. It establishes a complaints process and offending organizations can be made to pay fines and back wages. It should be noted that home and community care organizations (and organizations generally) may also be subject to federal and/or municipal laws. Federal and municipal jurisdictions are, however, beyond the scope of this research. The Ontario laws listed above are not exhaustive but are among the most prominent and applicable. There are also a number of mandatory social regulations that are broadly imposed on health care organizations. These regulations will affect home and community care organizations generally, 62 in that they are often considered to be health service providers. They may not, however, apply to some individual community care service agencies that do not deliver personal support services and are therefore not considered health service providers. These mandatory social regulations include: Health Insurance Act (1990): This Act stipulates what is covered by the Ontario Health Insurance Plan. “Section 13 of the General Regulation of this Act provides and defines the eligibility criteria for professional services that CCACs provide in the home” (CCAC, 2012a). Commitment to the Future of Medicare Act (2004): This Act established the Ontario Health Quality Council (now called Health Quality Ontario) to report on health care system. Some of the Council’s reporting can affect the home and community care sector. Personal Health Information Protection Act (2004): This Act identifies the “rules for the collection, use and disclosure of personal health information of individuals” gathered during the provision of health care services. It applies to all organizations that need to gather personal health information in order to provide services. Penalties for offences include fines. Health Care Consent Act (1996): The Act provides the rules with regard to providing consent for treatment. It is intended to ensure rules are applied consistently in all healthcare settings, help facilitate treatment for those who are unable to make decisions, enhance autonomy of individuals, promote communication between health providers and patients/clients, and permit intervention by a Public Guardian if required. Offences can lead to fines. Health Protection and Promotion Act (1990): This Act “provides for the organization and delivery of public health programs and services, the promotion and protection of health of Ontarians, and the prevention of the spread of disease”. Home and community care agencies may need to adhere to stipulations in the Act in the event of public health issues (i.e. communicable diseases). Offences can lead to fines. Substitute Decisions Act (1992): This Act establishes the criteria for determining when an individual is, and is not, able to make decisions that relate to their own well-being. Offences can lead to fines. Ministry of Health and Long-Term Care Appeal and Review Boards Act (1998): This Act establishes the Health Services Appeal and Review Board that conducts appeals. Among the appeals are those regarding eligibility for service under the Home and Community Care Services Act. Controlled Acts - Regulated Health Professions Act (1991): This Act identifies specific activities that healthcare professionals can perform within their scopes of practice. Most professions under the Act have specified controlled acts which they are entitled to 63 perform. For example, nurses may perform controlled acts for home and community are agencies. Offences can lead to fines or imprisonment. 4.1.2 Regulatory/expenditure policy instruments: Legislation and policies linked to funding As discussed above a number of government policies and Acts apply only to organizations that receive funds from the government to deliver home and community care services. These accountability requirements are thus “voluntary” in the sense that organizations may not necessarily need government funding to deliver services but are “mandatory” if organizations do deliver services with government funds. Some home and community organizations perceive these as mandatory requirements since they depend on government funding to survive. These laws and policies tend to capture more specific aspects of health care service delivery and help to hold health care service providers to account for their performance and use of government funds. As was the case with laws that apply broadly (discussed above), organizations are held to account to the government (and citizens). Sanctions for non-compliance differ from the previous laws in that the main consequence for non-compliance is the loss of current and/or future funding. The laws that apply to home and community care organizations receiving funding from the 10 MOHLTC include : Local Health System Integration Act (2006): This Act establishes Local Health Integration Networks (LHINs). This Act is intended to improve access to health care services for Ontarians, help improve care coordination across the system, and support “effective and efficient management of the health system at the local level” by LHINs. The Act provides LHINs with their mandate, governance, and accountabilities. This Act is particularly important to community care service providers as it stipulates that the LHINs and health service providers must enter into a service accountability agreement in the event that the LHIN provides funding for services. Community Care Access Corporations Act (2001): This Act establishes Community Care Access Centres (CCACs) as service agencies. The Act provides CCACs with their mandate, their governance, and their accountabilities (CCAC, 2012a). 10 Home and community care organizations may be subject to laws that are linked to funding from other Ontario government ministries. These laws are beyond the scope of this study and as such are not discussed. 64 Home and Community Care Services Act (1994) (formerly the Long-Term Care Act, 1994): This Act identifies the rights of clients through the “Bill of Rights,” “defines a basket of core services and addresses complaints and appeals” (CCAC, 2012a). It is intended to ensure the availability of community services for people in their homes and communities and caregiver support services; recognition of individual preferences based on ethnic, spiritual, familial and cultural factors; quality improvement in community services; integrated care of community based and health based services; equitable access to these services; effective and efficient management of resources; community involvement; and, cooperation and coordination across health sectors. This Act stipulates how the government is able to fund and/or provide these services, and identifies how agencies can be approved to deliver services (become an official Health Service Provider or HSP). Much of this Act overviews the rules governing HSPs and the guidelines to which they must adhere. Individuals, municipalities, and corporations can commit offenses against this Act. Offences can lead to fines. There are also a number of policies to which community care service (CCS) agencies who receive funding from the LHINs must adhere. 11 The penalties for non-compliance to these policies are mainly loss of funding. The policies linked to funding include: Assisted Living Services for High Risk Seniors Policy, 2011 (ALS-HRS): Updates and replaces the Assisted Living Services in Supportive Housing Policy (1994). The policy targets high risk seniors. Individuals who meet eligibility criteria may receive personal support, homemaking, care coordination and security check services, and possibly additional CCAC services that are covered by government funds. These services are provided by agencies approved under the Home Care and Community Service Act, 1994. The intent of this policy is to reduce unnecessary or avoidable ER visits, LTC admissions and Alternate Level Care (ALC) designations, reduce hospital ALC length of stay, reduce wait-time to discharge, and increase length of time in which high risk seniors remain in their home after hospital discharge. Community Support Services Complaints Policy (2004): This policy stipulates that community support service agencies that receive MOHLTC funding must have a written client complaint policy and procedures in place. The agency must also inform clients of the client “Bill of Rights” which is described in s.3 of the Long-Term Care Act, 1994. Attendant Outreach Service Policy Guidelines and Operational Standards (1996): These policy guidelines deal with the provision of attendant outreach services for individuals with physical disabilities who require personal support and homemaking services in their own home. This policy outlines the philosophy, policy objectives and goals, and 11 It should be noted that other Ministries may impose a series of policies on these agencies, particularly if they deliver services beyond home and community care services. These additional policies are not listed here as they are beyond the scope of this research. 65 operational standards of attendant outreach services. This policy is intended to provide information and guidance to providers and consumers of attendant outreach services. Policy and Guidelines for Screening of Community Personal Support Workers (2003): This policy stipulates that agencies who receive funding from the MOHLTC must have written policies in place regarding the screening of personal support workers at the time of hiring and throughout their employment. The guidelines are intended to assist agencies in developing these policies. Community Financial Guidelines (2011): This policy stipulates that agencies who receive funding from the MOHLTC or LHIN are expected to adhere to the terms of their MultiService Accountability Agreement (MSAA) or their Ministry funding agreement. The guidelines include which expenses are funded and which are not; inclusions and exclusions from the subsidy calculations; budget reallocation guidelines; and, guidelines on the registry of assets. The policy also includes a number of financial requirements including appropriate accounting practices (Generally Accepted Accounting Principles); restrictions on borrowing; collection of payments; dealing with unspent funds; purchasing; procurement of goods and services; and funding capital expenses. An important note is that the guidelines stipulate mandatory client user fees for meals-onwheels, wheels-to-meals/diners club, transportation, meals and transportation associated with adult day services, and home maintenance and repair. Supply Chain Guideline (2009): This policy overviews procurement policies and procedures for the broader public sector. This policy applies to broader public sector organizations which receive more than $10 million per fiscal year from the MOHLTC and Ministry of Education and Training, Colleges and Universities. The policy includes guidelines for information gathering, purchasing, evaluation of bids and proposals, contract awarding, and non-competitive procurement. Policies and procedures applicable at places of work: These will vary depending on where community service agencies are delivering services. For instance if an agency sends a volunteer or employee into a Long-term care facility or hospital, that employee is expected to abide by the policies and procedures of that organization. While the above laws, policies, and guidelines capture some additional aspects of home and community care services that are not covered in other mandatory laws, they only cover organizations that are designated as HSPs and/or organizations receiving LHIN funding. 4.1.3 Expenditure policy instruments: Government spending Grants, agreements, and contracts are all examples of government “expenditure” policy instruments in Doern and Phidd’s (1992) model. Expenditure instruments are considered to be only moderately coercive as the question of “who pays and who benefits” is less easily determined than in more coercive instruments (like regulation or direct service delivery). 66 Howlett and Ramesh (1995) consider these tools to be a mix of mandatory and voluntary instruments that “permit the government varying levels of involvement in shaping the decisions of non-state actors, while leaving the final decision to private actors” (p. 91). These tools are voluntary in the sense that organizations can choose whether to seek funding, but they are mandatory in the sense that organizations must adhere to accountability demands to receive funding. Similar to the cases above regarding instruments under legislation, organizations dependent on funding may perceive these demands as mandatory. Expenditure or “funding” instruments are most often used in instances where the state has little or no role in the provision of goods or services (Howlett, 2000), as is the case of home and community care service delivery. The requirement for information, such as reporting requirements attached to funding, is a tool associated with the exertion of government authority (Hood, 1983; Hood & Margetts, 2007), and is considered a more coercive tool within the repertoire of policy instruments. Government grants, agreements and contracts awarded to home and community care organizations in Ontario require organizations to provide performance and financial reports and also may include stipulations regarding how services are delivered and managed. 4.1.3.1 Government grants Home and community care agencies can get one-time grant funding from a variety of sources. The two most prominent agencies that provide grants to community-based and seniors’ programs are the Ontario Trillium Foundation and the federal-level New Horizons for Seniors Program. The Ontario Trillium Foundation is an arms-length government agency started in 1982 to provide additional funding to the social service sector. The foundation invests in communitybased initiatives to strengthen the capacity of the voluntary sector. The Foundation is currently mandated to allocate $120 million annually 12 in grant funds (Ontario Trillium Foundation, 2012a) through four different programs: 1. The Community Program: for activities that have a local impact in one or more communities within a single catchment area. 12 This was changed to $100 million annually when most recently verified May 31st 2013. 67 2. The Province-wide Program: for activities that have an impact across at least three catchment areas (or two catchment areas in the North). 3. The Future Fund: allocates $2 million to innovative projects that have a focus on Ontario’s future, like environmental projects and economic projects (Ontario Trillium Foundation, 2012b). 4. Community Capital Fund: allocates funds to non-for-profit organizations for infrastructure projects (Ontario Trillium Foundation, 2012c). Organizations awarded grants must provide reports to the Ontario Trillium Foundation as well as undergo an outcome evaluation to measure the success of the program at the end of the grant period (Ontario Trillium Foundation, 2012d). Reporting requirements differ depending on whether grants are single or multi-year or whether grants are for capital projects. Recipients are expected to report program outcomes and financial information at least once a year. Outcomes of interest include: • • • • • • • How many people benefited from the program Types of events held and number of people who attended Any media coverage of the program How OTF was recognized as being a project funder Volunteer contributions to the project Impacts: individual, organizational, community, not-for-profit/voluntary sector, economic Program sustainability (whether the program will/can continue) For the most part these outcomes are reported through check-boxes or by reporting numbers. Organizations are also expected to report financial information including a statement of other financial support for the program (i.e. donations or support from other government and nongovernment sources) and a complete financial statement for the program. Multi-year grants may have additional reporting requirements and are required to report each year (Ontario Trillium Foundation, 2012e). The New Horizons for Seniors Program is a federal grant program housed in Human Resources and Skills Development Canada (HRSDC). This program is specifically intended to support projects that are inspired or led by seniors who seek to improve the lives of other seniors in their communities. The focus of these grants is also to help seniors remain a part of their communities and to reduce their social isolation. The program supports five objectives: • “Promoting volunteerism among seniors and other generations; 68 • • • • Engaging seniors in the community through the mentoring of others; Expanding awareness of elder abuse, including financial abuse; Supporting the social participation and inclusion of seniors; and Providing capital assistance for new and existing community projects and/or programs for seniors” (HRSCD, 2012a). Grants are provided through a call-for-proposal model for different types of projects (e.g., community-based projects, or Canada-wide projects). Community service agencies are more likely to be awarded these grants and seem most often to have community participation and leadership grants (identified in the organizational environmental scan). Funded organizations are required to submit a final report to the New Horizons for Seniors Program no later than two months after the project completion date (HRSDC, 2012b). It is not clear from the website what information organizations must include in the report. Organizations winning either of these grants are accountable to the granting agencies for program outcomes. They are held to account for both program outcomes and for financial performance in terms of how grant funding was managed. The reporting requirements are relatively light when compared to those associated with LHIN service agreements and CCAC contracts (as will be discussed in the following section). However, the requirements attached to funding may make these policy tools more costly for the government as well as for the organizations that need to divert resources to meet those requirements. For the most part, noncompliance with accountability requirements (reporting) will result in a loss of current and/or future funding. 4.1.3.2 Government agreements and contracts In addition to one-time grant funds discussed above, home and community care agencies can receive ongoing government funding through agreements and contracts. These funds can come from different levels of government and from a variety of Ministries at the provincial level. Home and community care agencies in Ontario may receive funds from the MOHLTC (through LHIN and CCAC funds and in some rare cases directly from the Ministry), the Ontario Ministry of Community and Social Services/Children and Youth Services, Municipal governments, and the Federal government (primarily Veterans Affairs, the Public Health Agency of Canada and 69 13 Health Canada ). While there are many sources of funding for home and community care services in Ontario, these services are primarily funded through the LHINs to community care service (CCS) agencies for community care services and through CCACs to home care services (HCS) agencies for home care services provided. 14 These two government agencies provide the majority of the funding for home and community care services in Ontario and for this reason are the focus of the analysis. Specifics regarding the “for what” and “at what cost” aspects of LHIN funding and CCAC contracts will be discussed in more depth in the last section of this chapter. In general, organizations receiving LHIN funding are under Multi-Service Accountability Agreements (MSAAs), which stipulate numerous accountability requirements. Similarly organizations under CCAC contracts are held to account through numerous requirements. Requirements include the need to report on financial and performance process and outcome indicators; training requirements; organizational management requirements; and stipulations regarding human resource management. Sanctions for non-compliance with MSAAs and CCAC contract accountability requirements include loss/reduction of funding and termination of agreements and contracts. Similar to grants, these accountability requirements are mandatory for organizations under agreements or contracts. Dependency on funding will determine whether an organization perceives these demands as mandatory. 4.1.4 Expenditure/exhortation policy instruments: Non-government funders Non-government groups can also use expenditure tools. Home and community care organizations are accountable to their funders and other important stakeholders. These funders and stakeholders will be different depending on whether the organization is a for-profit or notfor-profit organization. For-profit corporate organizations may be accountable to their shareholders and may be required to report financial (and potentially performance) information to those shareholders. The cost of not meeting these accountability demands could be the 13 14 This includes First Nations and Inuit Home and Community Care programs. Note that CCAC’s are themselves funded through the LHINs in Ontario. 70 potential loss of shareholder support, which could have a significant financial impact on the organization. Not-for-profit home and community care organizations will have a number of different funders including corporate sponsorship, funding from supporting agencies, and donations. One of the main funders of not-for-profit home and community care organizations in Ontario is the United Way. Some not-for-profit home and community care organizations (more often CCS agencies) will also be United Way members and will receive funds from their local United Way branch. It is not clear how the United Way and other funders hold member organizations accountable for funds provided. Many organizations who receive funds from multiple sources put out annual reports which include financial and performance information. There may be additional reporting requirements for some funders; however, requirements were not found during the environmental scan. Another common source of funds for not-for-profit home and community care organizations is donations and fundraising. Donors will expect that the funds provided to non-profits will be used to support the organization’s mission and mandate; however, donors may not have the capacity to monitor how a non-profit spends those funds (Szper & Prakash, 2011). The inability of donors to monitor how funds are spent is a concern given that there have been a number of examples of the mismanagement of funds by non-profit organizations (Szper & Prakash, 2011; Waters 2008; Weiner, 2003). Bad publicity around managing funds could deter future donations or donors may ask for more information regarding a non-profit’s internal operations before they donate (Szper & Prakash, 2011). For this reason, donors and the public have been demanding a higher standard of accountability and transparency from not-for-profit organizations (Waters, 2008). Noncompliance with accountability demands from these groups could lead to a loss of trust and funding from donors. Waters (2008) suggests that not-for-profit organizations can demonstrate accountability by using the four components of stewardship: reciprocity (demonstrating gratitude to fundraisers), responsibility, reporting, and relationships nurturing (supported by sending out communications and annual reports to donors). In general, not-for-profits need to be transparent about how funds are used to demonstrate financial accountability to funders. Waters (2008) further suggests that to survive, not-for-profit organizations need to dedicate resources to relationship building with 71 donors as stronger relationships are found to be associated with greater, more sustained donations. Strengthened accountability would help to bolster these relationships and thus it is understandable why donors are key stakeholders to whom not-for-profit home and community care agencies are held to account. The exhortation component of these accountability requirements comes into play when organizations volunteer to report financial and performance information (often through annual reports). Reporting financial and performance information could be part of the organization’s attempt to voluntarily demonstrate accountability to funders and donors. Reporting to nongovernment funders is an example of how exhortation can work. Although funders and donors may not specifically demand accountability, organizations may wish to provide financial information to demonstrate money well-spent, strengthen accountability and transparency, and build relationships, thereby laying the foundation for future funding (Waters, 2008). Exhortation is a relatively non-coercive (Doern & Phidd, 1983) and weak instrument (Howlett & Ramesh, 1995), but is useful in instances where those trying to hold agencies to account have little ability to apply a more coercive instrument (Ibid). 4.1.5 Exhortation policy instrument: Accountability to other stakeholders Exhortation is particularly useful for other non-government stakeholders to hold home and community care organizations to account. Not-for-profit home and community care agencies may feel accountable to their clients, their clients’ caregivers and families, the communities they serve, and their volunteers, without whom they would not be able to provide their services. Organizations demonstrate that they feel accountable to these groups often through their mission and vision statements in which they identify their commitment to providing high quality care to clients. In some cases organizations specifically mention a commitment to families, volunteers and communities as well. For-profit organizations also demonstrate that they feel accountable to their clients, their clients’ caregivers and families, and in some cases the broader community, in their mission and value statements. This is understandable given that for-profit home and community care organizations rely on their clients as the main source of funding. Another important source of funding for forprofit corporate organizations (usually home care organizations) is shareholders. These organizations are accountable to shareholders in that the organization is expected to provide a 72 return on investment (Deber, 2004). For-profit organizations can exercise accountability to shareholders and stakeholders by providing information (reporting), and creating opportunities for meaningful discussion and dialogue (Cooper & Owen, 2007). For the most part a home and community care organization’s stakeholders hold agencies to account to ensure that services are being delivered as expected to meet the needs of clients and communities, and in the case of corporate for-profit organizations, that the organization is also making a profit. It is not clear how such organizations demonstrate accountability (possibly through annual reports or annual meetings). Stakeholders may hold home and community care organizations to account through exhortation, in that organizations may feel compelled to behave in ways that will meet stakeholder needs. Home and community care organizations may produce annual reports, hold annual general meetings, or seek other ways of demonstrating accountability to their stakeholders. The potential costs of not demonstrating accountability to these groups could be the loss of volunteers, shareholders, and support from the community. 4.1.6 Regulation, expenditure, exhortation or self-regulation: The case of accreditation Accreditation uses aspects of regulation, expenditure, and exhortation to hold organizations to account. Accreditation can be defined as a system that identifies explicit standards for health care organizations against which they can be measured (Shaw & Collins, 1995). Accreditation compares actual performance of health care organizations to a set of standards to determine how that organization is performing (Nandraj & Khot, 2003). Having organizations meet a set of standards is much like a regulatory instrument in that it specifically dictates activities and behaviours to which health care organizations must adhere. To demonstrate how accreditation can be used as an expenditure instrument, funders may require organizations to be accredited prior to receiving funding. Attaching accountability requirements to state and third party funding has been found to support the accreditation process in many countries (Nandraj & Khot, 2003). Accreditation helps to inform the public regarding health care organizational practices (Nandraj & Khot, 2003). The provision of information associated with accreditation helps to empower external groups (like citizens and government) to be able to hold organizations to account for performance. Thus accreditation also has an exhortation component in that it encourages organizations to meet standards by making performance information public. 73 Accreditation can also be considered a form of self-regulation. Maxwell’s (1996) discussion of accreditation in the British Columbia school system found that accreditation as a form of selfregulation was used to ensure accountability of schools to governments. Accreditation has been recognized to be an external quality assurance method in healthcare (Shaw, 2000). Thus, accreditation is a combination of instruments that can enhance the accountability of home and community care organizations to accreditors such as governments, funders and other stakeholders. There are a number of accreditation bodies across Canada and internationally that accredit home and community care agencies. While agencies may seek accreditation with any of the many bodies out there, the most prominent accreditors in this sector in Ontario are Accreditation Canada, CARF International, and the Standards Council of Canada (ISO). Accreditation Canada is a an independent, not-for-profit organization that provides accreditation for national and international health care organizations with the intention of promoting quality health care. It is accredited by the International Society for Quality in Health Care (Accreditation Canada, 2012a). Accreditation Canada provides accreditation to a wide variety of health care organizations by establishing accreditation standards for each sector. Standards are guided by expert-led Advisory Committees and are pilot tested at various health care organizations across Canada. Accreditation is considered to be a means to recognize that a healthcare organization has met national standards of quality (Nicklin & Dickson, 2009). These standards are available for a fee to organizations seeking accreditation. For the home and community sector there are standards for home care services and home support services. Both standards apply to organizations that offer clinical services that support clients, families, and caregivers who reside in the community. Home care services may include: home nursing care, rehabilitation, and therapies (physiotherapy, occupational therapy, speech-language therapy, social work, dietetics, and respiratory therapy) (Accreditation Canada, 2012b). Home support services include many personal support worker duties such as meal preparation and delivery, housekeeping, assistance with bathing or dressing, and assistance with ambulation (Accreditation Canada, 2012c). While standards are specific to each sector, there is a common set of required organizational practices for any accredited health care organization. Required organizational practices are in the areas of safety culture, communication, medication use, work-life/workforce, infection control, 74 and risk assessment (please see Appendix 4-A for a chart of Accreditation Canada’s required organizational practices). Commission on Accreditation of Rehabilitation Facilities (CARF) International offers accreditation in the fields of aging services, behavioural health, child and youth services, employment and community services and medical rehabilitation. CARF Canada was incorporated in 2002 and is recognized by the MOHLTC for long-term care homes and for the home care sector. CARF Canada is also working with Health Quality Ontario (HQO) to “align measurement and quality improvement activities with respect to Ontario’s long-term care sector” (CARF, 2012a). Like Accreditation Canada, CARF sets standards for organizations to meet to gain accreditation. These standards are available to organizations for a fee. The aging services/CARF-CCAC program offers standards for aging services to the following services/organizations such as “continuing care retirement communities, person-centered longterm care communities, nursing homes, adult day services, assisted living, aging services networks, dementia care specialty program, stroke specialty program, and home and community services” (CARF, 2012b). See Appendix 4-A for an overview of the CARF accreditation process (CARF, 2012c). The Standards Council of Canada (ISO) creates standards for health care personnel as well as standards for a number of other areas including: management systems, inspection bodies, and labs. Like with other accreditors, the set of standards must be purchased. While specific programs for home and community care are not accredited through ISO, personnel working in the sector can be accredited. There are also standards set for some medical equipment (i.e. hearing aids and syringes) that may be used as part of home and community care service delivery. The personnel certification program assesses the credibility, impartiality and technical competence of an organization’s personnel certification services that can include medical personnel. See Appendix 4-A for an overview of the ISO accreditation process. Accredited organizations undergo annual surveillance audits between initial accreditation and reaccreditation that occurs every three years (Standards Council of Canada, 2011). The cost of not receiving or of losing accreditation status can be high or low for an organization depending on the situation. Some agencies may not emphasize accreditation, while others rely on it to demonstrate accountability to funders, clients and their families. Some agencies may also be 75 required to get accreditation prior to receiving funding from other sources (as is the case with some CCAC contracts). Accreditation can also affect an organization’s “social fitness” as accreditation can improve social legitimacy, potentially supporting an organization’s survival (see discussion on social fitness in Chapter 2, section 2.3.1.2). 4.2 Breaking down the “for what” Determining the “for what” aspect of accountability frameworks can be analyzed along the lines of common characteristics that are identified in the accountability literature. As identified in Chapter 2 there are several key components across which accountability frameworks can differ: • • • The purposes of accountability (financial, performance or political) (Brinkerhoff, 2003 & 2004) The clarity of roles and responsibilities for both parties (Bergsteiner & Avery, 2009) Whether accountability serves to enhance citizen engagement (Abelson & Gauvin, 2004) This section describes accountability documents related to CCAC contracts and LHIN MSAAs across some of these different components, in an effort to identify how these tools vary by key components or characteristics of accountability frameworks. Document analysis was carried out as described in Chapter 3. The key components of accountability can be broken down into smaller constituent parts. The following table summarizes these components and how they are sought in CCAC contracts and MSAAs: Table 4-2: Components of accountability frameworks Accountability component Purpose Sub-component In CCAC contracts and MSAAs Financial Performance Cost stipulations Managing funds Balanced budgets Audited financial statements Accounting standards Financial indicators Governance and management Risk management and health and safety Performance indicators Access Assessment, care plans and transition Performance review 76 Accountability component Sub-component In CCAC contracts and MSAAs Political Procedural Assigning roles and responsibilities / direction of relationship Uni-directional Bi-directional Enhancing citizen engagement Professionalism Conflicts of interest Equity Promotion of values RFP process Procurement process Assigned responsibilities to home and community care organizations Assigned responsibilities to organizations and CCACs/LHINs Client satisfaction and complaints processes The following section will describe the process through which home and community care services agencies would win/receive contracts and agreements. LHIN MSAA Process Under the Local Health System Integration Act, 2006 (LHSIA) all organizations funded by LHINs to deliver services must have service accountability agreements in place. Prior to receiving an agreement, a health care organization must be an approved health service provider (HSP). Getting approval entails demonstrating leadership, governance and a proven track record, and then submitting a request to the MOHLTC for HSP status. The HSP application process does not happen very regularly. Most HSP organizations are organizations that had been funded prior to the start of the LHINs. 15 Once a health care organization is an approved HSP, it can submit a CAPS (Community accountability planning submission, defined in Chapter 1) to the LHIN to receive funding. The CAPS describes the program(s) the organization wishes to have funded and how much funding it requires for those programs. The CAPS process is negotiable. What is included in the CAPS is then translated into a MSAA between the LHIN and the service provider. 15 Information gathered from LHIN key informants 77 CCAC contracts In order to be awarded a CCAC contract, a home care service (HCS) agency must go through a competitive procurement process. The process begins with a CCAC posting a request for proposal (RFP) for services. HCS agencies then submit an application/proposal. Prior to doing so, they must apply for and receive prequalification level from the CCAC. Only prequalified applicants can submit RFPs. The prequalification process is open to prospective service providers (not yet assigned a prequalification level) and service providers who have a prequalification level who wish to apply for a level increase and/or wish to apply for prequalification to another services area. Agencies can apply as individual organizations or as a joint venture with other organizations. Service agencies are assigned one of three prequalification levels. Each level is based on experience (years delivering service) and financial capability (the amount of service in dollars that the organization is able to support) held by a service agency. Agencies are assigned to a level based on meeting the minimum experience and financial capability criteria associated with each level. The minimum criteria are different for each type of service being delivered. Organizations must also submit information regarding their litigation history (any litigation or arbitration that resulted from contracts completed or ongoing) (OACCAC, 2010). Once prequalified, organizations will provide their submission for the RFP, which includes their prequalification documentation, a price submission (including price scenarios for different service volumes), geographic regions that can be served, and a written quality section (RFP Consultation version). The written quality section includes information regarding the organizations’ ability to meet service requests, their plan to do assessment and develop client care plans, their ability to assign and evaluate appropriate service personnel, a review of organizational requirements (risk management program, quality management program, and human resource requirements), communications/record keeping methods, performance monitoring processes in place, management approach and resources [RFP Schedule C: Part B – 16 Written Quality Section Requirements] . After submitting to the RFP, HCS agencies go through an interview and site visit. 16 Contract and agreement document source information will be identified using square brackets in this section. 78 RFP submissions are then reviewed and assigned scores based on each of the sections they submit. Table 4-3 shows how the scoring is awarded: Table 4-3: CCAC contract score. [Source, adapted from RFP consultation, p. 24]. Written Quality Score Interview Score Site Visit Score Price Score 35% 20% 20% 25% 100% Based on scoring, agencies are awarded contracts and assigned service regions and client volumes. One agency can be awarded many contracts for the same or different services from one or more CCACs. Most CCACs list their contracted service providers on their website. As noted in Chapter 1, there have been no new RFPs for services (other than equipment and supplies) since the moratorium. Currently contracted service providers are those who were awarded contracts before the moratorium and have been granted renewals. 4.2.1 The accountability purposes of LHIN MSAAs and CCAC contracts As defined in the literature review (Chapter 2) there are three main purposes of accountability: financial, performance and political (Brinkerhoff 2003 & 2004). Brinkerhoff (2003) considers these three as key components of the “for what” aspects of accountability. In addition, a fourth key component was identified through the coding process of this study, procedural accountability. The LHIN MSAAs and CCAC contracts serve to support all four accountability purposes to varying degrees. In general, there is an emphasis on financial and performance accountability. 4.2.1.1 Financial accountability As discussed in Chapter 2, financial accountability concerns the tracking and reporting of allocation, disbursement, and utilization of financial resources using the tools of auditing, budgeting and accounting (Brinkerhoff, 2003). Generally, financial accountability focuses on procedural compliance. 79 The CCAC contracts and LHIN MSAAs focus strongly on ensuring financial accountability of home and community care agencies under contracts and agreements. This is accomplished by providing rules and guidelines in a number of areas: • • • • • • Making cost stipulations in which the LHIN or CCAC clarifies what can and cannot be covered by funding and under what circumstances funding agreements can be changed or discontinued. Stipulating how HCS and CCS agencies shall manage their funding. Requirements for maintaining a balanced budget, periodic audits, and the use of specific accounting practices. Required financial reporting. Stipulations regarding governance and management of the organization. Risk management and health and safety. 4.2.1.1.1 Cost stipulations First, there are a number of “cost stipulations” in which the contract and agreement documents specify how funding is to be used, including stipulations regarding employee benefits and vacation pay, and adherence to approved budgets. In the case of LHIN MSAAs, many of these cost stipulations are outlined in their CAPS (which forms the basis of the MSAA as shown above). In the CAPS, financial planning needs to be provided over three years, and the HSP must consider this planning when it forecasts service volume and indicator performance. Any operational change that may affect funding or service levels (reduction, elimination, or transfer of services) requires LHIN approval. The LHIN has the authority to adjust funding, require the repayment of excess funding, or adjust future amounts of funding on the basis of service adjustment, if the HSP forecasts a surplus, in response to the performance improvement process, or in the event the agreement is terminated. For the most part, the cost stipulations included in CCAC contracts are laid out in the RFPs in the volume scenarios provided by the service provider. The CCAC determines which volume and pricing is to be awarded to the service provider, after which few changes to these prices are allowed. Service providers are not permitted to make any adjustments to their pricing and compensation schedule, regardless of changes to costs or expenses, structure or organization, or employee labour disputes or settlements. The CCAC can put in change proposals to the contract that may have an impact on the costs incurred by the provider. The service provider can 80 negotiate with the CCAC regarding prices if, as a result of the CCAC’s changes, the costs incurred by the provider exceed 5%. The pricing of services awarded within the contracts to service providers include all the service providers’ costs and expenses in carrying out services including [CCAC Schedule 2, Section 1.2(5) & (6)]: • • • • • • • • • • Preparation, consultation, reporting and travel time cost and expenses related to any type of visit to a client or caregiver. Overhead expenses such as office and facilities costs, including rent, maintenance, property taxes, utilities and other expenses; office supplies and photocopying; computer hardware and software costs; taxes, duties, levies and other similar costs; and, telecommunication and courier costs. Equipment and supply costs. Costs and expenses related to subcontractors. Costs related to meetings required by the agreement including travel time, attendance, preparation of minutes, and other expenses. On-call support costs. All costs and expenses of providing services in French (if applicable), or other languages understood by the client (if applicable). All personnel costs and expenses including wages, salaries, benefits, allowances and severances; vehicle and transportation costs; and all training and development except for specific training that the CCAC agrees to provide and pay for on a case-by-case basis. Pay equity adjustments as defined in the Pay Equity Act, 1990. Requirement of MOHLTC policy that at least 10% of personal support service volumes must be delivered by full-time workers and 20% of personal support services volumes are delivered by part-time workers. While the prices associated with low and high volumes of services are mostly fixed, they can be renegotiated in the event that service volumes dip well below the low-volume thresholds stipulated in the contract. However, if an agreement between the parties cannot be reached then the contract is terminated. If volumes persistently go above the expected high volume thresholds renegotiation may occur or the CCAC can assign volumes to other services providers. In general, cost stipulations are in place to protect the CCAC and LHIN from incurring additional financial costs associated with the contracts and agreements. For the most part, the home and community care agencies must incur additional costs that may arise subsequent to the implementation of the contract or agreement is finalized. 81 4.2.1.1.2 Management of funds The MSAA requires that HSPs to undergo prudent and effective management of funding [MSAA Template, Section 10.3(a,v)] and that CCS agencies consider and/or adopt a range of cost management approaches. These are vague requirements, but the CAPS guidelines suggest budgetary management strategies [CAPS guidelines section 2.1(b)]: • • • • • • • • Back office integration - combining with other HSPs to reduce the cost of administration (e.g. sharing accounting services). Increasing supplementary revenue. Identifying program efficiencies by reviewing best practices in operations and service delivery. Relying on technology and automation in order to reduce time spent on paperwork. Enhancing community support through use of volunteers and in-kind contributions Consolidating programs. Partnering/combining with other organizations in order to achieve economies of scale and scope. Conducting effectiveness reviews to help direct resources to more effective programs and/or vulnerable clients. Additionally, a LHIN may suggest and even impose “additional terms of conditions on the use of the funding which it considers appropriate for the proper expenditure and management of the funding” [MSAA Template, Section 4.5(c)]. For instance the rural LHIN that was included in this study is mandating that all HSPs engage in back office integration in order to improve efficiency. The CCAC contracts provide less guidance with regard to management of funds beyond the stipulations they place on what funding is to cover (described in the above section). They mainly require that HCS agencies under contract have a risk management program in place that includes the management of financial risks, contingencies, liabilities and irregular transactions [CCAC Service Schedules, Section 7.2(2)(c)]. Additionally HCS agencies are required to meet CCAC “Quality Operating Standards” which include a standard of performance in accordance with sound management, financial, and commercial practices [CCAC contract schedule 4, Section 2.1 (3, f)]. 82 4.2.1.1.3 Balanced budgets, audits and accounting practices The LHIN MSAA clearly states that all HSPs receiving funding for services must have a balanced operating budget for each year they are under the MSAA in order to continue to receive funding [MSAA Template, Section 4.5(a, iv)]. A balanced operating position for the total organization (HSP) is defined as effecting a state of operations where the total expenses are less than or equal to all sources of revenue [CAPS guidelines, Section 2.1(b)]. A balanced budget is also one of the accountability indicators of organizational health that are captured by the MSAA. The proportion of the operating budget that is spent on administration is also as an accountability indicator used in the MSAA. Under CCAC contracts, the rules regarding managing budgets are also quite strict. Prequalifications for all services include an examination of financial capacity. The RFPs submitted by organizations must include prices that are deemed to be sustainable for the organization; those who submit prices that are too low can lose the RFP [CCAC RFP consultation, Section 10.3(1)]. Under CCAC contracts, HCS agencies are required to have risk management processes in place that deal with, among other things, insolvency or bankruptcy. Organizational insolvency is grounds for contract termination [CCAC Contract General Conditions, Section 12.1.3 (1)]. Under the MSAA, HSPs are required to remit audited financial statements as part of their yearly reporting to the LHINs. LHINs are also able to audit subcontractors of HSPs who hold MSAAs [MSAA Template, Section 3.2(b)]. HSPs funded by LHINs must also adhere to Ontario Healthcare Reporting Standards (OHRS/MIS), a set of reporting standards and chart of accounts that are consistent with national health care reporting standards, which include financial reporting. Audited financial statements are a requirement of HCS agency prequalification. Organizations under contract must provide audit reports (from external auditors) to the CCAC at the CCACs request [CCAC General conditions, Section 5.3 (3)]. The CCAC may also audit HCS agencies’ accounts and financial statements with 24-hours notice. This audit may be conducted by the CCAC or by an independent auditor chosen by the CCAC (at the CCACs expense). Providers are then obligated to remedy any deficiencies, inconsistencies, or inaccuracies at their own expense [CCAC General conditions, Section 5.4]. 83 The CCAC contracts specifically require HCS providers to submit financial data prepared in accordance with the Generally Accepted Accounting Principles that are in effect in Ontario (those that are put forward by the Canadian Institute of Chartered Accountants) [CCAC General Conditions, Section 1.2.3]. The HSPs accounts must also be kept in accordance to these standards and they must maintain these records for at least seven years. 4.2.1.1.4 Financial indicators Home and community care agencies under MSAAs and CCAC contracts must provide ongoing audited financial statements to both the LHINs and CCACs respectively. They must also report additional financial indicators as part of their ongoing reporting. Under LHIN MSAAs, HSPs must report on total margin, balanced budget, proportion of budget spent on administration, cost per unit service, cost per individual served, interest income, HST and other rebates, and a summary of revenues and expenses. HCS agencies under CCAC contract must report indicators that are mostly related to performance. Some of these have a financial component which will be discussed below in the section on performance indicators. 4.2.1.1.5 Governance and management While governance and management do not necessarily relate directly to accountability for funds, they do reflect accountability for the process of delivering services which is associated with financial accountability rather than performance accountability (Brinkerhoff 2003 & 2004). Governance and management requirements in MSAAs and CCAC contracts include stipulations regarding how home and community care agencies govern and manage their business, mostly with regards to provision of services under agreements and contracts. For instance, meeting performance requirements of CCAC contracts should not cause a provider to violate their own by-laws (passed by the providers’ board of directors) [CCAC General Conditions, Section 8.2 (d)]. Assessing human resources policies and management approaches is also part of the RFP process. HCS agencies applying for contracts must include the providers’ plans to get appropriate personnel management in place in the event that they win a contract [CCAC RFP Schedule C, Part B-4]. There also must be policies and procedures in place for services providers as an 84 organizational requirement of an HCS provider. It is not stipulated what must be included in these policies and procedures or what they are intended to cover [CCAC services schedules, Section 7.7]. The MSAA emphasizes ensuring appropriate governance more than CCAC contracts. There is an entire section of the MSAA dedicated (Section 10.3) to governance of the agency and requires agencies have policies and processes in place that: • • • • • • “Set out a code of conduct and ethical responsibilities” for all employees. Ensure effective: functioning of the organization, decision-making, and risk-management (including conflicts of interest). Ensure “prudent and effective management of funding” provided by the LHIN. “Enable preparation, approval and delivery of all reports.” “Address complaints about the provision of services.” Establish and ensure compliance with a performance agreement with the CEO that ties compensation to CEO performance. The CCS agencies must also agree to meet requirements of the Corporations Act, 1990 with respect to holding board meetings, decision-making requirements, and maintaining minutes for all relevant meetings [MSAA Template, Section 10.1(v)]. 4.2.1.1.6 Risk management and health and safety Related to governance and management are stipulations requiring organizations to have risk management and health and safety protocols in place. Risk management requirements reflect process accountability that is associated with financial accountability, similar to governance and management. Risk management and health and safety requirements are included in both CCAC contracts and MSAAs. Risk management relates to physical risks to the client or personnel delivering services, emergency situations (such as a public health issue, e.g. an outbreak of disease), or organizational risks that can be incurred by the agency. Potential physical risks for clients receiving CCAC services are identified at the time of CCAC client assessment; the case manager determines whether these safety risks can be managed by the HCS provider. Risk management information is then relayed to the HCS provider. The HCS provider must identify personal safety risks to clients in clinical assessments for nursing services. All HCS providers must include a description of how safety risks may be addressed in the client care plans. Incidents in which the physical safety of the client and/or caregiver was jeopardized 85 must be reported as a risk event to the CCAC. Risk events also include any breach of private client information. HCS agencies providing services under CCAC need to have Risk Management Programs in place and to establish such a program early in the RFP process. This program is intended to identify, assess, analyze, prepare for, manage, mitigate and potentially prevent both safety risks to the client and organizational risks [CCAC services schedule, Section 7.2]. The Risk Management Program aims to address all types of risk that could potentially affect the delivery of services or the agency itself. CCAC contracts also stipulate that organizations need to “protect themselves” against legal claims that may arise due to risk events or breaches of Personal Health Information Protection Act, 2004 [CCAC General Conditions, Section 9.1(4 & 5)]. HCS agencies also must have a valid certificate of good standing issued by the Workplace Safety and Insurance Board which is included in each annual report to the CCAC [CCAC services schedule, Section 8.5(d)]. The MSAA simply states that CCS agencies under the agreement must have procedures in place for effective and prudent risk-management, including the identification and management of potential, actual and perceived conflicts of interest [MSAA Template, Section 10.3 (iv)]. 4.2.1.1.7 Financial accountability in the LHIN MSAA and CCAC contracts Table 4-4 summarizes the financial accountability demands placed on home and community care agencies under LHIN MSAAs and CCAC contracts. What can be drawn from Table 4-3 is that both accountability frameworks heavily emphasize financial accountability and, for the most part, enforce strict guidelines with regard to the use of financial resources. Comparison of the two frameworks suggests that the LHIN MSAA appears to be slightly more intrusive on an organization’s autonomy given that there are strict stipulations regarding the management of funds and include additional financial indicators. The only exception is risk management processes that are more lenient for agencies under MSAAs than those under CCAC contracts. Table 4-4: Financial accountability in LHIN MSAAs and CCAC contracts Financial accountability Cost stipulations LHIN MSAA CCAC contract Strong, direct stipulations Strong, direct stipulations regarding what costs are covered regarding what costs are 86 Financial accountability Managing funds Balanced budgets Audited financial statements Accounting standards Financial indicators (beyond audited financial statements) Governance and management Risk management and health and safety 4.2.1.2 LHIN MSAA by funding. Potentially specific requirements regarding how funds are to be managed. Required Required yearly (can be conducted by LHIN) Must use national health care reporting standards. Must report on eight additional indicators Must adhere to a stringent set of management standards and applicable laws. Must have a risk management program in place (few guidelines) CCAC contract covered by funding. Few requirements regarding how funds are managed. Required Required for prequalification. Required on demand (can be conducted by CCAC) Must use accepted CICA accounting principles Must report performance indicators (some have a financial component) Must conduct business in accordance with applicable laws. Must have human resource policies in place. Must have a risk management program in place (specific guidelines). Must adhere to health and safety laws. Performance accountability As discussed in Chapter 2, performance accountability focuses mainly on outcomes. It seeks to hold organizations and agencies to account for agreed-upon performance targets (Brinkerhoff, 2003). The MSAA and CCAC contract focus on assuring accountability for performance is at least as strong, if not stronger, that the focus on focus financial accountability. Performance is assessed in the following areas: • • • • • • Performance indicators. Performance reporting. Access to services. Assessment and transition processes. Performance reviews and improvement processes. Human resources (professionalism). 4.2.1.2.1 Performance indicators Performance indicators in the MSAA and CCAC contracts are typically set by the LHIN and CCAC respectively. In CCAC contracts there are opportunities for HCS providers under contract 87 to identify their own indicators on which they can report, in addition to those required by the contract. HCS providers are required to identify at least ten performance indicators on which to report. It is also possible for HCS and CCS agencies to collect their own additional performance indicators, which may or may not be reported to the LHINs and CCACs. The LHIN MSAAs developed their set of performance indicators in early 2011. The performance indicators are made up of a set of core indicators, with additional sector specific indicators for each of the sectors covered by the MSAA (including CCS agencies). LHINS also have the opportunity to set LHIN specific indicators for their LHIN level accountability frameworks as well. The indicators are intended to “monitor the performance of the health care system and the health service providers delivering services” (LHIN Collaborative, 2011, p. 3 of 21]. Indicators are intended to capture three performance dimensions: 1. Person experience: The components include: access, effectiveness, safety and personcentered care and focuses on the needs of the client, caregiver and family to help ensure that Ontarians receive high quality care and are involved in decision-making around their own health. 2. Organizational health: Focusing on organizational factors, these indicators are intended to ensure the best use of health care resources to promote value for money. 3. System perspective: This area is intended to support working with health care partners and the community to integrate of health services. There are three types of indicators included in the framework: • • • Accountability indicators: These indicators are included in all MSAAs and could potentially trigger consequences if not met. Accountability indicators are associated with particular targets, benchmarks or corridors and could be tied to funding. These indicators are considered to be valid, feasible measures of system performance and are intended to allow for comparability across the system. Explanatory indicators: These indicators are intended to be complementary to the accountability indicators. They support planning, negotiation, and problem-solving. These indicators do not trigger consequences and are not necessarily reported in MSAAs. They are intended to support transparency, improvement and sustainability, effectiveness and efficiency. Developmental indicators: These indicators are not yet being reported on (but have the potential to be include in future requirements). They are currently in the developmental stages and still require further validation. There is a strong emphasis on organizational health indicators in the core set of indicators, and many focus on financial aspects of the organization. Performance indicators focus mainly on access indicators such as “how many individuals were able to access services.” For the CCS 88 sector there are no indicators relating to person experience, system perspective or volume/output. The only CCS sector specific performance indicators focus entirely on access: number of persons waiting for service, and average days on waitlists (developmental) (See Appendix 4-B for a list of core indicators and CCS sector specific indicators). Performance indicators are a key aspect of CCAC contracts for HCS providers and are included in Schedule 4 of the contract [CCAC contract schedule 4: Performance standards schedule]. Performance indicators that must be reported by all providers include: • • • • • • • • Number of accepted referrals from CCAC per month (could also be a financial indicator); Number of missed visits (fixed or hourly) per month; Number of accepted urgent service requests per month (could also be a financial indicator); Number of assigned provider personnel per client per quarter. Client groups are divided by number of hours/visits they receive per quarter (could also be a financial indicator); Percentage of initial reports the service provider sent to CCAC on or before the deadline per month; Percentage of risk event reports the service provider sent to CCAC on or before the deadline per month; Percentage of discharge reports the service provider sent to CCAC on or before the deadline per month; Percentage of fixed or hourly visits delivered in French each month (number of delivered services/number of requests). As part of the Quality Management Program that HCS providers are required to have in place under the CCAC contracts, providers are expected to measure and track the performance standards identified above, as well as any performance indicators that are developed internally by the service provider that relates to the quality of delivered services. The additional performance indicators differ by provider depending on the service being delivered (i.e. different indicators for nursing vs. personal support) [CCAC services schedules, Section 7.3(2,b)]. It is not clear in the contracts how many indicators, or which indicators, must be included in this group of additional indicators. Much like the LHIN MSAAs, the required performance indicators for CCAC contracts focus mainly on access indicators, which could also be used to track financial accountability. CCAC contracts also include monitoring indicators to supervise the performance of the organization in remitting required reports. In both the MSAAs and CCAC contracts there may be concerns 89 regarding whether these indicators appropriately capture quality of home and community care services; an issue identified by key informants and discussed in detail in Chapter 6. 4.2.1.2.2 Access to services As seen in the above section, performance indicators often capture access issues. There are also a number of stipulations and requirements, beyond performance indicators, in the LHIN MSAAs and in the CCAC contracts that are in place to ensure appropriate access to services. The MSAA focuses on ensuring that services are accessible by everyone in the catchment area regardless of location. There is also a requirement that services (and reports) be available in French. CCS agencies are also required to report to the LHIN if they wish to make any changes to the catchment area where they deliver services. Similarly CCAC contracts seek to ensure that services are available in French (in designated areas) and are provided across designated catchment areas. In addition, CCAC contracts require that HCS agencies under contract are available 24 hours a day, 7 days a week, cannot repeatedly refuse referrals on the basis of location, day/time of the week, the frequency of visits, the type of visit, or the ethnic, religious, or linguistic characteristics of needs of the client, and must report to the CCAC immediately if visits cannot be conducted or are missed. HCS providers under CCAC contracts are allowed to temporarily or permanently withdraw services from clients if providing these services may cause risk or harm to personnel, who must then work with the CCAC to help identify how services can be delivered [CCAC General Conditions, Section 3.1.5 & 3.1.5.6]. Additional visits that may be required must be authorized by the CCAC case manager prior to the visit; otherwise, service providers may not be compensated by the CCAC for additional or “unforeseen” visits [CCAC services schedule, Section 3.4]. 4.2.1.2.3 Assessments, care plans, and transition processes HCS providers under CCAC contract must demonstrate performance in assessment/care plan development and in providing appropriate transition processes for clients. The CCAC conducts the assessment of the clients to inform the client service plan. The HCS provider then receives the assessment information, which is then used to develop a client care plan. The service plan includes information such as amount and type of service to be provided, location of service, 90 client characteristics, expected health outcomes, and other services that the client receives [CCAC services schedules, Section 2.1]. The provider agency may also be required to conduct its own clinical assessment for clients requiring nursing services. This assessment includes much of the same information as the CCAC assessment, but also includes consultation with physicians as needed and determination of any medication required (for nursing services only) [CCAC nursing services schedule, Section 3.1.1(2)]. The HCS provider is also required to do ongoing assessment or “evaluation” of individual clients with respect to the client’s progress towards care plan goals. This evaluation must include consultation with client or caregiver, an analysis of client records, an evaluation of the client care plan, and an update of the care plan as required. Any updates to the plan with regard to amount of visits must be approved by the CCAC [CCAC services schedules, Section 3.5]. Assessments are conducted by the service personnel or by supervisors in the case of personal support and homemaking services. The evaluation for personal support and homemaking includes a review of referral information, a consultation with client or caregiver, identification of safety concerns, identification of additional equipment and supply needs, an evaluation of the care plan and updating the plan with regards to client goals [CCAC PSW and HM services schedule, section 3.5]. HCS providers are assessed on their ability to develop care plans in the RFP process through their submission and during the interview process. They also demonstrate accountability for assessment and care plans through the provision of ongoing reports on those assessments and care plans to the CCAC (reports identified in performance reporting). Transition plans are those put in place by the HCS provider to ensure smooth transition in the event that the provider starts or stops providing services to a particular client. The CCAC sets up a transition plan that must be carried out by the HCS provider. In this capacity the provider conducts a number of transition activities including adhering to the CCAC’s transition plan, identifying and establishing a transition team, developing a system of status reporting, providing weekly reports to the CCAC regarding provision of sufficient personnel, reporting any problems to the CCAC, and communicating with clients regarding the process [CCAC services schedules, Section 7.6]. When the provider is transitioning clients out of its services, it must refrain from 91 complaining about the CCAC to clients, cooperate with other providers, prepare discharge reports and attend transition meetings. Under the MSAA there is a brief mention of transition plans that stipulates that the LHIN is expected to help develop a transition plan in consultation with the CCS agency delivering the services. The MSAA does not stipulate requirements in terms of assessment or the development of care plans since clients are not tracked by the LHIN. The LHIN has a greater focus on the general delivery of services, rather than tracking the assessment, management and transitions of individual clients. 4.2.1.2.4 Performance reviews and improvement processes Performance reviews are built into both MSAA and CCAC contracts. HCS agencies under CCAC contracts are obligated to have a Quality Management Program in place for contracted services (this does not extend to other services delivered by the agency which are not covered under the contract). The Quality Management Program monitors, records, evaluates, and improves performance of service delivery. The program must include valid and reliable tools for process analysis; use of captured information to inform decision-making; establishing a process for identifying, implementing and maintaining improvements; a track record of improvements; and the involvement of personnel at all levels [CCAC services schedules, Section 7.3]. HCS agencies submitting RFPs must include a description of their Quality Management program and past experiences implementing performance improvement methods [CCAC RFP schedule C, Section B-2.2 & B-6]. They may also be asked about these processes in the interview stage of the RFP process [CCAC RFP consultation, Section 8.2.4]. There is also a performance improvement process in place for CCS agencies under LHIN MSAAs. The process may include the development of an improvement plan by the CCS agency that is approved by the LHIN, the conduct of a performance review, a revision of the CCS agencies obligations under the agreement, and/or an in-year or year-end adjustment to their LHIN funding. Improvement processes carry forward from one agreement to the next [MSAA Template, Section 7.4]. CCS agencies are also required to engage in performance meetings with their LHINs to discuss any identified problems with their performance targets and to identify ways to improve on their targets [MSAA Template, Section 7.3]. 92 4.2.1.2.5 Professionalism CCAC contracts and LHIN MSAAs include guidelines for the type of training and expertise that HCS and CCS frontline service personnel must have in order to provide services under contracts or agreements. This is a strong requirement for the services delivered by HCS agencies under CCAC contracts. The CCAC contracts stipulate that frontline staff must be qualified and registered to practice their profession in Ontario. This does not apply to personnel delivering personal support and homemaking services (personal support workers or PSWs) because they are not regulated by a professional body; rather, PSWs must be supervised by an individual that has appropriate qualifications (e.g. a Nursing Manager) [CCAC Schedule 1, Section 1]. In each of the different CCAC service schedules there are additional stipulations regarding required qualifications of personnel who deliver the services. The schedules often refer to providers needing to adhere to their College’s standards and guidelines. The service provider is expected to evaluate the performance and competency of their personnel and manage any restrictions imposed by the personnel’s professional college. There are also long lists about what activities each provider can, and is expected to, carry out as part of providing services. These lists are in accordance with the lists of activities that the professional colleges have in place. There is also a list of activities PSWs can do with clients, as well as a list of activities they can do after being trained by a “regulated health professional” [CCAC PS and HM services schedule, Section 3.3]. While there are many references and rules regarding the types of activities that can be provided by different professional and non-professional personnel in the CCAC contracts, there are few such guidelines in the MSAA. The only stipulations provided in the MSAA are that services are to be provided by persons with professional qualifications, expertise, licencing and skills necessary to complete their tasks [MSAA Template, Section 10.4 (i)]. In contrast to the MSAA, the CCAC contracts rely heavily on professional norms to ensure accountability for service provider personnel and front-line staff. 4.2.1.2.6 Performance accountability in the LHIN MSAA and CCAC contracts While both LHIN MSAAs and CCAC contracts include many provisions to ensure performance accountability, there are more stringent and explicit rules guiding organizational performance 93 under CCAC contracts as compared to MSAAs. These contracts demand that clients are followed more closely (through assessments, care plans and transitions) and rely on professionalism to provide additional weight to their accountability framework. Table 4-5 provides a summary of how the LHIN MSAAs and CCAC contracts support performance accountability. What is important to note is how CCAC contracts and MSAAs seem to be defining performance. Performance accountability under the LHIN MSAAs and CCAC contracts is focused mainly on process level indicators and issues of access, with minimal emphasis on health outcomes. The adequacy of current CCAC contract and MSAA performance indicators in relation to quality of home care service delivery is discussed in greater detail in Chapter 7. Table 4-5: Performance accountability in the LHIN MSAAs and CCAC contracts Performance accountability Performance indicators LHIN MSAA • • Few for CCS agencies Focus on access CCAC contract • • • Access • • Assessment, care plans and transition • Must provide services in French to any client that requests French services Must provide services across designated geographic area • Brief stipulations regarding transition plans (unclear) • • • • • • • • Performance review • Done ad hoc in reaction to poor performance • • Few required indicators included in contract Additional indicators identified by organization are required Focus mainly on access and monitoring Must provide services in French (in designated areas) Must provide services across designated geographic area Must be available 24/7 Must report missed visits Can refuse services if there is perceived risk Must be able to conduct clinical assessment (where applicable) Focus mainly on intake assessment rather than re-assessment Must be able to develop and follow care plans that are informed by CCAC assessment (supports case management) Must follow CCAC transition plans (supports case management) Must have a quality management program in place Unclear as to whether improvement processes are ongoing or on an ad hoc basis. 94 Performance accountability Professionalism • 4.2.1.3 LHIN MSAA Few stipulations – “must be qualified” CCAC contract • • Specific stipulations Reliance on professional norms Political/democratic accountability Political/democratic accountability emphasizes issues of equity, and highlights how accountability can promote trust and reflect common values (Brinkerhoff, 2003 & 2004). While political/democratic accountability is part of the MSAA and CCAC contracts, it occupies a less prominent position than financial or performance accountability discussed above. For the most part, home and community care agencies are held to account for conflicts of interest, ensuring equity, and the promotion of values; all of which fits with the political/democratic accountability focus on building trust with citizens by ensuring that funded agencies act responsibly. 4.2.1.3.1 Conflicts of interest For HCS agencies under contract with CCACs, conflicts of interest are described as [CCAC General conditions, Section 3.4.1 & 3.4.2]: • • • • • Using their position for financial gain or the financial gain of a spouse; Taking advantage of having access to the client for the purposes of “selling or promoting other services or goods offered by the provider”, giving the client materials that “describe the service provider and the range of their services”, giving the client materials that describe no-cost community services available to them, or accepting or soliciting gifts; Engaging in any activity that could reasonably result in actual, potential or perceived conflict of interest; Engaging in outside work that will interfere with obligations of the agreement of which gives them (real or perceived) any advantage; Hiring of CCAC current or former directors, contract management, employees that were involved in the RFP process for that organization. The CCAC contract clarifies that the intention is not to prevent the HCS provider from providing private services to clients, but to ensure they are not violating the conflicts of interest listed above. Failure to disclose actual, potential, or perceived conflict of interest is grounds for contract termination [CCAC General Conditions, Section 12.1.3 (1,b, E, iv)]. HCS agencies also must disclose perceived, potential or actual conflicts of interest in the RFP process. Conflicts of interest at this stage generally relate to the RFP process itself rather than 95 with the delivery of services. RFP conflicts of interest include instances where the agency has access to CCAC confidential information with respect to the evaluation criteria or process, and providing the names of all individuals who played a role in preparing the RFP [CCAC RFP consultation, Section 5.1.2]. Any other potential, perceived or actual conflict must be disclosed and can either be waived by the CCAC or lead to disqualification. Conflicts of interest are also a concern in the MSAA for HSPs although there are far fewer stipulations than the CCAC contracts regarding what constitutes a conflict of interest. The MSAA simply requires that the HSP must fulfill agreement obligations without any actual, potential or perceived conflicts of interest. It also requires that the HSP disclose any situation that may be interpreted as an actual, potential or perceived conflict of interest [MSAA Template, Section 3.3]. 4.2.1.3.2 Ensuring equity Equity issues in these documents mainly focus on ensuring access to services. Specifically both the MSAA and CCAC contracts have a number of stipulations that CCS and HCS agencies make services available in French. For HCS providers under CCAC contracts this applies to providers who operate in designated areas and are required to provide services in French. In the CCAC contracts there are also stipulations that services cannot be refused on the grounds of ethnic, religious or linguistic characteristics of the client [CCAC services schedules, Section 2.2.5(e)]. Referrals and assessments sent to HCS providers from CCACs include stipulations regarding ethnic, spiritual, linguistic, families and cultural requirements of clients, and it is required that the provider assign personnel who are responsive to these unique needs [CCAC service schedules, Section 3.2.2]. The provider may be responsible for all costs and expenses of interpretation services if required, and can be required to provide their personnel with antidiscrimination and anti-harassment education as necessary [CCAC service schedules, Section 7.4.1(l)]. HCS agencies delivering services are also required to deliver services at any location in their designated service area. CCS agencies under MSAAs are also not permitted to restrict or refuse provision of services on the basis of geographic area [MSAA Template, Section 3.1(d)]. 96 4.2.1.3.3 Promotion of values Both the CCAC contracts and MSAAs require that funded agencies promote the values and interests of the CCACs and LHINs. Under CCAC contracts this is simply stated as a requirement to “protect the interests of the CCAC” under the required Quality Operating Standard [CCAC contract schedule 4, Section 2.1.3 (i)]. HCS providers are also required to assist the CCAC with media relations and must refrain (including personnel) from making complaints to the clients about the CCAC (particularly in instances where the contract is terminated) [CCAC Service schedule, Section 7.6.2.2(c)]. CCS agencies under the MSAA must also ensure that they acknowledge that they received funding from the LHIN and government of Ontario in any publication. 4.2.1.3.4 Political/democratic accountability in the LHIN MSAAs and CCAC contracts The political/democratic accountability requirements for home and community care agencies are much less stringent than financial and performance requirements. These elements of the agreements/contracts demonstrate to citizens that government funded services are free of conflicts of interest, are delivered equitably, and promote shared values. Table 4-6 summarizes the political/democratic accountability elements in the LHIN MSAA and CCAC contracts. Table 4-6: Political/democratic accountability in the LHIN MSAAs and CCAC contracts Political/democratic accountability Conflicts of interest • Equity • Promotion of values • 4.2.1.4 LHIN MSAA CCAC contract General stipulations that organizations must disclose conflicts of interest • Relates to providing access to services regardless of geographic location or language Agencies must promote values and interests of LHIN • • Very specific stipulations regarding conflicts of interest during service delivery and in the RFP process Relates to providing access to services regardless of language or ethnicity Agencies must promote values and interests of CCAC Procedural accountability Document analysis of CCAC contracts and MSAAs revealed a fourth purpose: procedural accountability. It is intended to capture stipulations regarding the procurement process and the 97 process through which contracts and agreements are awarded. These stipulations may include rules regarding prequalification, submitting proposals, and the proposal review process. This purpose is to ensure that the awarding of contracts and agreements is done in a fair and equitable manner. HCS agencies competing for CCAC contracts must abide by many stipulations regarding the RFP submission process to ensure a fair competitive process. For example, there are clear guidelines regarding the prequalification process, how applicants are to fill out forms and what needs to be included (i.e. how to demonstrate experience, financial capabilities, and litigation history), and how assessments are carried out. The OACCAC is in charge of the prequalification process. It circulates prequalification documents, makes decisions on prequalification, and is the only body that can amend these documents [CCAC prequal instructions]. The rules regarding prequalification also clearly state the rights of the OACCAC and the actions it can take throughout the process. This document is intended to provide transparency in the prequalification process. Prequalification occurs at three levels and are assigned to each type of service. There is also procedural accountability in the RFP process for CCAC contracts. The RFP process is said to offer an “open, fair and competitive procurement process” [CCAC RFP consultation, Section 1.1 (2)]. The CCACs put in place a “Fairness Monitor” to advise and provide guidance with respect to fairness issues during the RFP process [Ibid, Section 1.2]. The consultation document provides specific stipulations regarding the RFP process and clearly states the responsibilities of both the CCAC and the applicants, including the costs that must be covered by the applicant [Ibid, Section 3.12]. Included in these stipulations are a clear method for how applicant questions will be addressed, stipulations regarding “prohibited contacts” identifying who applicants cannot contact at the CCAC during the RFP process, and a clear statement of how proposals are to be evaluated [Section 8.2]. For CCS agencies under MSAAs procedural accountability is mainly sought for the procurement of goods and services by CCS agencies under MSAAs. The MSAA requires that CCS agencies have competitive procurement policies in place for the acquisition of services or goods valued at over $25,000. CCS agencies that receive more than $10,000,000 in funding must procure goods in accordance with the Ministry of Finance “Supply Chain Guideline” [MSAA Template, 98 Section 4.8]. There are no other procedural stipulations regarding the awarding of LHIN funding for CCS agencies, or any other HSP, other than HSPs must be not-for-profit agencies. 4.2.1.4.1 Procedural accountability in the LHIN MSAAs and CCAC contracts This procedural accountability focuses mainly on the role and responsibilities of the CCACs for ensuring that the RFP process is fair and equitable. This is particularly important given the widespread protests that occurred after Hamilton’s CCAC disqualified two non-profit home care agencies with a history of service provision in the area from the right to making a bid in 2007 (Kushner et al., 2008). This decision was protested by the service providers and citizens because no satisfactory reason, beyond pricing, was given for disqualifying these agencies. This issue led to the second moratorium that has suspended the RFP process across CCACs for most services (Ibid). To remedy any perception of procedural bias, the CCACs now have specific procedural stipulations regarding both the prequalification and RFP processes. 4.2.2 Enhancing citizen engagement Accountability can be used as a mechanism to enhance citizen engagement to establish, or reestablish, trust between citizens and decision-makers (Abelson & Gauvin, 2004). In the LHIN MSAAs and CCAC contracts, citizen engagement is supported through the use of client satisfaction survey and complaints. Clients have the opportunity to provide feedback and input into how services are being delivered. While not necessarily a deliberative approach that incorporate public feedback into decision making, a method often used to support citizen engagement (Ibid), surveys and complaints procedures allow for “citizens” to have some input into how services are being delivered. 4.2.2.1 Client satisfaction and complaints HCS agencies under CCAC contract must have a client satisfaction monitoring system in place. The system must be able to receive, handle, respond to and track all queries, complaints and requests. The provider must also communicate to clients and caregivers that complaints can be submitted directly to the CCAC [CCAC services schedule, Section 7.1(2)]. Client satisfaction monitoring is also a part of the Quality Management Program that must be in place [CCAC services schedule, Section 7.3 (2,h)]. The CCAC may also collect client satisfaction information 99 regarding the quality of services, in which case the provider must cooperate with the CCAC in the delivery of client surveys [CCAC General Conditions, Section 11.1 (6)]. HCS providers under CCAC contract must notify the CCAC in the event of client complaints [CCAC General Conditions, Section 5.1.7(1)]. They also must report on the number of complaints received per quarter (also part of the Quality Management Program). The only stipulations in the MSAA regarding client satisfaction or complaints is that CCS agencies under the MSAA must have policies in place that can address client complaints regarding the services, management or governance of the agency [MSAA Template, Section 10.3 (a, viii)]. There are no stipulations in the MSAA regarding the use of client satisfaction tools. 4.2.2.2 Citizen engagement in the LHIN MSAAs and CCAC contracts It is not clear what impact these surveys have on service delivery and whether there are processes in place to follow-up with clients or to communicate how their concerns are being addressed. While these tools may be useful to CCACs, LHINs and home and community care agencies, there does not seem to be evidence that they are used to support citizen engagement in a manner suggested by Abelson and Gauvin (2004). 4.2.3 Assigning clear roles and responsibilities Bergsteiner and Avery (2009) assert that accountability relationships will tend to be stronger when there is role clarity in which expectations and obligations are clearly understood by both parties. While we can look to accountability documents to identify what roles and responsibilities are assigned and to whom, it is also important that the parties perceive these roles and responsibilities as being clear in order to strengthen accountability. This following section will focus on what roles and responsibilities are assigned to both parties, and in Chapter 6 the perception of clarity by parties will be discussed. 4.2.3.1 Roles and responsibilities for home and community care agencies under MSAAs and CCAC contracts For the most part, the roles and responsibilities for home and community care agencies are covered in the above sections with respect to how HCS and CCS agencies are held to account for financial, performance, and political/democratic purposes. These responsibilities are clearly laid 100 out for agencies and often consider multiple scenarios and situations. When examining the documentation alone, the roles and responsibilities for service providers are generally clearly stated, particularly in CCAC contracts RFPs and prequalification documents. Whether stipulated responsibilities are perceived as clear by organizations is discussed in Chapter 6. The MSAA agreements tend to provide less clarity than the CCAC contract documents with respect to the roles and responsibilities of service providers. For instance, there is much less clarity and direction regarding the specific means by which services are delivered and how potential clients are identified as eligible. It is also not entirely clear whether CCS agencies will need to adopt, or merely consider, the range of cost management approaches suggested in the MSAA (such as back office integration processes). 4.2.3.2 Roles and responsibilities for the LHINs and CCACs Both MSAAs and CCAC contracts also include a number of responsibilities for LHINs and CCACs; signaling that these accountability frameworks support bi-directional accountability. However, there are far fewer responsibilities assigned to LHINs and CCACs as compared to those assigned to home and community care agencies. In general the LHIN must help to ensure that the terms of the MSAA are fulfilled. To that end LHINs are required to support CCS agencies in: • • • • • • • • • Providing guidance, approve and monitor performance obligations. Monitoring in-year forecasts of the financial position of funded services. Setting up performance meetings as necessary. Providing training where necessary. Developing performance indicators (ongoing and often in consultation with providers). Providing HSPs with amendments to manuals, guidelines or policies that impact on the HSP. Providing and cancel funds – LHIN may not be obligated to provide full or any funding if the LHIN does not receive expected funds from the MOHLTC. Conducting a review of financial and non-financial records of the HSP during the term of the agreement and for seven years after the agreement. Developing transition plans in consultation with the HSP. The LHINs also have the authority and responsibility of terminating agreements. CCACs are also assigned a number of roles and responsibilities with regard to contracts with HCS agencies. Prior to the signing of contracts, the CCACs are responsible for the evaluation of 101 RFPs, assignment of prequalification status, and final selection of HCS agencies. Unlike the LHINs, CCACs are also responsible for key aspects of service delivery such as: • • • • • • Overseeing and commencing the transition process for clients who begin receiving services from a new agency (both at the start and end periods). Conducting intake assessment of clients and setting up the client services plan (Services schedules). Referring clients and requesting services (regular and urgent service requests) and preparation of referral information package (Services Schedules). “Providing authorization for additional time/services for clients (Services schedules) or withdrawing services” (CCAC Schedule 4). Providing and delivering some (not all) equipment needs (Services schedules) – equipment provision is stipulated for each different service type, equipment related to administration is not included. Disseminating client surveys (for use by the CCAC to assess performance). CCACs also have a number of responsibilities related to paying HCS agencies and managing their volumes and market share. As part of this role CCACs are able to increase or decrease an agency’s market share as well as the service volumes stipulated in the contract at their discretion. CCACs can also introduce changes to service or performance standards. CCACs are also responsible for the termination of contracts. Other responsibilities assigned to the CCAC in the contracts include: • • • • • • Providing approval for subcontractors and determine whether subcontractors need to be replaced on the basis of poor performance Requesting meetings with providers Sharing in mediation costs with service provider where mediation is required Dealing with third party requests for access to information made to service providers Permitting disclosures of information at their discretion Auditing!(under!its!discretion)!of!providers!accounts,!financial!information,!financial! statements!and!performance!information. 4.2.3.3 Assigned roles in the LHIN MSAAs and CCAC contracts In general, the roles and responsibilities assigned to service providers are much more clear and strict than those assigned to LHINs and CCACs. The responsibilities of LHINs and CCACs are primarily in place to support service delivery, ensure that payments are made17, and identify which costs need to be covered by service agencies. For the most part LHIN and CCAC 17 The LHINs and CCACs can make changes to payment structure at their discretion. 102 responsibilities are in place to protect them from financial liability and provide them with added control over the delivery of services. 4.3 MSAAs and CCAC contracts “at what cost”: Answerability and sanctions Answerability and sanctions are key aspects of accountability (Brinkerhoff, 2003). Strategies that support answerability may include regulation, oversight, monitoring and reporting, which sanctions may include requirements, standards, penalties, professional codes of conduct, incentives (to encourage and discourage behaviour), and soft sanctions (public exposure and publicity) (Ibid). 4.3.1 Answerability: Reporting requirements The CCAC contracts and MSAA include a significant number of financial and performance reporting requirements for home and community care agencies delivering services. 4.3.1.1 Financial reporting In most cases financial reports must maintain a consistent structure. CCS agencies under the MSAA must maintain all financial records in a manner consistent with General Accepted Accounting Principles or international financial reporting standards [MSAA Template, Section 8.3, ii]. CCS agencies must also do their financial reporting on the web-based Ontario Health Reporting System (OHRS) and use a financial and statistical reporting template provided by the LHIN called the Web Enabled Reporting System (WERS) 18 [MSAA Schedule C]. As part of the WERS submission CCS agencies must submit quarterly and annual financial statements. Agencies must also report multi-year financial forecasts in their CAPS submissions. HCS agencies under CCAC contract also must submit annual audited financial statements to the CCAC for each of the years of the contract [CCAC General Conditions, Section 5.5]. Additionally, the CCAC can request that agencies provide detailed records on a weekly, monthly and cumulative basis for each full or partial fiscal year regarding volumes and service prices. At 18 The WERS was changed to the Self-Reporting Initiative (SRI) in October 2012. 103 the very least the provider must submit this information quarterly (CCAC Schedule 2, Section 1.3(1)). In addition to remitting financial statements HCS agencies under CCAC contracts must adhere to standard requirements for submitting billing requests to the CCAC for services rendered; this may be either in electronic or hard copy. It may also be required that the HCS provider attend CCAC training sessions (at the providers expense) that cover submission of electronic statements and software [CCAC schedule 2, Section 2.1 (4)]. The CCAC may also change this format at any time and require that providers meet these new requirements at their own expense. The required risk management system for HCS agencies under CCAC contract must also include a process in place to report to the CCAC regarding financial risks, contingencies, liabilities and irregular transactions [CCAC services schedules, Section 7.2(2,c)]. 4.3.1.2 Performance reporting Performance reporting for the MSAA and CCAC contracts occurs mainly quarterly and/or yearly. Some reports for the CCAC contracts will occur at irregular intervals, as they need to be filled out as issues arise, such as risk event reports or discharge reports. For the most part, performance reporting for both MSAA and CCACs follow consistent structures to which CCS and HCS agencies must adhere. For HCS agencies under CCAC contract, they need to fill out standardized performance reports (as stipulated in Schedule 4 of the contract). In addition to the reporting of performance indicators HCS agencies need to submit a number of reports related to service delivery. These include: • • • Initial reports: Initial reports provide client information and summarize the care plan for the client. Must be submitted seven days after the first visit with the client [CCAC services schedules, Section 5.3]. Change of status reports: These reports identify the need to change client care plans. Changes must be consistent with the client service plan initially created by the CCAC at the time of client intake [CCAC services schedules, Section 5.4]. Risk event reports: Risk events are any event that causes illness or injury to the client or service provider personnel, or any damage to property or equipment. Adverse events are risk events that are specifically related to a client, cause unintended injury to a client that result in disability, death or increase use of healthcare resources, or are events caused by health care management. These reports must be submitted no later than 3 days after the event [CCAC services schedules, Section 5.5]. 104 • • Client interim reports: These reports summarize the services provided to the clients, the client’s health condition, and a progress report regarding meeting care plan goals. These are submitted to the CCAC 3 days after the CCAC’s request a report [CCAC services schedules, Section 5.6]. Discharge reports: These reports provide information on the client’s final visit, the client’s functional status, the reasons for discharge, description of progress made towards goals and recommendations for any further requirements. These reports are sent to CCAC seven days after the CCAC’s recorded discharge date in the client care plan [CCAC services schedules, Section 5.7]. These reports are filled out by service providers or supervisor (in the case of PSWs providing personal support and homemaking services). Performance report submission is monitored by CCACs and LHINs. For HCS providers under CCAC contracts that monitoring is built right into the performance reporting structure. For CCS agencies under MSAAs, the LHIN not only monitors the submission of quarterly performance reports but they can also enforce financial penalties on the CCS provider is reports are late [CAPS guidelines, section 2.6]. 4.3.1.3 Reporting requirements in the LHIN MSAAs and CCAC contracts There are significant reporting requirements in place for home and community care agencies under MSAAs and CCAC contracts. Reporting is the main tool through which accountability for service delivery is enforced for both CCAC contracts and MSAAs. 4.3.2 Answerability: Monitoring and oversight There are a number of monitoring and oversight stipulations in the MSAAs and CCAC contracts. With regard to CCS agencies under the MSAA, LHINs will monitor performance results against targets on a quarterly basis [CAPS guidelines, 2.1(a) & 2.3], and will regularly monitor the financial position of LHIN-funded services and forecasts [CAPS guidelines, 2.1.b]. Some monitoring activities will trigger meetings between the LHINs and CCS agencies, for instance in the event that there are performance variances [CAPS guidelines, 2.3]. Meetings can also be considered as a monitoring and oversight activity. With regard to HCS agencies under CCAC contracts, CCACs will monitor financial performance by conducting financial audits [CCAC general conditions, Section 5.2.13]. Any discrepancies found could trigger a meeting between CCAC and HCS agencies [CCAC schedule 2, 1.3(3)]. 105 The CCAC will also monitor performance by monitoring performance indicators [CCAC general conditions, 7.2 (2)]. If the CCAC has concerns regarding performance they can ask to have a meeting with the HCS agency in which the agency must answer questions regarding their performance. This meeting may lead to the implementation of a performance improvement plan [CCAC general conditions, 11.1 (1&2)]. There are a number of potential meetings that could occur between HCS agencies under CCAC contract and CCACs. These include regular quarterly meetings (these may occur more frequently) to discuss general issues [CCAC services schedule, 8.1]; as needed meetings to resolve identified issues that relate to applicable laws [CCAC general conditions, Section 5.1(3)]; meetings that are triggered by events like an anticipated strike or lockout (this could then lead to triggering the transfer process) [CCAC general conditions, 14.8.6(2)]; and, meetings around client service plans [CCAC services schedule, 3.3.4(2a)], orientation sessions [CCAC services schedules, 7.5], or transition plans [CCAC services schedules, 7.6.1 (f)]. Other oversight activities may be required beyond general monitoring and meeting requests. For HCS agencies, the CCAC may hire a third party assessor in the event that services are suspended to a particular client [CCAC general conditions, 3.1.5 (b&c)]. Additionally, financial and performance auditing can occur on the HCS agency’s premises, a form of direct oversight. The CCAC may also, at any time, inspect or survey the HCS agency [CCAC general conditions, 11.1(3)]. The CCAC also requires internal oversight within the HCS agency. For instance agencies may need to have service supervisors in place (often Nursing Managers) for certain front line staff [CCAC schedule 1, Section 2]. Service Managers provide assistance [CCAC services schedules, 3.2.2], or supervise the delivery of PSW and homemaking services by front line staff. Service Managers are also responsible for filing out all service related reports for personal support and homemaking services delivered by PSWs. 4.3.2.1 Monitoring and oversight in the LHIN MSAAs and CCAC contracts The CCACs and LHINs engage in regular, ongoing monitoring of the activities of home and community care agencies. Among their monitoring activities is the requirement that agencies engage in meetings at the request of CCACs and LHINs to further discuss what was found during monitoring, and to suggest potential changes to service delivery to remedy any issues or 106 problems. There are fewer provisions with regards to oversight activities. The agreements and contracts include provisions that allow CCACs and LHINs to potentially engage in some oversight, but this is never direct supervision of the delivery of services. The LHINs tend to engage in less oversight than the CCACs. LHIN staff may enter CCS agency premises to gather information as required to inspect records [MSAA Template, Section 8.2]. In general, monitoring and oversight are used as a means to ensure answerability for accountability requirements; however, they are not as important as the use of reporting. 4.3.3 Sanctions There are two main consequences that face home and community care agencies that do not fully comply with MSAAs or CCAC contracts. The first is reduction of funding and/or contract volume and the second is termination of the contract. 4.3.3.1 Reduction of funding and/or contract volume For HCS agencies under CCAC contracts, reductions in contract volume or withholding of payments can occur if an HCS provider under contract: • • • • Fails to implement transition plans [CCAC General conditions, Section 3.7 (3)] Fails to perform “any of its obligations,” including the carrying out of services [CCAC General conditions, Section 11.2(1) & Section 11.3] Fails to reach required market share over an extended period of time (the CCAC can then reduce the market share) [CCAC General Conditions, Section 2.6(6)] Fails to submit a resubmitted claim to the satisfaction of the CCAC in which case the CCAC can refuse payment [CCAC schedule 2, 2.3(3)] CCS agencies under MSAAs may also experience reduced funding or a financial penalty. This consequence occurs in the event that [CAPS guidelines, Section 2.6 & MSAA Template, Section 8.1(e)]: • • • • • The CAPS submission is incomplete or inaccurate Quarterly performance reports are late or not provided Financial or clinical data requirements are late, incomplete or inaccurate Fails to meet accountability indicators Breaches any obligations of the agreement (MSAA Template, Section 4.2(iii)) 107 4.3.3.2 Termination Termination of CCAC contracts can occur if the HCS agency: • • • • • Defaults on the contract. Default is defined as when an HCS agency becomes insolvent or unable to pay debts, files for bankruptcy, transfers the agreement to another party, abandons the agreement, fails to meet accepted service request percentage, fails to meet assignment of service personnel requirements, fails to submit reports, fails to meet requirements relating to client information privacy, protection and management, fails to deliver services in French (if required), fails to collect and submit performance quality information, submits false or misleading information to the CCAC, persistently fails to meet quality operating standards, fails to disclose conflicts of interest, and/or makes false statements in the proposal (RFP) [CCAC General conditions, Section 12.1.3 (1&2)]. Fails to achieve accreditation status (if these are required in the agreement) the CCAC may not renew the contract [CCAC General conditions, section 3.12(2)]. Fails to make reasonable efforts or comply with CCAC proposed security directives as regards client information privacy and protection [CCAC General conditions, section 5.1.2(2)]. Fails to appropriately deal with claims that the provision of services infringe on copyright laws [CCAC General conditions, section 9 (3)]. Fails to perform “any of its obligations,” “including the carrying out of services” [CCAC General conditions, Section 11.2(1)]. The CCAC may also terminate contracts for any reason that is related to any actions (or failure to act) on the part of the service provider [CCAC General conditions, Section 12.1.1]. Contracts can also be terminated in the event that the CCAC refers less than the lowest volume for an extended period of time and if new prices cannot be renegotiated to deal with these circumstances [CCAC Schedule 2, Section 3.4.2]. The HCS agency is also able to terminate the contract in the event that the CCAC becomes insolvent or files for bankruptcy; the CCAC abandons the agreement; or the CCAC is in material breach of the agreement [CCAC General conditions, Section 12.2.1]. For CCS agencies under LHIN MSAAs, agreements can be terminated without cause, if the LHIN does not receive necessary funding, or with cause [MSAA Template, Section 12.1]. Termination with cause occurs in the event that the CCS agency under the MSAA: • • • “Knowingly provides false or misleading information” to the LHIN; Is in material breach of the agreement defined as: misuse of funding, failure to provide services as per the agreement, failure to provide the Compliance Declaration, failure to implement of follow a performance agreement, improvement process or transition plan, failure to respond to LHIN requests in a timely manner, and failure to inform the LHIN of conflicts of interest; Is unable to provide services; 108 • • • • Is unable to reasonably continue to provide services; Loses and/or changes necessary business or corporate status; Files for bankruptcy; “Ceases to carry on business.” 4.3.3.3 Other sanctions Non-compliance can result in another sanction included in MSAAs and CCAC contracts. For example, home and community care agencies may experience fines. If a financial audit of a HCS conducted by the CCAC finds that the HCS agency has a deficiency, inconsistency or inaccuracy that exceeds $10,000 then the agency must reimburse the CCAC for the costs and expenses of the audit [CCAC General conditions, Section 5.4(3)]. CCS agencies under the MSAA could be on the hook to repay part or all of their funding if they provide false information to the LHIN, breach conditions of the agreement and do not take steps to remedy the breach, or breaches any Applicable Law [MSAA Template, Section 5.1 (f)]. HCS agencies under service contracts may also be required to remove personnel that have committed serious misconduct or if the CCAC is dissatisfied with the performance of the personnel [CCAC General Conditions, Section 3.3 (2)]. The agency may be given the opportunity to investigate problems with the personnel prior to being required to remove that staff [CCAC General Conditions, Section 3.3 (4)]. Public disclosure of information, such as performance information, may also be used as a sanction (a form of shaming if performance is poor). CCACs are allowed to disclose performance monitoring findings to the Government of Ontario, to other LHINs, and to the general public if they choose [CCAC general conditions, Section 7.2 (4&5)]. 4.3.3.4 Remedy HCS and CCS agencies may be given the opportunity to remedy instances of non-compliance prior to experiencing sanctions. The CCAC contracts include provisions that providers will be given reasonable amounts of time to fix issues related to personnel, identified deficiencies in financial and performance audits conducted by the CCAC, and performance in terms of service delivery. In terms of performance the provider will be required to attend meetings with the CCAC in order to identify methods in which performance issues can be rectified. If the agency 109 remedies issues lost funds may be reinstated; however, if issues are not remedied this will potentially trigger a termination of the contract. As identified in the “monitoring” section above, variation in meeting performance targets could trigger meetings between LHINs and CCS agencies. 4.4 Multiple accountabilities for the HCC sector: Document analysis summary Home and community care agencies in Ontario are potentially subject to a wide array of accountability requirements from a variety of different government and non-government bodies. For the most part accountability requirements are attached to funding and as such organizations who receive funding from many different sources will be subject to many different accountability requirements. When we examine two prominent accountability frameworks that cover home and community care agencies providing services with government funding we get a better sense of exactly what accountability is for. Of note is that these frameworks primarily support financial and performance accountability (focusing mainly on process and access performance), are unevenly bi-directional (the accountee has significantly more responsibilities than the accountor), and rely mainly on answerability and sanctions to enforce accountability. In Chapter 7, these findings will be incorporated with findings from the survey and key informant interviews to answer research questions #2, #3, and #4. 110 Chapter 5 Quantitative findings: Survey results 5 Introduction This chapter presents findings from the survey and environmental scan that address four of the thirteen propositions outlined in Chapter 2. As discussed in Chapter 3, the environmental scan includes organizations that deliver home and community care services in two Ontario regions of interest; this constitutes the sampling frame for the study. The findings presented in this chapter include: 1. A discussion of survey response rates. 2. An analysis of the environmental scan to determine whether there is any significant bias in the survey sample. 3. Descriptive statistics of the survey sample. 4. Analysis of the survey data to answer research question #2: What is the array of realized organizational responses to accountability requirements? 5. Analysis of the survey data to answer research question #3: How do responses vary as a function of organizational factors? Specifically examining four propositions put forward regarding organizational responsiveness to accountability demands. 5.1 Survey response rates: Challenges associated with organizational surveys Of the 250 organizations in the sample frame, 196 were in the urban region and 54 were in the rural region. Only 58 of the urban regions organizations and 34 of the rural region organizations were OCSA members. Emails were sent directly to organizations that were not OCSA members and had accessible email addresses or web-based contact sheets. This ensured these organizations were included in the final sample. The emails included a cover letter (see Appendix 3-4) and link to the survey. Only 91 urban organizations of the remaining 138 urban organizations and all of the remaining 20 rural organizations identified in the environmental scan could be contacted electronically. Emails were sent three times: July 8th 2011, July 18th 2011 and July 25th 2011. Phone calls were made to remaining organizations urban region in the environmental scan that were accessible by phone. Only 10 organizations in the urban region could be reached by phone. All organizations were called twice. 111 • Survey response rates o OCSA members: N=106 of 498, RR= 21.29%. o Rural direct email and web-based contact sheets: N=12 of 91, RR=13.19%. o Urban direct email and web-based contact sheets: N=1 of 20, RR=5%. o Urban direct calls: N=2 of 10, RR=20%. o Rural direct calls: N=0 Survey data were inspected and duplicates removed resulting in a total survey response of 114 organizations for a total response rate of 18.66% (114 of 611). This response rate is not surprising given that response rates for organizational surveys tend to be much lower than surveys administered to individuals. In their systematic review of response rates in published studies of organizational research using surveys, Brauch and Holtom (2008) found that the average response rate for organizational surveys was 35.7% with a standard deviation of 18.8 whereas average response rates for surveys of individuals was 53.7% with a standard deviation of 20.4. They suggest that the number of published studies with low response rates demonstrates the academy’s “tacit recognition of the increased difficulty in obtaining responses” at the organizational level (p.1154). Hager, Wilson, Pollak, and Rooney, (2003) also argue that organizational surveys with 15% response rates have been acceptable in the literature. The response rate found in this study is acceptable because it falls within one standard deviation of the average found by Baruch and Holtom (2008), is well above the minimum response rate of 10% found in their systematic review, and is also above the acceptable level identified by Hager et al. (2003). 5.1.1 Organizational survey challenges There are number of potential reasons why this survey experienced the low response rate characteristic of organizational surveys. First, this survey targeted high-level management such as CEO’s, executive directors, managerial staff, program coordinators, financial staff, and quality officers who may not have found the topic to be of interest. In their systematic review Cycyota and Harrison (2006) found that surveys which relied on executives had an overall response rate of 32%. They attributed low response rates to surveys lacking topical salience defined as “a joint characteristic of survey content and the current or continuing interest of the target population” (p. 136). While informal discussions with individuals and research partners working in this sector revealed that accountability in the home and community care sector is a key concern for these 112 organizations, this topic may not have constituted a “current” interest for potential respondents, thus accounting for the low response rate. Second, the complexity of the survey may have hindered response rates. In some instances, multiple respondents from a single organization were required to answer the survey since not one individual had the capacity to answer all questions. Although respondents were given the opportunity to send the survey to colleagues and have multiple people from a single organization answer the survey, this additional step may have acted as a deterrent for respondents. Furthermore, respondents’ sense of authority and capacity to answer research questions may act as a deterrent to response (Tomakovic-Devey, Leiter, & Thompson, 1994). which may have also played a role in the response rate. Thirdly, respondents’ concerns regarding confidential financial information and the length of the survey may have low response rates (Tomakovic-Devey et al., 1994). Unfortunately financial information was required as part of this survey and thus may have contributed to lower response rates, particularly from private for-profit organizations. The length of the survey (see Appendix 3-F) could have also deterred respondents. Finally, organizations generally, and home and community care organizations in Ontario in particular, are often over-surveyed, leading to lower response rates (Weiner & Dalessio, 2006). Our research partner at OCSA flagged “survey burnout” as a potential problem affecting our response rates. Given these identified challenges, a low response rate is understandable. As noted above, although the response rate is low it is within the acceptable range for organizational surveys. 5.2 Descriptive analysis of the survey Descriptive statistics were used to analyse the organizational characteristics of those that answered the survey. As noted earlier, the survey was distributed to home and community care organizations that were OCSA members across Ontario. Organizations who answered the survey were primarily located in the Toronto Central LHIN (24.75% of survey respondents) and Champlain LHIN (20% of survey respondents) (see Appendix 5-A, Table 5A-7), however all LHIN regions were represented. Most organizations (28%) represented in the survey were medium sized organizations (see Appendix 5-A, Table 5A-8). 113 Most organizations in the sample deliver community care services and personal care services locally. The highest proportion of survey respondents (between 40% and 60%) said their organizations delivered personal care, homemaking, adult day programs, meals on wheels, friendly visiting, transportation, security checks, home help, meal plans, and foot care locally (see Appendix 5-A, Table 5-9). Organizations providing home care services tended to deliver one of two bundles of home care services: 1) personal care with respite, social work and homemaking, and 2) professional services (nursing, physiotherapy, occupational therapy, speech-language therapy, and dietetics) (see Appendix 5-A, Table 5A-10). Most organizations delivering home care services delivered between one and four services (see Appendix 5-A, Table 5A-11). There was no discernible pattern of service bundles for organizations delivering community care services, with the exception that a high proportion of organizations who deliver meals on wheels also provide transportation services (see Appendix 5-A, Table 5A-12). This pattern is not surprising given both services require vehicles to transport food and/or individuals. Organizations delivering community care services tended to provide between one and ten services (see Appendix 5-A, Table 5A-13). The survey asked organizations for the proportion of full-time, part-time/casual, and volunteer staff. A high percentage (36%) of organizations rely heavily (80-100% of total staff) or not at all (23%) (0% of staff) on volunteers. Most organizations (58%) had 1-20% of their staff as paid full-time or part-time casual employees (see Appendix 5-A, Table 5A-14 and Figure 5A-1). Organizations represented in the survey get funding from a number of sources: 82% of organizations received LHIN funding and of those 26% receive between 80-100% of their funding from LHINs (see Appendix 5-A, Table 5A-15). The second most prominent funding sources for organizations in the sample are user fees (82% get funding through user fees) and donations (63% receive donations) (see Appendix 5-A, Table 5A-15). A quarter of organizations in the sample (25%) receive 80-100% of their funding from home care services (see Appendix 5A, Table 5A-16), while 47% receive 80-100% of their funding from community care services (see Appendix 5-A, Table 5A-17). 114 Organizations represented in the sample hold a number of memberships and partnerships. The majority of organizations in the sample (72%) are members of OCSA (see Appendix 5-A, Table 5A-18). This is not surprising given that most organizations were sampled through the OCSA member list-serve (see Chapter 3 discussion of survey methods). Organizations had partnerships with local neighbourhood centres (16%), community support association networks (37% of urban respondents in an urban network, and 5% of rural respondents in a rural region network), home at last programs 19 (10%), as well as a number of other networks (see Appendix 5-A, Table 5A-19). Most organizations (74%) in the sample produce an annual report (see Appendix 5-A, Table 5A20). The majority of organizations in the sample are not accredited with Accreditation Canada (72%), CARF (88%), ISO (98%), NQI (98%), HAO (95%), or Salvation Army (95%), but of those who are, 23% are accredited by Accreditation Canada (see Appendix 5-A, Table 5A-21). 5.3 Survey sample characteristics As covered in Chapter 3, the environmental scan inventories organizations in the two regions and captures a set of their characteristics. Organizations that were represented in the survey were identified in the environmental scan and a statistical comparison was conducted between the two groups across key organizational variables. Cross-tabulations were run to see differences between survey respondents and non-respondents, and ANOVA was used to determine whether differences were significant. 5.3.1 Organizational size Survey respondents and non-respondents were compared by their organizational size. Organizational size was determined based on the total revenue of the organization (see Appendix 5-B for a detailed description of how size was determined). Non-respondents were significantly more likely to be small (p<0.05) (see Appendix 5-A Table 5-1). The difference between respondents and non-respondents was also found to be significant when testing absolute values for revenue. However, revenue data used to determine organizational size was missing for 144 19 Home at Last programs are partnerships between hospitals and HCC agencies that help seniors move more quickly from hospitals back to the community. Home at Last programs are present in most LHINs across Ontario. 115 organizations in the sample, because of this the sample is likely underpowered, meaning a potentially high likelihood of Type II error. 5.3.2 Services delivered Survey respondents and non-respondents in the rural and urban region of interest were compared by the services delivered. Survey respondents operating in urban locations differed significantly from non-respondents in terms of five services: occupational therapy, dietetics, adult day programs, friendly visiting, and foot care. In each instance, there was a higher proportion of respondents who delivered these services as compared to non-respondents. Significant differences between urban region respondents and non-respondents were found only for provision of recreation services; with a higher proportion of respondents delivering recreation services as compared to non-respondents (see Appendix 5-A, Table 5A-2). When the number of home care and community care services delivered is examined, urban region respondents were significantly more likely to deliver one to six home care services (p<0.05) (see Appendix 5-A, Table 5A-3). These findings suggest that organizations that are more active in delivering home care services are represented in the survey. The difference between respondents and non-respondents in the number of community care services delivered was not significant. 5.3.3 Memberships and partnerships Survey respondents and non-respondents were compared by the number of memberships and partnerships held. There was no significant difference between survey respondents and nonrespondents. 5.3.3.1 Contracts and agreements Comparisons of numbers of contracts/agreements held were made between survey respondents and non-respondents. Non-respondents from the urban region were significantly less likely to hold CCAC contracts, and were significantly less likely to hold one or three CCAC contracts as compared to respondents from the urban region (p<0.01) (see Appendix 5-A, Table 5A-4). Survey respondents were significantly more likely to hold CCAC contracts with one or more CCACs (p<0.001) (see Appendix 5-A, Table 5A-5). As for LHIN MSAAs, urban respondents 116 were significantly more likely to hold urban region MSAAs as compared to non-respondents (ANOVA, p<0.001) (see Appendix 5-A, Table 5A-6). 5.3.4 NFP/ FP status No significant differences were found between respondents and non-respondents when organizations were compared based on not-for-profit or for-profit status. 5.3.5 Human resources Survey respondents and non-respondents were compared regarding whether they use volunteers. The difference between respondents and non-respondents was not significant. 5.3.6 Overview of survey sample characteristics The most notable differences between the survey respondents and non-respondents were that respondents tended to deliver more different types of home care services and were more likely to hold CCAC contracts. This suggests that there were potentially a higher proportion of survey respondents who deliver home care services as compared to the sample population represented in the environmental scan. Given that home care services (delivered under CCAC contracts) and community care services (delivered under LHIN MSAA’s) are examined separately in the analysis this higher representation of home care organizations is acceptable. 5.4 Organizational responses to accountability requirements 5.4.1 Dependent variables As discussed in Chapter 2, this research project draws on Oliver’s (1991) theory of organizational responsiveness to identify potential organizational responses to accountability requirements. Oliver’s suggested strategic responses are collapsed into two possible response categories for the purposes of this research: compliance and non-compliance. Three possible responses were included as dependent variables that were captured in the survey. These responses include: 1. Compliance: This response represents conformity to external demands; it is operationalized as organizations currently or previously holding CCAC contracts and/or MSAAs and planning to apply to those contracts and agreements in the future. 117 2. Compromise: This response represents an organization’s attempt to balance, pacify or bargain external demands from constituents. Organizations may engage in different behaviours in order to meet accountability requirements such as engaging in subcontracting or partnering. This response is operationalized as compliant organizations that are also engaged in sub-contracting or partnering under CCAC contracts or LHIN MSAAs. Organizations who provide sub-contracting services to other organizations for fulfillment of their CCAC contract or LHIN MSAA is also included as an example of a compromise response. 3. Non-compliance/avoidance: This response represents an organization’s attempt to preclude the necessity to conform by avoiding the behaviour that will require them to conform. This response is operationalized as organizations that do not plan to apply to CCAC contracts and MSAAs in the future. As discussed in Chapter 2, potential organizational responses to accountability requirements may be more nuanced and complex. These responses have been simplified in order to make them operationalizeable for survey data collection. Table 5-1 identifies how survey variables were categorized according to Oliver’s (1991) framework. Table 5-1: Operationalized dependent variables Response Compliance Compromise (sub-group of compliant organizations) Non-compliance Avoidance Survey variables Hold MSAA or CCAC contract Previously held MSAA or CCAC contract Plan to apply to MSAA or CCAC contract Hold MSAA or CCAC contract Previously held MSAA or CCAC contract Plan to apply to MSAA or CCAC contract Subcontracted to other organizations Subcontracted for other organizations Partnering Do not plan to apply to MSAA or CCAC contract Table 5-2 summarizes the number of organizations in the sample that demonstrated the above responses. Table 5-2: Number of organizations in the survey that demonstrate different responses Response LHIN MSAA Compliance Compromise Non-compliance/avoidance No. organizations 37 16 27 Total N 64 Missing 50 118 CCAC contract Compliance Compromise Non-compliant/ avoidance 10 6 50 60 54 The results in Table 5-2, show that very few organizations demonstrate compromise responses to CCAC contracts. As such this response could not be tested using statistical methods. While the focus of this research is on organizational responses to CCAC contracts and LHIN MSAAs the survey also captured responses to other funding sources including Ontario Trillium Grants, New Horizons Grants, Veterans Affairs funding, and First Nations funding. Some respondents indicated that they also received funding or held grants with the United Way, Interim Federal Health, or Municipal governments. Descriptive statistics for all organizational response-related survey variables can be found in Appendix 5-C Tables 5C-14, 5C-15, 5C-16 and 5C-17. The two organizational responses captured by the survey were compliance and noncompliance/avoidance. A sub-group within the compliance response is compromise. It is usually considered a non-compliance response, but for this study was used as a sub-category of compliance in order to make compliance and non-compliance mutually exclusive groups. Findings that identify the array of realized organizational responses are addressed in Chapter 6. 5.4.2 Explanatory variables As discussed in Chapter 2 there are five factors that are expected to have an impact on organizational responses: cause, constituents, content, control and context. The survey captured organizational characteristics related to three of these factors including cause, constituents and context. These factors are operationalized as follows: 1. Cause: This factor relates to an organization’s desire to conform to its environment in order to improve its chances of survival. It is expected that highly visible organizations will be more likely to comply with external demands in order to demonstrate conformity. Larger organizations tend to have higher visibility and as such larger organizations are expected to be more likely to comply with external demands. Organizational size is determined by total revenue. See appendix 5-B for a discussion of how size is defined based on the survey sample. 2. Constituents: This factor suggests that the number of relationships an organization has will impact on how it responds to external demands. The organization’s response will also vary with regard to how dependent that organization is on the constituent imposing the external demand; higher dependence is expected to elicit a greater likelihood of 119 compliance. Dependence is operationalized as percent of total organizational revenue received from an external body. Number of constituents is operationalized as number of association memberships, number of network memberships, and number of accrediting bodies with whom an organization holds or is in the process of acquiring accreditation. 3. Context: This factor refers to contextual factors that are expected to have an impact on how an organization responds to external demands. This factor is operationalized as notfor-profit (NFP) or for-profit (FP) status, and access to financial and paid human resources. Access to financial resources is operationalized as organizational size (larger organizations are expected to have better access to financial resources) and access to paid human resources is operationalized as percent of full-time staff and percent of volunteer staff. Table 5-3: Dependent and explanatory variable definitions - quantitative data Variable name Organizational responses Compliance Description Dummy variable, coded 1 if organizational response is compliance as defined in Table 5-a, coded 0 if organizational response is non-compliance/avoidance Compromise Sub-group of compliance. Dummy variable, coded 1 if compliant organization engaged in compromise behaviours as defined in Table 5-a, coded 0 if compliant organization does not engage in compromise behaviours. Explanatory variables Cause Organizational Categorical variable based on total revenue. Small size organizations: total revenue < $400,000. Medium organizations: total revenue $400,000 - $4,000,000. Large organizations: total revenue > $4,000,000. Constituents Organizational Continuous variable of percent of total revenue received dependence from a particular funder. Association Continuous variable of the number of association memberships memberships held by an organization. Network Continuous variable of the number of network memberships memberships held by an organization. Networks include groups of organizations who work together to plan and coordinate service provision. Accreditation Continuous variable of the number of accrediting bodies with whom an organization holds or is in the process of acquiring accreditation. Context Status Dummy variable, coded 1 if organization is FP, coded 0 if organization is NFP Percent FTE staff Continuous variable of the percentage of staff in the organization that are full-time Percent Volunteer Continuous variable of the percentage of staff in the SAS Code Msaacomp, Ccaccomp Msaanoncompc ccacnoncompc Size S_LHIN, S_CCAC S_totasc S_totnet S_totacr S_fpnfp FTEPerc VPerc 120 staff organization that are volunteers 5.4.2.1 Relationships between explanatory variables The relationship between independent variables was examined using a correlation matrix and factor analysis. 5.4.2.1.1 Correlations Correlations between variables were tested using Pearson’s r. In cases of binomial variables, specifically FP-NFP status, Cramer’s V was used. These correlations are presented in Table 5-4. Table 5-4: Explanatory variable correlation matrix Size S_ccac Size 1.000 S_ccac 0.243 1.000 S_lhin -0.057 -0.446*** S_totasc 0.287* 0.016 S_totnet 0.195 -0.075 Totacr 0.100 0.086 S_fpnfp+ 0.069 0.810*** FTEPerc 0.269* 0.053 VPerc -0.210 -0.076 +Cramer’s V * significant p <0.05 ** significant p<0.01 *** significant p<0.001 S_lhin S_totasc S_totnet Totacr S_fpnfp+ FTEPerc VPerc 1.000 0.136 0.117 -0.042 0.512 0.007 -0.040 1.000 0.471*** 0.256* 0.239 -0.027 0.050 1.000 0.225* 0.321 -0.164 0.291* 1.000 0.054 0.004 -0.218 1.000 0.845 0.590 1.000 -0.702*** 1.000 Several relationships were significant, although few of those relationships showed strong correlations. Two exceptions, bolded in Table 5-4, are the relationship between for-profit status and CCAC funding. This correlation between these two variables, suggests that organizations that receive more funding from CCACs tend to be for-profit providers (Cramer’s V=0.810, p<0.001). Given that these explanatory variables are not modeled together in any of the following analyses this correlation will not impact any of the findings. The other correlation of note is that organizations with a high percentage of volunteers tend to have a lower percentage of full-time staff. These explanatory variables are modeled together, requiring one to be removed. Volunteer percentage was selected for removal as the indicators are intended to demonstrate access to resources and access to full-time staff is considered a more reliable resource than volunteer staff. 121 5.4.2.1.2 Factor analysis Exploratory principal component factor analysis was conducted on the independent variables in order to see if there were any latent variables that could influence findings. Eigenvalues over 1.0 and a scree plot were used to determine the factor solution. The scree plot did not show a clear factor cut off (see Appendix 5-A, Figure 5A-2). Eigenvalues suggested a three factor solution (see Appendx 5-A, Table 5A-22). A three factor solution describes 63% of the variance. The principal component factor analysis was run again under a three factor solution. Unrotated and rotated solutions were examined (see Appendix 5A, Tables 5A-23 and 5A-24). The rotation allows the pattern loadings to become more pronounced. The varimax rotation (Table 5-5) is used for analysis because it is an orthogonal rotation that assumes that few variables are correlated. It is the appropriate rotation to use because the correlation matrix revealed only one significant correlation. Table 5-5: Three factor solution, factor analysis VARIMAX rotation Rotated Factor Pattern Factor1 Factor2 Factor3 Percent revenue from CCAC 0.85606 0.11188 0.14968 FP/NFP status 0.68323 -0.19092 0.35504 Percent revenue from LHIN -0.77159 0.07595 0.18354 Number of total networks -0.17425 0.75596 -0.11278 Number of total association memberships -0.21440 0.70412 0.29303 Number of accreditors 0.23599 0.52299 -0.07993 Percent full-time staff 0.02255 -0.25256 0.83279 Organizational size 0.12970 0.36647 0.70095 The first factor shows a relationship between for-profit status, funding from CCACs and funding from LHINs. This factor is understandable since LHINs do not fund for-profit agencies, and forprofit agencies tend to deliver home care services rather than community care services. The external influence in this case is how home and community care services are delivered separately by CCACs and LHINs, that community care agencies are almost entirely not-for-profit agencies, and that the LHINs only fund not-for-profit organizations. 122 The second factor suggests that there is a relationship between the number of association memberships, network memberships and accreditations held by an organization. The latent variable is likely organizational activity in the broader home and community care sector. An organization that is highly active in the sector will likely have a high number of stakeholders in multiple facets of the sector. The final factor is the relationship between the percentage of full-time staff and the size of the organization. This factor suggests a latent variable of resource access, in which large organizations with better access to resources can afford to hire more full-time staff than smaller organizations that may rely on other forms of employees, like part-time and volunteer staff. 5.4.3 Organizational factors that affect organizational responsiveness to MSAAs and CCAC contracts This section explores how the factors of cause, constituents and context affect organizational responsiveness. Four propositions related to these factors are examined using binomial logistic regression because the dependent variables are binary: compliance = 1 and non-compliance = 0. Binomial regression was used instead of multinomial because the compliance response is operationalized as a sub-group of the compromise response rather than a separate response. A multinomial regression would thus not be appropriate as the responses are not exclusive. Given the small sample size, a less conservative alpha level of 0.1 was selected. While an alpha of 0.05 is traditionally used it has been argued that there is “no good reason” for choosing this level (Kennedy, 1998, p.64) and there is evidence to support the use of a less conservative alpha in this case. First, a less conservative alpha level has been recommended for logistic regression modeling with small sample sizes (Chao-Ying, Tak-Shing, Stage, & St.John, 2002a). Second, other studies examining organizational responsiveness also use an alpha of 0.1 (Calabrese, 2011; Üsdiken, Sözen, & Enbiyaoğlu, 1988). Finally, while a more conservative alpha level increases the potential likelihood of a Type I error (Greene, 1999; Pindyck & Rubinfeld, 2000), the risks of doing so are relatively low and as such are acceptable. Four methods of assessment were used to evaluate the effectiveness of the binomial logistic regression models as recommended in the literature (Chao-Ying, Lee, & Ingersoll, 2002b). The first method is to look at the overall model to determine whether it demonstrates an improvement 123 over the intercept-only or “null” model. The likelihood ratio, score, and Wald tests were used to test the overall model. These tests examine whether the predictors, taken together, significantly predict the outcome (Stevenson, 2008). The second method of assessment is to look at tests of individual predictors (Chao-Ying et al., 2002b). Individual predictors are tested using likelihood ratio estimates, and Wald tests for individual predictors. The Wald test examines whether the individual coefficients are significantly different than zero (Stevenson, 2008). The third method of assessment is to examine the goodness-of-fit of the model (Chao-Ying et al., 2002b). The goodness-of-fit test examines how well a model describes a response variable (Bewick, Cheek, & Ball, 2005). The Hosmer-Lemeshow (H-L) was chosen because it is a commonly used goodness-of-fit test used when the data contain both categorical and continuous explanatory variables (Stevenson, 2008; see also Lemeshow & Hosmer, 1982). The final method of assessment is to examine the validations of predicted probabilities or the “degree to which predicted probabilities agree with actual outcomes expressed as either a measure of association or a classification table” (Chao-Ying et al., 2002b, p. 6). This tests the strength of the association of the predictors to the outcome, much like a correlation. Four measures are used to test this: Kendall’s Tau-α (rank order correlation coefficient without adjustment for ties), Goodman-Kruskal’s Gamma (based on Kendall’s but adjusts for ties), Somers’s D statistic (extension of Gamma in which one variable is designated dependent and the other independent) and the c statistic (the probability that predicting the outcome is better than chance, values range from 0.5-1.0; 0.7 or higher is considered strong) (Chao-Ying et al., 2002b). If all four methods of analysis support the expected relationship between the independent and dependent variable then the relationship is considered to be strongly supported. If two or three methods of analysis support the relationship then the relationship is considered to be moderately supported. If only one method of analysis supports the relationship then the relationship is considered to be weakly supported. And finally, if all four methods do not provide support to the relationship then the relationship is rejected. Organizational responses to LHIN MSAAs and CCAC contracts were separated as these represent two different government funding sources which have their own unique accountability requirements. 124 5.4.3.1 CAUSE: Organizational size As stated above, the cause factor is related to an organizations visibility and it is expected that highly visible organizations will conform to external demands that improve their social fitness. This leads to the first proposition based on the literature: Proposition 1. Larger organizations will be more likely to comply with accountability requirements. 5.4.3.1.1 LHIN MSAAs A logistic regression examined whether organizational size is a predictor of organizational compliance to LHIN MSAAs. Regression results are presented in Table 5-6. Table 5-6: Logistic regression analysis of 48* organizations compliance response to LHIN MSAA in relation to their size. β Predictor Wald’s e & CI df p β SEβ ᵡ² (odds ratio) Intercept -1.317 0.965 1.858 1 0.172 N/A Size 0.853 0.456 3.494 1 0.062 2.346 (0.959; 5.734) Test ᵡ² df p Likelihood ratio test 3.802 1 0.051 Score test 3.712 1 0.054 Wald test 3.494 1 0.062 Goodness-of-fit test Hosmer & Lemeshow 1.998 1 0.158 Note: SAS programming code: [PROC LOGISTIC; MODEL MSAACOMP (event = ‘1’) = SIZE/LACKFIT;] Somers’ Dxy: 0.309. Gamma: 0.475. Kendall’s Tau-α: 0.151. c: 0.654. All statistics reported herein use 4 decimal places in order to maintain statistical precision. N/A = not applicable. *This number is less than the total 56 organizations identified in Table 5-2 as some of these organizations had missing data on their size. The likelihood ratio, score and Wald tests show that the overall model is a better fit than the intercept-only or “null” model. The H-L test supports the model, however the strength of the association between predictors in the model and the outcome is only moderate. The individual predictor of size was found to be significant and would suggest that for every unit increase in size an organization is 2.346 times (95% CI 0.959, 5.734) more likely to comply with LHIN MSAAs. These findings offer moderate support for the proposition. 125 5.4.3.1.2 CCAC contract A logistic model was used to examine whether organizational size is a predictor of organizational compliance to CCAC contracts. Regression statistics are presented in Table 5-7. Table 5-7: Logistic regression analysis of 49* organizations compliance response to CCAC contracts in relation to their size. Predictor Wald’s eβ & CI df p β SEβ ᵡ² (odds ratio) Intercept -3.519 1.508 5.443 1 0.020 N/A Size 0.895 0.613 2.128 1 0.145 2.447 (0.735; 8.141) Test ᵡ² df p Likelihood ratio test 2.341 1 0.126 Score test 2.234 1 0.135 Wald test 2.128 1 0.145 Goodness-of-fit test Hosmer & 7.452 1 0.006 Lemeshow** Note: SAS programming code: [PROC LOGISTIC; MODEL CCACCOMP (event = ‘1’) = SIZE/LACKFIT;] Somers’ Dxy: 0.319. Gamma: 0.428. Kendall’s Tau-α: 0.098. c: 0.660. All statistics reported herein use 4 decimal places in order to maintain statistical precision. N/A = not applicable. *This number is less than the total 60 organizations identified in Table 5-2 as some of these organizations had missing data on their size. ** More than 25% of the cells had an expected frequency of less than 5, which suggests that H-L may not be an appropriate test The overall model does not demonstrate an improved fit over the null model when examining the likelihood ratio, score and Wald tests. The H-L test would suggest that the model needs to be reworked; however, this test is likely not appropriate because the frequencies were too low. The strength of the association between predictors is only moderate, and the individual predictor was not found to be significant. Taken together, these findings suggest that there is a moderate association between organizational size and the ability to comply with MSAAs, but that this association is much weaker for CCAC contracts. 5.4.3.2 CONSTITUENTS: Dependence and multiple stakeholders Using survey data we can test two propositions that are associated with the constituents factor from the theoretical framework. 126 5.4.3.2.1 Dependence First, proposition 2a, which focuses on the influence of organizational dependence, will be examined using survey data. Proposition 2a: Organizations are more likely to comply with accountability requirements from stakeholders upon whom they are highly dependent for funding. 5.4.3.2.1.1 LHIN MSAAs A logistic model was used to examine whether organizational dependence on LHIN funding is a predictor of organizational compliance to LHIN MSAAs. Regression statistics are presented in Table 5-8. Table 5-8: Logistic regression analysis of 53* organizations compliance response to LHIN MSAAs in relation to the percent of funding received from the LHINs. β Predictor Wald’s e & CI df P β SEβ ᵡ² (odds ratio) Intercept -0.029 0.514 0.003 1 0.954 N/A Percent LHIN 0.0056 0.008 0.460 1 0.460 1.006 (0.990; 1.022) funding Test ᵡ² df P Likelihood ratio test 0.462 1 0.497 Score test 0.624 1 0.497 Wald test 0.460 1 0.498 Goodness-of-fit test Hosmer & 10.623 9 0.303 Lemeshow** Note: SAS programming code: [PROC LOGISTIC; MODEL MSAACOMP (event = ‘1’) = S_LHIN/LACKFIT;] Somers’ Dxy: 0.104. Gamma: 0.107. Kendall’s Tau-α: 0.052. c: 0.552. All statistics reported herein use 4 decimal places in order to maintain statistical precision. N/A = not applicable. *This number is less than the total 56 organizations identified in Table 5-2 as some of these organizations had missing data on their size. ** More than 25% of the cells had an expected frequency of less than 5, which suggests that H-L may not be an appropriate test The model statistics suggest a better fitting model as compared to the null model; however, none of the tests were significant. The H-L statistic supports the model (however it may be inappropriate), but the predictor statistics do not suggest a strong association between the 127 predictor and the outcome. Finally, the individual predictor was not found to be significant. These findings do not support the proposition. 5.4.3.2.1.2 CCAC contracts A logistic model was used to examine whether organizational dependence on CCAC funding is a predictor of organizational compliance to CCAC contracts. Regression statistics are presented in Table 5-9. Table 5-9: Logistic regression analysis of 47* organizations compliance response to CCAC contracts in relation to the percent funding received from CCACs. β Predictor Wald’s e & CI df P β SEβ ᵡ² (odds ratio) Intercept -2.390 0.565 17.888 1 <0.001 N/A Percent CCAC 0.035 0.011 9.455 1 0.002 1.036 (1.013; 1.059) funding Test ᵡ² df p Likelihood ratio test 11.019 1 0.001 Score test 14.446 1 <0.001 Wald test 9.455 1 0.002 Goodness-of-fit test Hosmer & 1.073 1 0.300 Lemeshow** Note: SAS programming code: [PROC LOGISTIC; MODEL CCACCOMP (event = ‘1’) = S_CCAC/LACKFIT;] Somers’ Dxy: 0.609. Gamma: 0.772. Kendall’s Tau-α: 0.176. c: 0.804. All statistics reported herein use 4 decimal places in order to maintain statistical precision. N/A = not applicable. *This number is less than the total 60 organizations identified in Table 5-2 as some of these organizations had missing data on their size. ** More than 25% of the cells had an expected frequency of less than 5, which suggests that H-L may not be an appropriate test. The likelihood ratio, score and Wald tests all show a significant model; however, the null model was found to be significant as well. The H-L statistic supports the model, and there are fairly strong associations between the predictor and outcome according to the Somers’ D, Gamma, and c statistics. The individual predictor statistics suggest that organizational dependence on CCAC is a significant (p=0.002) predictor of compliance to CCAC contracts; for each unit increase in dependence (in this case that would be each percentage increase in funding) organizations were found to be 1.036 times (95% CI 1.013, 1.059) more likely to comply with CCAC contracts. These findings provide strong support for the proposition. Our findings suggest that dependence 128 is highly associated with compliance for the CCAC contracts, but not as much for the MSAA agreements. 5.4.3.2.2 Number of stakeholders The theoretical framework suggests that conflicting demands will influence how an organization responds to each of the different demands. The following proposition was suggested: Proposition 2b: Organizations that have multiple dependencies on different stakeholders who have differing accountability requirements are less likely to have the same response to all requirements. To test this proposition we would need to examine a more comprehensive array of organizational responses, including responses to other requirements beyond LHIN MSAAs and CCAC contracts. The survey data does allow us to determine whether the number of different stakeholders affects an organization’s likelihood to comply or compromise with LHIN MSAAs and CCAC contracts. Although examining only compliance and compromise responses does not fully address the proposition, it does provide some insight into whether the number of stakeholders has an impact. This proposition will be addressed more fully in Chapter 7 using both quantitative and qualitative data. The number of stakeholders was broken down into three groups (network memberships, association memberships, and accreditors) rather than being aggregated. This was done because each of the groups makes different demands on organizations. Membership in an association does not require much interaction between the organization and the association, whereas network membership may require an organization to attend meetings or be involved in collaborative programs or services. Accreditation involves more extensive interaction as compared to association and network memberships, and requires an organization to go through an intensive accreditation process (see Chapter 4). Many memberships with associations may not affect how an organization responds to other demands because these stakeholders may not demand many resources from the organization, whereas having a number of accreditors can cause a significant burden of work, which would affect accountability demands from other stakeholders. As the demands from these different groups are different we would expect that membership with these groups would have varying consequences on an organization’s responsiveness to demands from the LHINs or CCACs. 129 5.4.3.2.2.1 LHIN MSAAs A logistic model was used to examine whether numbers of network, association, or accreditation memberships were predictors to organizational compliance to LHIN MSAAs. Regression statistics are presented in Table 5-10. Table 5-10: Logistic regression analysis of 63* organizations compliance response to LHIN MSAAs in relation to the number of stakeholder and accreditation relationships held. Predictor Wald’s eβ & CI df P β SEβ ᵡ² (odds ratio) Intercept -0.632 0.495 1.632 1 0.201 N/A Total networks 0.161 0.153 1.114 1 0.291 1.175 (0.871; 1.584) Total associations 0.269 0.195 1.913 1 0.167 1.309 (0.894; 1.916) Total accreditors 0.101 0.398 0.064 1 0.800 1.106 (0.507; 2.414) Test ᵡ² df P Likelihood ratio test 5.614 3 0.132 Score test 5.209 3 0.157 Wald test 4.787 3 0.188 Goodness-of-fit test Hosmer & 7.600 8 0.474 Lemeshow** Note: SAS programming code: [PROC LOGISTIC; MODEL MSAACOMP (event = ‘1’) = S_TOTNET S_TOTASC TOTACR /LACKFIT;] Somers’ Dxy: 0.348. Gamma: 0.357. Kendall’s Tau-α: 0.173. c: 0.674. All statistics reported herein use 4 decimal places in order to maintain statistical precision. N/A = not applicable. *This number is less than the total 60 organizations identified in Table 5-2 as some of these organizations had missing data on their size. ** More than 25% of the cells had an expected frequency of less than 5, which suggests that H-L may not be an appropriate test. The test statistics of overall fit (likelihood ratio, score and Wald tests) would suggest that the model is an improvement over the null model, although none of the statistics demonstrated significance. The H-L test also supports the model; however, the cell counts were low. The association statistics also demonstrate a weak association between the predictors and outcome, and none of the individual predictors were found to be significant according to the likelihood estimate. A second model was used to examine whether numbers of network, association, or accreditation memberships were predictors to organizational compromise to LHIN MSAAs. Regression statistics are presented in Table 5-11. 130 Table 5-11: Logistic regression analysis of 36* organizations compromise response to LHIN MSAAs in relation to the number of stakeholder and accreditation relationships held. Predictor Wald’s eβ & CI df P β SE ᵡ² (odds ratio) Intercept -1.471 0.777 3.581 1 0.058 N/A Total networks 0.147 0.195 0.567 1 0.452 1.158 (0.790; 1.697) Total associations 0.138 0.220 0.393 1 0.531 1.148 (0.746; 1.765) Total accreditations 1.077 0.661 2.658 1 0.103 2.936 (0.804; 10.713) β Test ᵡ² df p Likelihood ratio test 4.900 3 0.179 Score test 4.726 3 0.193 Wald test 4.299 3 0.231 Goodness-of-fit test Hosmer & 8.249 7 0.311 Lemeshow** Note: SAS programming code: [PROC LOGISTIC; MODEL MSAANONCOMPC (event = ‘1’) = S_TOTNET S_TOTASC S_ACCAN TOTACRE/LACKFIT;] Somers’ Dxy: 0.431. Gamma: 0.442. Kendall’s Tau-α: 0.219. c: 0.716. All statistics reported herein use 4 decimal places in order to maintain statistical precision. N/A = not applicable. *This number is less than the total 60 organizations identified in Table 5-2 as some of these organizations had missing data on their size. ** More than 25% of the cells had an expected frequency of less than 5, which suggests that H-L may not be an appropriate test. The test statistics of overall fit (likelihood ratio, score and Wald tests) do not demonstrate that the model is an improvement over the null model. The H-L test does support the model; however, the cell counts were low. The association statistics also demonstrate moderate associations between the predictors and outcome, and none of the individual predictors were found to be significant according to the likelihood estimate. The two logistic models thus do not suggest that the number of stakeholders that an organization has will impact on their likelihood of compliance or compromise behaviours. 5.4.3.2.2.2 CCAC contracts A logistic model was used to examine whether numbers of network, association, or accreditation memberships were predictors to organizational compliance to CCAC contracts. Regression statistics are presented in Table 5-12. 131 Table 5-12: Logistic regression analysis of 59* organizations compliance response to CCAC contracts in relation to the number of stakeholder and accreditation relationships held. β Predictor Wald’s e & CI df p β SEβ ᵡ² (odds ratio) Intercept -3.389 0.873 15.087 1 <0.001 N/A Total networks -0.078 0.209 0.139 1 0.709 0.925 (0.615; 1.392) Total associations 0.394 0.227 3.019 1 0.082 1.483 (0.951; 2.312) Total accreditors 1.412 0.681 4.293 1 0.038 4.102 (1.079; 15.591) Test ᵡ² df p Likelihood ratio test 10.448 3 0.015 Score test 11.646 3 0.009 Wald test 7.074 3 0.070 Goodness-of-fit test Hosmer & 5.207 7 0.635 Lemeshow** Note: SAS programming code: [PROC LOGISTIC; MODEL CCACCOMP (event = ‘1’) = S_TOTNET S_TOTASC TOTACR /LACKFIT;] Somers’ Dxy: 0.580. Gamma: 0.597. Kendall’s Tau-α: 0.166. c: 0.790. All statistics reported herein use 4 decimal places in order to maintain statistical precision. N/A = not applicable. *This number is less than the total 60 organizations identified in Table 5-2 as some of these organizations had missing data on their size. ** More than 25% of the cells had an expected frequency of less than 5, which suggests that H-L may not be an appropriate test. The test statistics of overall fit (likelihood ratio, score, and Wald tests) were all significant, but they do not show that the model is an improvement over the null model. The H-L test does not support the model, although the cell counts were low which impacts of the validity of this test. The association statistics demonstrate moderate to strong associations between the predictors and outcome. For every additional association membership organizations were 1.483 times more likely (95% CI 0.95, 2.312) to comply with CCAC contracts; this relationship was found to be significant (p=0.082). For every additional accreditation membership organizations were 4.102 times more likely (95% CI, 1.079, 15.591) to comply with CCAC contracts; this relationship was also found to be significant (p=0.038). Because there were only 10 possible observations for organizations exhibiting compromise responses to CCAC contracts, a logistic regression could not be run. Chi square analysis found 132 no significant relationships between network, association and accreditation membership and compliance or compromise responses. These findings provide only moderate support for the suggestion that the number of stakeholders an organization has will affect the organization’s likelihood to comply with CCAC contracts. Findings suggest that number of stakeholders held by an organization is only moderately associated with compliance to CCAC contracts, and it weakly associated with compliance and compromise with LHIN MSAAs. 5.4.3.3 CONTEXT: Access to resources It is expected that an organization’s access to resources will impact on their likelihood for compliance. Proposition 5a: Organizations with better access to resources will be more likely to comply with accountability requirements. To test this proposition organizational access to resources was operationalized as: organizational size, percentage of full-time staff, and not-for-profit/for-profit status. Since only not-for-profit organizations can hold LHIN MSAAs, that predictor is dropped from the model for LHIN MSAAs. 5.4.3.3.1 LHIN MSAAs A logistic model was used to examine whether organizational size and percentage of full-time staff were predictors of organizational compliance to LHIN MSAAs. Regression statistics are presented in Table 5-13. Table 5-13: Logistic regression analysis of 54* organizations compliance response to LHIN MSAAs in relation to the organizations size and human resource distribution. Predictor Wald’s eβ & CI df p β SEβ ᵡ² (odds ratio) Intercept -0.880 0.907 0.942 1 0.332 N/A Size 0.404 0.435 0.862 1 0.353 1.497 (0.638; 3.510) % Full-time staff 0.030 0.019 2.344 1 0.127 1.030 (0.992; 1.070) Test Likelihood ratio test Score test Wald test ᵡ² df p 5.158 4.531 3.979 2 2 2 0.076 0.104 0.137 133 Goodness-of-fit test Hosmer & 11.582 9 0.238 Lemeshow** Note: SAS programming code: [PROC LOGISTIC; MODEL MSSACCOMP (event = ‘1’) = SIZE FTEPERC VPERC/LACKFIT;] Somers’ Dxy: 0.294. Gamma: 0.297. Kendall’s Tau-α: 0.145. c: 0.647. All statistics reported herein use 4 decimal places in order to maintain statistical precision. N/A = not applicable. *This number is less than the total 60 organizations identified in Table 5-2 as some of these organizations had missing data on their size. ** More than 25% of the cells had an expected frequency of less than 5, which suggests that H-L may not be an appropriate test. The test statistics of overall fit suggest that the model is a better fit over the null model. The likelihood ratio test also finds the model to be significant (p=0.076). The H-L also supports the model; however, the association statistics show weak associations between predictors and outcome, and the predictors themselves were not found to have a significant impact on the outcome according to the likelihood estimates. At best this suggests weak support for the proposition. 5.4.3.3.2 CCAC contracts A logistic model was used to examine whether organizational size, percentage of full-time staff, and status were predictors of organizational compliance to CCAC contracts. Regression statistics are presented in Table 5-14. Table 5-14: Logistic regression analysis of 47* organizations compliance response to CCAC contacts in relation to the organizations size, human resource distribution, and status. Predictor Wald’s e & CI df P β SE ᵡ² (odds ratio) Intercept -3.367 1.504 5.015 1 0.025 N/A Size 0.899 0.627 2.056 1 0.152 2.458 (0.719; 8.400) % Full-time staff -0.011 0.019 0.355 1 0.551 0.989 (0.953; 1.026) Status 5.860 (0.224; 1.768 1.665 1.127 1 0.288 153.265) β β Test ᵡ² df P Likelihood ratio test 3.323 3 0.344 Score test 3.431 3 0.330 Wald test 3.069 3 0.381 Goodness-of-fit test Hosmer & 6.691 7 0.462 Lemeshow** Note: SAS programming code: [PROC LOGISTIC; MODEL CCACCCOMP (event = ‘1’) = SIZE 134 FTEPERC VPERC S_FPNFP/LACKFIT;] Somers’ Dxy: 0.345. Gamma: 0.349. Kendall’s Tau-α: 0.109. c: 0.673. All statistics reported herein use 4 decimal places in order to maintain statistical precision. N/A = not applicable. *This number is less than the total 60 organizations identified in Table 5-2 as some of these organizations had missing data on their size. ** More than 25% of the cells had an expected frequency of less than 5, which suggests that H-L may not be an appropriate test. The only test statistic that supports the model is the H-L test. In any case, the cell counts were low and may render the statistic inappropriate. These findings do not support the proposition for organizational compliance to CCAC contracts. The logistic models suggest that access to resources is not associated with compliance to CCAC contracts, and only weakly associated with compliance with MSAAs. 5.5 Summary of survey findings Four propositions related to cause, constituents, and context factors were tested using logistic regression of survey data. Table 5-15 summarizes the quantitative findings related to those propositions: Table 5-15: Summary of survey findings Proposition Cause Proposition 1. Larger organizations will be more likely to comply with accountability requirements. LHIN MSAA CCAC contract Moderate support Weak support Constituents Proposition 2a: Organizations are more likely to comply Not supported with accountability requirements from stakeholders upon whom they are highly dependent for funding. Proposition 2b: Organizations that have multiple dependencies on different stakeholders with differing accountability requirements are less likely to have the same response to all requirements. Context Proposition 5a: Organizations with better access to resources will be more likely to comply with accountability requirements. Strong support Not supported Moderate support Weak support Not supported 135 The models reveal that as organizational size increases the likelihood that a home and community care agency will comply with the MSAA also increases. Higher financial dependence and having accreditation was found to increase HCC agency likelihood of compliance with CCAC contracts. These quantitative findings will be discussed in light of qualitative findings in Chapter 7. 136 Chapter 6 Qualitative findings 6 Introduction This chapter presents findings from the key informant interviews that address nine of the thirteen propositions outlined in Chapter 2. As discussed in Chapter 3 key informant interviews were conducted with accountors (representatives from urban and rural CCACs and LHINs of interest) and with accountees (representatives from organizations upon whom LHIN and CCAC accountability requirements are imposed. Qualitative data from the document analysis (Chapter 4) and environmental scan are also used to explore propositions. The findings presented in this chapter include: 1. A description of the organizations represented by the interviewees. 2. Analysis of interview data in relation to research question 2: What is the array of realized organizational responses to accountability requirements? 3. Analysis of qualitative data (interviews, document analysis and environmental scan) in relation to research question 3: How do responses vary as a function of organizational factors? Specifically this chapter examines nine propositions put forward regarding organizational responsiveness to accountability demands. 4. Additional themes: the problem with indicators and unintended consequences of accountability frameworks. 6.1 Descriptive information of interview participants Twenty semi-structured interviews were conducted with representatives from two CCACs (one urban, one rural) two LHINs (one urban, one rural), and 13 organizations (five rural, four urban, and four that operate across Canada with branches in the urban and rural locations). Multiple interviews were conducted with two of the larger organizations (one individual representing the parent organization and the other one, or two, representing branch sites). Three separate interviews were conducted with one of the larger organizations (one individual representing the overall organization, and two interviews were conducted with and two others representing local branches with LHIN MSAAs and CCAC contracts), and three of the interviews were carried out with two individuals from an organization. These three “group” interviews were conducted as multiple representatives from an organization were required to answer interview questions. 137 The organizations in the sample represent a range of home and community care agencies that primarily serve seniors (an inclusion criterion for the study). The organizations vary in size, status (the majority are not-for-profit agencies), and location (urban or rural). Organizations also vary in the types of home and/or community care services provided. All organizations primarily serve seniors (as that was an eligibility criteria for inclusion in the study). See Table 6A-1 in Appendix 6-A for a summary of organizational characteristics. As discussed in Chapter 3 participant selection was purposive and criterion based. Most participants representing LHINs and CCACs were directors of performance management and accountability. Participants representing home and community care agencies held high level roles such executive director, senior director, or manager. Participants were involved in the LHIN MSAA and CCAC contracts in a variety of ways including contract/agreement management, monitoring activities, attending meetings, managing relationships, procurement, preparing proposals, indicator development, and providing feedback. The individuals selected to be interviewed from the LHINs, CCACs, and agencies were those identified as having the background and expertise to answer questions. The most important factor in participant selection after the appropriate organization was identified was the ability to answer questions. See Table 6A-2 in Appendix 6-A for a summary of participant characteristics. 6.2 Organizational responses as reported by interviewees As discussed in Chapter 2, organizational responses were theorized to fall into two categories: compliance and non-compliance, with non-compliance comprising behaviours such as compromise and manipulation, avoidance, and defiance. Interview data were examined in terms of realized responses of home and community care organizations to CCAC contracts and LHIN MSAAs. 6.2.1 Compliance Compliance was operationalized as total conformity to external demands. With regard to CCAC contracts and LHIN MSAAs this would include holding contracts/agreements, meeting all reporting requirements, meeting performance targets in contracts/agreements, and the perception that organizations are compliant with contracts/agreements. 138 6.2.1.1 Perception of compliance Participants viewed “meeting all accountability requirements” as organizational compliance with accountability requirements of CCAC contracts and MSAAs. Participants perceived themselves as meeting the accountability requirements of CCAC contracts and MSAAs if their organization was not breaching contracts, meeting all reporting requirements of contracts/agreement on time, and not experiencing sanctions (such as contact from the CCAC or LHIN regarding performance) for non-compliance. “I’m going to say yes [we meet CCAC contract requirements]. That is because of the regular conversations, the emails back and forth between the [CSA 5-1] staff and the CCAC staff. When we are not meeting their requirements, this is where we are reminded.” (CSA 5-1) “We have never missed the dateline [for MSAA reports] … Usually we were amongst the first to get on the new reporting system at the ministry.” (CSA 2) The LHIN representatives considered meeting legal requirements of the contracts as a part of compliance as well: “As I said, some of the smaller agencies they didn’t realize that they weren’t meeting certain obligations, legislative requirements, liabilities, all of those sort of things. For the most part they are now but there are still times when they don’t necessarily meet all of them.” (Rural LHIN) 6.2.1.2 Meeting performance and financial targets Missing performance and financial targets was the most cited reason for organizational noncompliance by participants. Participants from six organizations identified that meeting performance and financial targets was an important part of compliance with MSAAs and CCAC contract accountability requirements: “Well we are well within our performance indicators. Our budgeting process is well within requirements and we have quality improvement programs. We meet all of [the LHIN’s] criteria so far.” (CSA 9) A number of organizations did not see meeting performance targets as being the same as being compliant with contracts. Five participants identified their organization as “meeting accountability requirements” but later went on to describe how their organization was missing performance targets, sometimes on a regular basis. In some cases participants who reported 139 “meeting requirements” had even experienced sanctions for not meeting targets. These participants tended to see compliance more in terms of delivering services as stipulated in contracts and agreements rather than meeting performance targets: “We certainly meet all of the service specifications. Are we meeting the target so 20 that we are green , absolutely everywhere, no not really.” (CSA 8) Some participants saw compliance in terms of meeting performance targets in relation to whether other organizations were meeting targets: “What I’m saying is we meet accountability requirements as well as anyone does but we have work to do. We always have improvements to do and we are not one hundred percent green in everything.” (CSA 8). “Obviously at some time our indicators are not on target but that would be true with any provider where you might not be totally within the target all the time.” (CSA 7) These findings would suggest that meeting performance targets was not always associated with compliance, even though organizations unmistakably saw meeting reporting requirements, service requirements, and legal requirements as part of compliance. Organizations perceive themselves as compliant if they had not experienced harsh sanctions (such as reduced funding or loss of contract/agreement) due to missing targets. Based on these findings we can understand compliance to refer to organizations that hold a contract/agreement, meet reporting requirements, perceive themselves as compliant, and have not experienced harsh sanctions. 6.2.2 Non-compliance Non-compliance was expected to consist of three potential behaviours: compromise and manipulation, avoidance, or defiance. 6.2.2.1 Compromise and manipulation Compromise and manipulation were expected to consist of behaviours including the negotiation of contracts/agreements, mergers/partnerships and shifting services and/or populations served in order to meet accountability requirements. 20 Organizations are assigned green, yellow or red colours for performance targets of the CCAC contract by the CCAC. “Green” refers to meeting the performance target. 140 6.2.2.1.1 Negotiation Most organizations did not engage in negotiations for either the LHIN MSAA or the CCAC contract. Participants found that agreements and contracts were standardized and set by the province. Organizations were merely expected to sign the contracts and/or agreements and meet their requirements. “…the MSAA is not a negotiation, it’s an imposition.” (CSA 2) “…first they put the paper down said this is what we want and then we have the choices saying yes we agree or no we walk away.” (CSA 3) “…the CCAC contracts are a standard type of contract so there is little negotiation that goes on there.” (CSA 5) In the case of the LHIN MSAA the only negotiation that was reported to have occurred was around service volumes and performance indicators. This mainly occurred as part of the CAPS process that is part of the agreement development process (discussed in Chapter 4): “The MSAA… I kind of think there is a little more negotiation because in those cases we might write a proposal so we almost kind of project what we could offer as a matrix.” (CSA 5) “Individual organization negotiation happens when they submit their planning submission that actually goes to populate the content in the schedules. We’ll get into the negotiations at the agency level around well, how much admin are you actually putting into this service or this is your target for your supportive housing program, but last year your target was a lot different. How come there is a big change? It’s that kind of understanding in negotiating targets than budgets, volumes, that kind of thing. That’s the essence of the negotiation. It’s about their own particular services budgets and volumes. Legal text and the design, the schedules, that’s not negotiated at all.” (Urban LHIN) Similarly, participants reported that CCAC contracts were only negotiated around service prices and performance indicators; the actual content of the contract was non-negotiable: “What can sometimes be worked out is the price or something like that…The template wasn’t negotiable but in terms of some of the recent small niche volumes that have come up and gone to RFPs where we’ve submitted proposals, we have had the opportunity…”(CSA 7) “The extension this time was based on the 2011 template which was produced with the OACCAC and the Ontario government. Then that template is used as a guideline for the CCAC to issue the contract and each 141 CCAC there are certain aspects of that guideline template that they can fit, change up I guess and fit to their own program. So there are certain indicators for example as part of the contract that if we said oh well, we don’t agree with that indicator or whatever… I don’t really know… I guess there is a negotiation process. I guess there is to a certain extent.” (CSA 43) Some participants from both organizations and the CCACs suggested there was a negotiation process that happened in the development of the CCAC contract templates, however this would not be considered an individual organizational response to the accountability requirement as these negotiations were between the OACCAC and home and community care agency representative groups populated by individuals from different home and community care organizations (like OCSA). 6.2.2.1.2 Partnerships and sub-contracting Organizations identified partnering as a response to help the organization meet accountability requirements. In relation to CCAC contracts, partnering seemed to occur mainly between CCAC contracted HCC agencies in order to help manage clients that required a lot of hours: “We do a lot of client work together, case conferencing, shared clients if you would because some of our clients are again heavy duty, require a lot of hours and sometimes we just can’t fill them all. So the other agency, CCAC goes to the other agency and so we are both in there. So we are helping each other, that kind of thing.” (CSA 4-3) In relation to MSAAs, partnering occurred more around back office integration in order to improve efficiencies and cut reporting and administrative costs: “I’ve seen a couple of organizations enter into agreements where they are sharing their back office…. It probably has to do with size of the organization and the demand, the expectations around reporting and the realization that probably buying that report writing or that back office from somebody else is just as efficient and cheaper than trying to maintain their expertise… The partnering that I’ve seen has been around just finding more efficient ways of operating as organizations... One particular case they are sharing bookkeeping services, so they get better price point, value for their dollars. So those back office efficiencies are materializing as organizations are just trying to work smarter, more efficiently as organizations.” (Urban LHIN) In addition to partnerships some home care organizations under CCAC contracts engaged in subcontracting in order to ensure that the organization could meet service volume targets: 142 “We have organized subcontracting agreements so it just provides an ability if a client really needs bulk hours that we can pair our resources with another agency and still take it over and be responsible for that.” (CSA 4-2) After competition for CCAC contracts became more sophisticated in 2007, one agency under a CCAC contract holds several sub-contracts as a way to support smaller community agencies that are no longer able to successfully compete for contracts. The larger organization found that the smaller organizations were providing a broader basket of services than was offered by the larger organization. Furthermore, sub-contracting to these smaller agencies meant clients could keep their existing care providers. Supporting smaller organizations through sub-contracts was seen to promote continuity and better care for clients. 6.2.2.1.3 Service changes No participants identified changes to types of services or how services were delivered in response to accountability requirements. Some organizations suggested that front line staff had to reduce time with clients in order to meet reporting requirements: “… it takes time to… do all these reports and … keeping on top of all the obligations, hm, and so that less time you can actually meet with people and, hm, and stay on top of the human aspect of the work.” (CSA 10) 6.2.2.1.4 Other organizational changes Organizations underwent a variety of internal changes in order to meet MSAA and CCAC contract accountability requirements. These changes include human resource modifications such as changing human resource roles within the organization (i.e. assigning specific staff to manage contracts and agreements) and reducing the number of full-time staff positions (to cut costs), shifting business models (i.e. not-for-profits becoming more “business focused”), changes to the sharing of best practices (mainly in relation to CCAC contracts given the competitive bidding process), and changes in policies and procedures in the organization. “I think probably some policies, procedures, practices, processes have been put in place to meet contract requirements and to meet our accountability.” (CSA 4-3) Some participants saw these changes as a result of the evolving nature of their organizations and the drive to provide high quality services rather than as a reaction to CCAC contract and MSAA accountability requirements. 143 “I think it constantly changes really. The basics are kind of the same but I think you are always tweaking processes and making changes and adapting. I think that’s never-ending. Again that wouldn’t be due to the CCAC contract. That’s just the way we do business… So it wasn’t necessarily the contracts that make you do things differently. Those government contracts have always been in place. It’s more the drive for providing the best quality service to our clients and government funders.” (CSA 7) 6.2.2.1.5 A new perspective on compromise and manipulation: Summary of findings Study findings suggest a new perspective on the concepts of compromise and manipulation. Oliver’s (1991) notion of compromise and manipulation behaviours was as an organization’s exertion of power to modify or influence external demands placed upon it. Negotiation behaviours are the only response that fit into Oliver’s conception of compromise, as it is the only instance in which an organization uses its power to modify accountability requirements between home and community care agencies and the LHINs and/or CCACs. We can thus understand the compromise response as an individual organization that engages in negotiation prior to signing agreements and contracts. The other organizational responses, including the creation of partnerships, sub-contracting with other organizations, maintaining a basket of services delivered, the adoption of new policies and procedures that support compliance, increasing the business-focus of the organization, and changes to human resource roles and responsibilities, involve the organization changing its internal practices and structures in order to comply with external demands. These responses are not an exertion of power in order to modify demands, nor are they an exertion of power to coopt, influence, or control the external demand and as such do not fit either of Oliver’s (1991) definitions of compromise or manipulation. Rather, the above responses are examples of organizations making internal changes to how they operate in order to better meet external accountability demands; which can be called internal modification behaviours. The internal modification category should be included as a sub-category of compliance as behaviours associated with internal modification are intended to support compliance to, rather than subvert, external demands. 144 6.2.2.2 Avoidance Avoidance was identified as an organization’s attempt to preclude necessity to conform by avoiding the accountability requirements all together. This was operationalized as organizations that do not plan to continue pursuing contracts or agreements. This behaviour was identified in the survey (see Chapter 5). Only one organization in the interview sample engaged in avoidance behaviours towards the LHIN MSAA in the rural region. This particular organization returned LHIN funding so that it was no longer held to the MSAA, and stated that it would never apply to a LHIN MSAA in the future. Participants representing the LHINs and CCACs identified that this organizational response was uncommon and the case represented in the sample was unique. Although an uncommon response, study findings suggest avoidance is a potential response to, at the very least, the LHIN MSAA. Avoidance behaviours include organizations that do not plan to pursue contracts or agreements and organizations that remove themselves from agreements and contracts by returning funding. 6.2.2.3 Defiance Defiance involves an organization actively dismissing external demands (Oliver, 1991; see Chapter 2). Defiance was operationalized as financial penalty or loss of contracts or agreements due to non-compliance. Interview participants identified that the above sanctions, while uncommon, will be incurred by organizations under MSAAs and CCAC contracts. The definition of defiance here focuses more on the outcomes of an organizational response rather than the response itself. The qualitative data reveals what types of organizational behaviour will trigger harsh sanctions. Participants revealed that contracts were lost due to either missing targets or missing reporting requirements: “We lost the home first contract because of not being able to meet the commitments that were required…It had to do with the staffing and part of it was the percentage of referrals that had to be accepted and so our challenge was….the program exploded and staffing is an issue.” (CSA 5) Three organizations identified that they had lost CCAC contracts. They were either large or medium sized home and community care organizations that had lost CCAC contracts. 145 Organizations that had lost CCAC contracts had several at one time and had only lost a portion of them. No participants in the interview sample reporting losing an MSAA; however, the participant from the urban LHIN reported that there were instances in which organizations lost funding (through the MSAA) as a result of refusing to submit reports. “It’s actually two cases where I can recall organizations just refused to submit any reports…. We stopped funding [them].” (Urban LHIN) Financial penalties were most related to CCAC contracts and came in the form of reduced volumes. A number of organizations represented in the sample had gone through a reduction in contract volume due to missing performance targets. The participant from the rural CCAC explained how this was a sanction they were pursuing at the time of the interview: “There are sanctions there you can… penalize them financially. It doesn’t specify how much. We are seeking to do that with one provider right now, where we’ve worked with them for several months to have their performance improve, and now we are going to use the clause where we can financially penalize them.” (Rural CCAC) Findings reveal that the actual response of the organization that triggers harsh sanctions like lost contracts/agreements and/or financial penalties, occurs when HCC agencies miss targets or fail to meet reporting requirements. However, missed targets and reports alone will not necessarily trigger such harsh penalties. Furthermore, participants did not necessarily see missing targets as an example of non-compliance (as discussed above). CCAC and LHIN representatives also demonstrated an understanding that missed targets often occur but are understandable and can be related to external factors beyond the control of the organization: “If it’s a volume requirement, not everybody’s meeting their requirements but there are reasons behind it… We have it happen all the time where people don’t necessarily meet the requirements of the MSAA but there are reasons behind that.” (Rural LHIN) “I think the one that comes to mind, that is very tough right now, is the human resource factor. It’s been predicted forever, we are in a nursing crisis, and a PSW crisis, and a therapy crisis. Service providers compete with hospitals and long-term care homes, and retirement homes. So I think when there is a lack of resources in the area, we see it from every provider. It’s not just one agency not able to have enough nurses to provide the care, they are all struggling. That’s where they may not be meeting the requirements, but quite likely, nobody in that area is meeting the requirements because of the stiff competition and frankly the lack of nurses available.” (Rural CCAC) 146 CCACs and LHINs engage in a process of graduated sanctions for HCC agencies that miss targets. The first level of the graduated sanction is for the LHIN or CCAC to contact the organization to get more information regarding the missed target. If the explanation is satisfactory then no further sanctions are pursued. If, however, the explanation is insufficient, the LHIN or CCAC will set up improvement plans for the agency and enhance monitoring through more frequent (often monthly) meetings and reporting requirements. “If an agency is forecasting a deficit or has an issue, they’ll have a discussion with us, or performance they will have a discussion with us... If it’s a small variance, we’ll have the phone call. If the explanation is there and it seems like they will be back on track, if it seems like it might be a few quarters, or if it’s happened for a few quarters, we’ll have the in-person meeting. If that doesn’t work after a year we’ll go to enhanced performance monitoring, which basically states we are meeting every month, and helping them with their performance improvement, to make sure they are staying on track…. If somebody is consistently not meeting their performance obligations then we do have certain courses. We have performance improvement plans. We have enhanced performance monitoring. Few of our agencies have been under.” (Rural LHIN) “If we run into an issue, say we have a provider who we suddenly see that they are having issues with quality, we get a bunch of client complaints maybe about medication-related issues or rude staff, then we would bring the provider in and we would meet with them and show them the data that we have and then ask them for a performance improvement plan. Then we would monitor it say two to three months later, pull the data, show them how they are doing…If we haven’t seen improvement in the specified timeframe, then we might take additional measures which could include reducing volume up into and including cancelling the contract if the quality issues were severe enough. That has happened. [Cancelling contracts] doesn’t happen often. It’s a pretty severe measure that we would take. So it doesn’t happen often, but it has happened.” (Urban CCAC) If these efforts fail, the LHINs and CCACs consider financial penalties and contract/agreement termination. Under CCAC contracts, organizations only have to miss targets over two quarterly reports before the CCAC could enforce financial penalties or terminate contracts. However, most CCACs do not follow this requirement and rather use the form of graduated sanction described above: “They only have to not meet the performance measures for two months in a row, and you could cancel their contract. That would be the quarterly reports. If they didn’t meet those requirements for two periods in a row, which is a very small time, we could actually cancel their contract….Very few CCACs actually do that. I think it would actually be very punitive.” (Rural CCAC) 147 Given these findings, missing targets and only experiencing low-level sanctions (such as being contacted by the LHIN or CCAC or going through improvement plans) are not considered as defiance responses. These responses are common and were not perceived as an indication of non-compliance by many participants. Even LHIN and CCAC representatives did not consider missing targets that generated only low-level sanctions to be an indication of non-compliance. The defiance response can be understood to denote organizations that experience financial penalty or loss of contract/agreement due to not meeting requirements (such as missing targets or missing reports). 6.2.3 Participating organizations’ responses Based on the definitions of compliance and non-compliance informed by the qualitative data, we can assign organizational responses to the organizations that were represented by interview participants (16 participants from 13 organizations, see above section 6.1). These findings are presented in Table 6-1. Note that while there were 13 organizations that participated some organizations engaged in multiple responses. Table 6-1: Interview participants' organizational responses to LHIN MSAAs and CCAC contracts Response Description of response (where Number of applicable) organizations that engaged in response MSAA Compliance 3 Internal modification Compromise Avoidance CCAC Internal modification Changes to policies and procedures. Staff increased focus on indicators and board increased focus on governance HR changes to manage limited funds Reduced client time in order to meet reporting requirements Becoming more business-focused Sub-contracting, changes to HR roles Negotiated agreement Returned LHIN funding 6 Becoming more business-focused Sub-contracting, changes in HR roles 6 1 1 148 Response Compromise Defiance Description of response (where applicable) Changed business model No longer sharing best practices Changes to policies and procedures Sub-contracting, improved service delivery processes, reduced client time to meet reporting requirements Negotiated prices and indicators Negotiated price and volumes Lost contracts Reduced and lost contracts Reduced contracts Reduced and lost contracts Number of organizations that engaged in response 2 4 Three of twelve organizations reported compliance with the LHIN MSAA while none reported that they were compliant with CCAC contracts as operationalized in this study. The majority of organizations reported engaging in internal modification (6 of 12 for MSAAs and 6 of 8 for CCAC contracts). Few organizations engaged in compromise (1 of 12 for MSSAs and 2 of 8 for CCAC contracts) and defiance behaviours (4 of 8 for CCAC contracts). Only large organizations with multiple CCAC contracts engaged in the defiance response. Finally, there was only one organization that responded with avoidance to the LHIN MSAA. Internal modification is more closely related to compliance than non-compliance, suggesting that the majority of organizations in the sample tended towards compliance to accountability requirements. 6.3 Organizational factors that affect organizational responses Oliver’s (1991) theory suggests a number of potential organizational factors that could affect organizational responses to external demands (see Chapter 2). Organizational size, financial dependency, number of stakeholders, and access to resources were examined in Chapter 5 using survey data. This chapter will examine size, dependency, autonomy, external demand flexibility and strictness, and accountor/accountee interaction to answer additional propositions set out in Chapter 2. Table 6-2 summarizes the dependent and independent variables examined in this chapter. 149 Table 6-2: Dependent and explanatory variable definitions, qualitative data. Variable name Description Organizational responses Compliance Organizations that hold a contract/agreement, meet reporting requirements, perceive themselves as compliant and have not experienced harsh sanctions. Internal Organizations that engage in internal organizational changes modification that help the organization comply with external demands. Behaviours could include: partnership, sub-contracting, adopting new policies and procedures, increasing the business-focus of the organization and making changes to HR roles and responsibilities. Compromise Organizations that engaged in negotiation prior to signing agreements and contracts Avoidance Organizations that do not plan to pursue contracts or agreements and organizations that remove themselves from agreements and contracts by returning funding. Defiance Organizations that experience financial penalty or loss of contract/agreement due to not meeting requirements (such as missing targets or missing reports). Explanatory variables Cause Organizational Participant reported organizational size size Constituents Dependence Perceived organizational dependence on LHIN and CCAC Participant reported amount of revenue from LHIN and CCAC Stakeholders Participant reported stakeholders Participant reported conflict between stakeholder demands Participant reported additional resources required to meet all demands from stakeholders Content Organizational Coded mission, vision and value statements of organizations goals External Purpose of accountability of MSAA and CCAC contracts demand goals Autonomy Perceived impact on organizational autonomy to deliver services Perceived impact on organizational autonomy to administer programs Inevitability Perceived organizational dependence on LHIN and CCAC Participant reported amount of revenue from LHIN and CCAC Perceived flexibility of MSAA and CCAC contracts Source Interviews Interviews Interviews Interviews Interviews Interviews Interviews Interviews Environmental scan Document review Interviews Interviews 150 Variable name Control Coerciveness Strictness Role clarity Interaction Professional norms Context Organizational size Additional resources Quality culture 6.3.1 Description Source Policy instrument coerciveness Perceived strictness of sanctions Participant reported role clarity of accountor and accountee Participant reported interaction between accountor and accountee MSAA and CCAC contract reliance on professional norms Document review Interviews Interviews Interviews Participant reported organizational size Interviews Document review Participant reported need for additional resources to meet Interviews accountability requirements of MSAA and CCAC contract Participant reported organizational culture with regard to Interview where responsibility for quality lies: individual, organization or collective Responsibility for quality identified in MSAA and CCAC Document review contracts: individual, organization or collective. CAUSE: Organizational size As discussed in Chapters 2 and 5, the cause factor is related to an organization’s size. Proposition 1, which was tested using survey data, can also be explored using interview data. Proposition 1. Larger organizations will be more likely to comply with accountability requirements. With regard to the MSAA, the findings from the interviews show that medium sized organizations represented by interview participants engaged in compliance behaviours while small organizations either strove for compliance through internal modification, or engaged in non-compliance behaviours like avoidance and compromise. There was one instance in which a small organization engaged in compliance and a large organization engaged in compromise. This finding may suggest support for the proposition with regard to the MSAA. With regard to the CCAC contract a number of large organizations (and their branch organizations) engaged in non-compliance such as defiance and compromise behaviours. This finding does not support the proposition. See Appendix 6-A, Table 6A-3 for qualitative data table. 151 6.3.1.1 Findings summary of the CAUSE factor Qualitative findings show support for the proposition with regard to MSAAs, but not with regard to CCAC contracts. These findings are aligned with the quantitative findings that found moderate support for the proposition with regard to MSAAs and only weak support with regard to CCAC contracts. 6.3.2 6.3.2.1 CONSTITUENTS: Dependence and managing multiple stakeholders Dependence In Chapter 5 survey data were used to test whether financial dependence on LHINs and CCACs influences organizational responsiveness. Interview participants were asked whether they felt they were dependent on the LHIN and/or CCAC to survive, and how much of their funding they received from the LHINs and CCACs. Participants tended to link their perceived dependence on the LHIN or CCAC to how much of their funding came from the LHIN and CCAC. In general, participants reported dependence on the LHIN or CCAC if they received 50% or more of their funding from that source. Five participants did not see their organization as fully dependent, but instead saw funded programs as reliant on the LHINs or CCACs that funded them: “I’m not going to say site [is dependent on the CCAC]. I’m going to say the programs. So the nursing program, the home support program, because we are predominantly funded by CCAC, yes, very much so. Again that’s one of the negatives if you will because if we were not awarded, say the nursing contract, we wouldn’t have work for our staff.” (CSA 5-1) Participants from organizations that were funded by both LHINs and CCACs reported that their organizations were more dependent on CCACs than LHINs to survive, because CCAC contracts funded most of their programs. “I think if we were to lose our CCAC contracts we would not be able to survive. But if we were to keep our CCAC contracts then lose our LHIN contracts we would continue. “ (CSA 4-1) 6.3.2.2 Managing multiple stakeholders Interview participants all reported having multiple stakeholders in addition to LHINs and CCACs including clients/patients and their families, the community in which they operate, their boards of directors, donors, other funders (including government agencies), other home and 152 community care agencies, networks, government agencies (i.e. municipal governments, other provincial ministries, federal government, accreditors, volunteers, and unions. Figure 6-1 shows the number of organizations in the sample that identified each group as a stakeholder. 10! 9! 8! 7! 7! 7! 5! 7! 5! 3! 1! Figure 6-1: Interview sample organizations' stakeholders as identified by interview participants. Presented by number of organizations that identified each stakeholder (N=16 interview participants). Other home and community care agencies, government agencies, and clients/patients/families were among the most identified stakeholders by interview participants. Interview participants also identified their organization’s boards of directors, donors, funders and networks as key stakeholders. Figure 6-2 illustrates that most interview participants identified that their organization had between four and six stakeholders. 6.00%! 25.00%! 1!to!3! 4!to!6! 69.00%! 7!to!11! 153 Figure 6-2: Number of organizational stakeholders identified by interview participants (N=16 interview participants). Participants identified that they could be held to account to different stakeholders through reporting financial and performance data, holding annual general meetings, providing high quality care to clients and their families, and/or by creating an open dialogue between themselves and stakeholders. “I think we need to keep [stakeholders] aware of where we’re going with all these. Number one you can’t go to the community and say you need this. You need to go to them and say ‘what do you need and why?’...And we also through the community engagement. We have the obligations to listen to what their needs are and have a program based on that. So the key engagement is definitely another way we’re trying to keep that of the community” (CSA 2) 6.3.2.2.1 Conflicts between stakeholder demands In trying to meet multiple demands, participants identified that their organizations often had to juggle accountability requirements from the different stakeholders. Participants revealed that when accountability requirements from different stakeholders conflict, meeting divergent requirements could be challenging or impossible. One type of conflict arises between demands from unions and accrediting bodies and requirements of the MSAAs and CCAC contracts: “From a union perspective what the workers want and what the union pushes for isn’t necessarily what’s in our contract. For instance we used to have a call ahead process where the workers would call the client and it wasn’t anywhere in the collective agreement. So the employer had to back away from that but really from a contractual perspective it’s unfortunate that we had to if they think it was a really good opportunity for the CSW to touch base with that client prior to going to the home…So you have those push and pulls. Say for instance our funder might dictate something to us like something from either the percentages of full-time and part-time that the ministry has implemented and you have to have a certain percentage of fulltime guaranteed and part-time guaranteed staff. Well we have a union we have to go back and negotiate these things with. We can’t just implement them like a nonunionized employer may.” (CSA 4-2) Other conflicts arose between MSAA and CCAC demands and the needs of clients. Participants reported problems with balancing LHIN and CCAC requirements for patient data while trying to respect client privacy, and providing what the organization considers to be high-quality care to clients while respecting the role of the CCAC as case manager. 154 “I think the struggle is [the CCACs] are contracting the services to a service provider so they are funding the service for the client and they have expectations in that regard and as providers of the service in the client’s home we have accountabilities as well to the client. So where there are issues where there’s discrepancies in how service could be provided or issues that are identified, that’s where it becomes perhaps challenging.” (CSA 5-1) Other participants added that the sheer numbers of accountability requirements could become overwhelming and require substantial staff time and resources. Participants felt additionally overburdened when different stakeholders require the same information in different ways: “[The demands] aren’t so much in conflict with each other. It’s just that they can overwhelm because there are so many. The conflict is more around finding the time to be able to do it… Part of the amount of work that gets generated around trying to report out is sometimes, because different funders will have different kinds of reporting. Where somebody may count a youth up to the age of twelve, somebody else may count a youth up to the age of eighteen. Or a senior may start at the age of fifty-five, or may start at the age of sixty-five. So it’s trying to line up all those different definitions, that there isn’t the consistency among the different funders. That complicates it more than perhaps needs be. It complicates it on our side.” (CSA 13) A few participants did not perceive accountability demands of different stakeholders to conflict. One participant saw that meeting the accountability requirements of the LHIN also served to meet accountability requirements of donors and client stakeholders: “I don’t think anything under the MSAA really, in terms of accountability for how we use government money, I don’t think it’s necessarily outlandish or unexpected. Donors and clients and volunteers are all taxpayers.” (CSA 6) 6.3.2.3 Examining propositions Proposition 2a: Organizations are more likely to comply with accountability requirements from stakeholders upon whom they are highly dependent for funding. Proposition 2b. Organizations that have multiple dependencies on different stakeholders with differing accountability requirements are less likely to have the same response to all requirements. Proposition 2c. When differing accountability requirements from different stakeholders are not well aligned, organizations are less likely to have the same response to all requirements. Interview data can be used to examine proposition 2a. The data from the interviews does not provide a specific enough picture to determine how organizations respond to demands from other 155 stakeholders as would be required to answer propositions 2b and 2c. We can, however, examine whether perceived conflict between multiple accountability requirements, and additional resource demand caused by multiple demands affect organizations response to LHIN MSAAs and CCAC contract. Table 6-3 identifies how organizational dependence and stakeholder conflict relate to organizational response. Table 6-3: Financial dependence and stakeholder conflict affect on organizational responsiveness to MSAAs and CCAC contracts. Response Dependence (Proposition 2a) Stakeholder conflicts and demands MSAA Compliance Financially dependent on the MSAA Reported low stakeholder conflict Internal modification Either the organization as a whole or specific funded programs are financially dependent on the MSAA Reported stakeholder conflict and additional resource demands from multiple stakeholders Compromise Specific funded programs dependent on MSAA Stakeholder conflict and additional resource demand of multiple stakeholders Avoidance Not financially dependent No stakeholder conflict reported Organization, programs or branch financially dependent on CCAC funding Reported stakeholder conflict and additional resource demands Compromise Branches financially dependent Reported stakeholder conflict and additional resource demands Defiance Organizations, branches and programs dependent on CCAC funding; however, receive CCAC funding from multiple CCACs on multiple contracts across Ontario Reported stakeholder conflict and additional resource demands CCAC Internal modification See Appendix 6A, Table 6A-4 for full data set. High financial dependence seems to influence compliance and internal modification behaviours towards LHIN MSAA agreement. One notable exception is compliant despite low dependence (see Appendix 6A, Table 6A-4 for data set). Although there are examples of non-compliance behaviours to CCAC contracts by highly dependent organizations, these organizations were larger organizations or branches of larger organizations that only reported dependence for particular programs or branches. The larger organization could still survive even if funding from 156 the CCAC is lost and as such the organization is not fully dependent. Research findings thus support proposition 2a. While the number of stakeholders alone does not seem to influence organizational response, there is a pattern of response related to perceived stakeholder conflict (see Appendix 6A, Table 6A-4). Two of the three organizations that are compliant with the MSAA reported not having experienced conflict with other stakeholder requirements; nor did they report feeling they required additional resources to meet all the demands. The third compliant organization reported not experiencing conflicts when asked directly, but further probing revealed the organization had experienced some conflict when trying to manage client needs for privacy with the LHIN and CCAC requirements for personal data (in this case immigration papers). For the most part, however, perceived conflict seemed to affect an organization’s likelihood of compliance. The allocation of significant resources to meet multiple demands influenced organizational responses. Three of five organizations that experience resource pressures are found to engage in either compromise or defiance behaviours. Two of the five organizations engage in internal modification, specifically the behaviour of shifting front-line worker time towards reporting and away from service delivery (CSA 8 and CSA 11, see Table 6A-4). These organizations are also highly financially dependent on the LHIN and CCAC respectively. It is thus understandable that despite reported conflict, they would engage in internal modification (compliance behaviour) to meet requirements of their most important stakeholder. 6.3.2.4 Summary of how constituents affect responsiveness Qualitative findings suggest that perceived conflict between accountability demands from multiple stakeholders can affect an organization’s propensity to comply with LHIN MSAA and CCAC contracts. They also show that high dependency on funding from MSAA and CCAC contracts will encourage organizations to comply with those accountability requirements despite conflicting demands from other stakeholders. 157 6.3.3 CONTENT: The role of organizational goals and autonomy 21 Oliver‘s (1991) content factor, discussed in Chapter 2, suggests that goal incongruence and an external demands infringement on organizational autonomy will influence responsiveness. This section will explore the impact of goal incongruence and autonomy on organizational responsiveness. 6.3.3.1 Organizational goals and goal incongruence To explore the effect of goal incongruence we need to examine the goals of the accountability frameworks, the goals of the organization, and the organization’s response. The goals of the accountability frameworks were identified in Chapter 4 as part of the document analysis. Organizational goals can be identified from organization’s mission/value statements, and organizational responses can be gathered from interview data presented in this chapter. 6.3.3.1.1 Goals of MSAAs and CCAC contracts The goals of the MSAA and CCAC contracts are illustrated by the “for what,” or the purposes, of these accountability tools. The document analysis reveals that while financial, performance, political and procedural accountability are all represented in MSAA and CCAC contract accountability requirements there is a heavy emphasis on financial and performance accountability. In general, it is found that the MSAA has more stringent financial requirements imposed on organizations as compared to organizations under CCAC contracts perhaps suggesting that the MSAA favours financial accountability more so than the CCAC contracts. In contrast, the CCAC contracts have more stringent rules regarding performance accountability as compared to MSAAs. In the MSAA and CCAC contracts financial accountability focuses on the management of funds and balancing of budgets, meeting accounting standards, appropriate governance, and financial risk management. Performance accountability focuses on access indicators, provision of care plans, performance reviews/improvement, and professionalism. 21 Goal incongruence occurs when the goals of an external demand and those of an organization are in conflict, see Chapter 2 for a full discussion. 158 6.3.3.1.2 Organizational goals Organizational goals of interview participants can be identified from their mission, vision and value statements that were gathered as part of the environmental scan. Examining these statements revealed the following organizational goals are identified: supporting status and volunteerism, commitment to clients, ensuring accessibility, providing professional services (professionalism), being innovative, supporting the improvement of quality of life of clients, commitment to leadership, delivering services through teams/partnerships, influencing social/health policy, and ensuring accountability for services (for a description of goals see Appendix 6-C). The main areas of overlap between organizational goals and the goals of the MSAA and CCAC contracts are access and professionalism. The organizational goal of “accountability” could also be considered to be in alignment with MSAA and CCAC contract accountability goals since adhering to accountability requirements of the MSAA and CCAC contract demonstrates accountability. 6.3.3.1.3 Exploring propositions in relation to organizational goals Proposition 3a. Organizations are more likely to comply with accountability requirements if they align with their organizational goals. Proposition 3b. Organizations will engage in compromising responses to accountability tools that are not aligned with organizational goals during the development and implementation stages of accountability requirements. The propositions above suggest that goal alignment may lead to compliance while non-alignment may lead to non-compliance responses that occur prior to the accountability requirements being implemented. Given that the only response that occurs in the development and implementation stages of requirements is negotiation, proposition 3b would suggest that organizations are more likely to engage in compromise if goals are not well aligned. Almost all organizations had goal congruence with accountability frameworks (see Appendix 6A, Table 6A-5). As such it cannot be determined whether goal congruence is a factor in organizational responsiveness. 159 6.3.3.2 Autonomy Participants reported that LHIN MSAAs and CCAC contracts had an impact on organizational autonomy by affecting how they administratively run their organizations, and how they deliver services. For example, participants reported that their organizations have to operate within the confines of the agreement, have to adopt particular technologies and IT, and have to do group purchasing as part of their agreements. This last requirement is specific to some LHINs in which they have adopted back-office integration models, requiring all LHIN funded organizations (including hospitals, CHCs) to do all their purchasing and benefits as a group to save money. Unfortunately, this practice compromises an organization’s ability to purchase locally, especially from organizations that give donations. “…half way through the year [the MSAA came] out with the back office integration and they basically told us we couldn’t buy local anymore… the purchasing was a major stumbling block for us. When we raise eighty percent of our funds locally, and we would not … be putting our money back into the community” (CSA 1) Participants also noted that the CCAC contracts change how their organizations deliver services and in particular, the planning and delivery of care for clients and the education and management of front-line staff. “In every way possible they decide what our care plan must have in it. They decide what our….we have so little room to manoeuvre. So if they order that this client have three times a week service, unless we go back to them and say this client needs more or this client is now doing better, we can’t just fix their wound. We have to fix it in the way they say we have to fix it.” (CSA 8) “They intrude by defining what kind of education a particular specialty supervisor needs to have. So for wound care they require a particular kind of education that is a certificate that’s only available in the States. It didn’t even make any sense. It’s not available here. We had to ask their permission to get, to allow our staff to have the qualification that was available in Canada. That’s just dumb.” (CSA 8) One organization noted that infringement on autonomy was dependent on the organization’s performance. This response is not surprising given that missing performance targets can trigger enhanced monitoring and implementation of improvement plans. “…it depends I think if you’re not meeting performance you have less autonomy … when you are meeting performances it is fairly hand off.” (CSA 5-1) 160 There were a number of participants that did not feel as though the MSAA or CCAC contracts compromised their autonomy. One organization noted the importance of maintaining autonomy: “I don’t see a lot of what’s in the MSAA to restrict how we provide services to the people that we support. We are still able within, even though we have the MSAA, to be flexible. I don’t want to ever lose that.” (CSA 6) Another organization also noted that the CCAC was open to suggestions for innovative practice: “I don’t feel [the CCAC contract] infringes on our autonomy. Due to the agreements we become limited to do certain things but it’s not our sole source of revenue. We have a lot of desire to become innovative. CCAC, many of them are quite open to being approached with different innovative ideas and ways to improve service delivery. So from autonomy and how we operate our business, although they have certain reports, again play by the rules, I don’t find it necessarily limiting to our autonomy as an organization what we need to accomplish.” (CSA 7) 6.3.3.3 Perceived inevitability and flexibility As discussed in Chapter 2, perceived inevitability can be operationalized as strong financial dependence and whether organizations perceive the demands as flexible. Inflexible demands will more likely been seen as inevitable. Most participants whose organizations hold MSAAs felt that the MSAA is “somewhat” flexible. Participants reported that their organizations are given the opportunity to explain missed targets, are able to amend indicators and terms in the agreement, and are able to shift funds around as needed. “It is somewhat flexible. Hmm, you know, these agencies, for example, have been counting, once statistic wrong and that’s wrong for years, hm, we reinstituted major changed to count it properly that when we place a home helper with the family, hm, we now count that as one matched regardless whether the home helper sees that family one or twenty five times. We used to count that as twenty five visits, hm, and the provincial standard is no. You count the matches. So, we made that change. We sent the, you know, notice off to the LHIN that we’ve being doing it wrong and here is why and they said that’s fine and make sure you noted on your A&R and your account reconciliation report. So, I feel that’s flexibility.” (CSA 3) Both LHIN representatives also felt the agreement is flexible in terms of providing explanations for performance issues and providing room for organizations to shift funding as required: “That’s something we encourage all our organizations. The way I speak to our organizations is essentially the MSAA defines a basket of service and a pool of money. Your responsibility is to understand the needs and demands are for the community you serve and we expect you to continue to monitor that and adjust. You 161 don’t have to come to me asking permission to move money from equipment to salaries but we do ask you to let us know where there are some major shifts. Essentially you’ve got some flexibility to move to meet the demands as they arise.” (Urban LHIN) Two organizations, however did not see the MSAA as flexible at all, and felt they have to deliver services and meet expectations exactly as written in the agreement: “…we didn’t always like who we were dealing with and the response like a when you raise a concern and somebody says, too bad , too bad you sign the MSAA.” (CSA 1) With regard to CCAC contracts, about half of the participants whose organizations hold CCAC contracts felt the contract is flexible, but only with regard to meeting performance targets. Otherwise the contract was seen as rigid. “If we do have a particular challenge at any given day I do find them quite flexible to discuss and understand the challenge we may be having. If we don’t meet a particular indicator in a given month they don’t serve us with a legal breach of contract although technically I guess they could. They are good….we can work with them but the contract itself is not flexible.” (CSA 7) One participant saw the contracts as becoming less and less flexible over time, even in regard to performance targets: “So start with CCAC. There is becoming less and less flexibility. So over time there is less, there is less tolerance for non-performance.” (CSA 5) 6.3.3.4 Examining propositions in relation to autonomy and inevitability Proposition 3c. Organizations will be less likely to comply with accountability requirements that infringe on their autonomy. Proposition 3d. Organizations will be more likely to comply with accountability requirements that are perceived as inevitable, despite their impact on organizational autonomy. Table 6-4: Perceived inevitability and organizational autonomy affect on organizational responsiveness to MSAAs and CCAC contracts. Response Perceived inevitability and Perceived impact on autonomy flexibility of demand MSAA Compliance Financially dependent on the MSAA No impact on autonomy but consider demand flexible. Internal Either the organization as a whole or No impact on autonomy (one exception 162 Response Perceived inevitability and flexibility of demand modification specific funded programs are financially dependent on the MSAA. Most consider demand flexible with regard to meeting targets Perceived impact on autonomy Compromise Specific funded programs dependent on MSAA, consider MSAA flexible with regard to meeting targets. Not specified. Avoidance Not financially dependent, do not consider MSAA flexible CCAC Internal Organization, programs or branch modification financially dependent on CCAC funding. Consider CCAC flexible with regard to targets. Compromise Branches financially dependent. Consider CCAC flexible with regard to targets. Defiance Organizations, branches and programs dependent on CCAC funding; however, receive CCAC funding from multiple CCACs on multiple contracts across Ontario. Consider CCAC flexible with regard to targets. that perceived impact on administrative autonomy). Impact on administrative autonomy Impact on autonomy to deliver services. No impact on autonomy. Impact on autonomy to deliver services. See Appendix 6A, Table 6A-6 for full data set. Table 6-4 shows how perceived inevitability and autonomy relate to organizational response. When we look at autonomy along with the inevitability indicators, nine organizations behave as suggested by the propositions (CSA 1, 2, 4-1, 5, 5-1, 8, 9, 10 and 12, see Appendix 6A, Table 6A-6). One excellent example is CSA 1 that avoided the MSAA specifically due to its affect on the organizational autonomy. CSA 1 was able to do so because it was not financially dependent: “So, there are two [reasons why we left the MSAA]. The amount of work, the administrative demand to be with the LHIN and the other thing that would be, hm, is to back office integration.” (CSA 1) Most organizations only show partial support for the propositions, mainly due to organizations being financially dependent but perceiving demands as flexible, making it difficult to determine 163 whether demands are perceived as inevitable. The propositions are generally more strongly supported for MSAAs than for CCAC contracts. An important finding is how participants who reported flexibility in requirements mainly reported flexibility in terms of the organization’s requirement to meet targets. Rather than inflexibility leading to compliance, it is more likely that flexibility helps with compliance given that LHIN and CCAC flexibility around organizations meeting targets prevents many organizations from experiencing harsh sanctions which could lead to a defiance response. 6.3.3.5 Summary of how content affects responsiveness Organizations that perceived MSAA accountability demands as inevitable due to financial dependence were more likely to comply with those demands, despite their impact on organizational autonomy. The influence of perceived inevitability on organizational compliance was not as strong with regard to CCAC contracts. It could not be determined whether goal alignment between organizations and accountability requirements had affected organizational responsiveness. 6.3.4 CONTROL: Strict penalties, role clarity, interaction, and professionalism. As discussed in Chapter 2, it is expected that more coercive policy instruments, perceived stricter penalties for non-compliance, clearly defined roles, and consistent norms-based organizational interactions that enforce compliance will lead organizations to comply with accountability requirements. The document analysis in Chapter 4 finds that the LHIN MSAAs and CCAC contracts constitute expenditure policy instruments, considered to be a “moderately” coercive policy instrument (Doern & Phidd, 1983). However, expenditure tools could be considered mandatory in instances where organizations are financially dependent on them. We can thus argue that organizations that are financially dependent on LHIN and CCAC funding may see these tools as more coercive than organizations that are not financially dependent. The above analysis has already demonstrated how financial dependence will influence an organization’s propensity for compliance behaviours. 164 6.3.4.1 Strictness Interview participants were asked whether they felt sanctions for non-compliance to LHIN 22 MSAAs and CCAC contracts were strict. Participants from five of twelve organizations reported they felt that penalties for non-compliance with the MSAA are strict. Most of the five participants felt the sanctions are strict because they potentially involve rescinding funding: “Well there are financial penalties and when you are on a shoestring budget and have absolutely no flexibility to have your funding threatened in any way is extremely stressful for a volunteer board of directors who ultimately the responsibility rests with them. So yes I think…I would hate to be in the position that there were sanctions against our agency.” (CSA 9) Some respondents (including the representative from the rural LHIN) felt that the level of strictness is dependent on whether the LHIN decides to enforce sanctions as outlined in the agreement: “I think that if they were enforced to the degree that is written then yes [it is strict].” (CSA 4-1) With regard to the CCAC contracts, three of eight respondents, and both urban and rural CCAC representatives, reported that sanctions for non-compliance are strict due to the fact sanctions involve the cancelling of contracts and reducing volumes: “Yeah. Basically CCAC can pull my contract during the duration of it. So if I had failing performance indicators on a repeat basis they have the ability to pull that contract. They have the ability to reduce my volumes. So they are very clear and they can be very harsh in what they could do. I don’t normally see it. They are very reasonable in their approach to the contract and indicators but the language is certainly in the contract. They could be very aggressive.” (CSA 4-2) The majority of respondents (five of eight) however, felt that penalties are fair and reasonable in the way they are enforced. Many participants felt that the CCAC with whom they hold contracts is understanding of the challenges their organization face in trying to meet targets. “I think most CCACs are realistic about the context. So they have eight providers of PS [personals support] services and none of us are meeting their missed visits target, 22 One of the organizations interviewed did not provide information on perceived strictness. This particular interview ran long and not all questions could be asked. 165 there’s a reason. The missed target is probably not achievable… I think they are aware of the realities and so there is some understanding … they look at us in context I think is fair to say. If everyone else is meeting a target and we are not they are going to seriously look at me.” (CSA 8) Additional participants cited the graduated sanctions approach as being reasonable and did not see it as particularly strict: “I think that they’re reasonable and, you know, trying to work with the organization to improve performance over time…I think they have been fairly reasonable in not to saying okay, here’s the outcome and tomorrow if you’re not meeting it, you’re going to get the big hammer… the sanctions don’t come because you don’t miss one… particular target usually, they come because you, you have a few target that you’re not meeting and you haven’t been able to meet them over time and they run out of patience with you, with working with you trying to make, get you to meet them.” (CSA 5) 6.3.4.2 Role clarity Another way for accountability requirements to exert greater control is to ensure that the roles and responsibilities of both parties are clear. Accountability relationships will tend to be strong when expectations and obligations are clearly understood (Bergsteiner & Avery, 2009). Chapter 4 covers which roles and responsibilities are included in the LHIN MSAAs for both accountors and accountees. Interview participants also identified whether they perceived their (and the LHIN’s and CCAC’s) roles and responsibilities as laid out in the agreements/contracts. Almost all participants asked about the LHIN MSAA (10 of 12) identified that the responsibilities of the organization under an MSAA are clear. One respondent felt that the increased clarity of the new agreements as compared to older versions make the MSAA operate more like the CCAC contracts: “[The LHINs] are at the stage now where they are operating very much like the CCACs where they are very clear on their contracts…” (CSA 4-2) Most respondents also felt that the responsibilities of the LHIN are clearly stated; although, one did not feel this was the case and felt that lack of clarity erodes bi-directional accountability: “[The LHIN’s] responsibilities are fluid and certainly the agencies don’t have that flexibility at all. If we don’t comply we don’t get funding. We don’t have any kind of hold on the LHIN to make them as accountable to use as we are to them.” (CSA 9) 166 Most respondents (6 of 8) also felt that the responsibilities of the home and community care agency are clear under CCAC contracts. Where lack of clarity was identified it was mainly around which organization (the HCC or the CCAC) has responsibility for the client: “It’s sometimes unclear about who owns the client or not who owns the client but who’s responsible. You know, the agencies …are providing the care but we often feel that because the CCAC is providing us with the contract that they have the ultimate say. So, um, you know, like a shift of power, I think there’s been a shift in the balance of power and I think that definitely affect the client, that’s my read on it… where I find that really grey and then unclear is that the overlapping of rules especially like come to case managing and application to the client” (CSA 12) 6.3.4.3 Interaction A final way an external demand can exert greater control over an organization is through informal norms-based interactions between the body imposing the demand and the organization upon which the demand is placed. Participants identified a number of different ways in which HCC agencies interact with the LHINs and CCACs. These include: Reporting: Interaction mainly occurs around reporting. This may happen quarterly or potentially more frequently if reporting is more frequent. Meetings: Interaction occurs during either regular scheduled or ad hoc meetings set by either the LHIN or CCAC. These can occur monthly, bi-monthly or quarterly. Performance review: Interaction between LHIN or CCAC agencies occurs through performance reviews and improvement plans. These types of interactions are similar to reporting but happen more frequently than quarterly reporting which occurs when a HCC agency is undergoing an improvement plan. Case management: This type of interaction occurs between CCACs and HCC agencies only. This interaction has to do with the actual delivery or services to clients. As the CCAC is the case manager these interactions happen extremely frequently, often daily, to coordinate the care of clients. Committee work: Committees set up by the LHIN or CCAC to address particular issues around service delivery or for particular projects or initiatives. With the exception of committee work, all of these interactions are themselves forms of accountability. Participants identified that, in addition to reporting, performance improvement plans/reviews and meetings are ways in which the LHINs and CCACs hold them to account. Interaction for the purpose of case management is simply a part of delivering services for 167 CCACs and as such would equally reinforce behaviours to all organizations under CCAC contracts. Given that the interaction itself is perceived by organizations as a form of accountability, it would be tautological to argue that interaction supports compliance to accountability requirements. Interaction can affect organizational compliance to other types of external demands. As such, proposition 4b (see Chapter 2) cannot be examined. While the type of relationship held between accountors and accountees has been found to affect how agents respond to accountabilities (Frink & Kilmoski, 2004), data regarding relationships was not gathered as part of this study. Future studies of organizational responsiveness should include an examination of relationships between accountor and accountee. What can be examined from this data is effect of role clarity, identified as an important factor in accountability relationships (Bergsteiner & Avery, 2009; Thomas, 1998). Proposition 4b is thus amended to examine role clarity rather that level of interaction. 6.3.4.4 Examining propositions in relation to strictness and role clarity Proposition 4a. Organizations will be more likely to comply with accountability requirements that are perceived to carry strict penalties for noncompliance. Proposition 4b: Organizations will be more likely to comply with accountability requirements that have clearly defined roles and responsibilities for the accountee. To answer these propositions we need to examine participants’ perception of how strict the penalties to non-compliance are for LHIN MSAAs and CCAC contracts (for proposition 4a) and their perceived role clarity (for proposition 4b) in relation to organizational responsiveness; presented in Table 6-5. Table 6-5: Perceived strictness and role clarity affect on organizational responsiveness to MSAAs and CCAC contracts. Response Perceived strictness of Role clarity accountability MSAA Compliance Perceived demand as strict HCC role was clear. One organization reported the LHIN role was not clear. Internal Most organizations perceived modification demand as strict. Most reported HCC and LHIN roles were clear. Compromise Not specified. HCC role clear. 168 Response Perceived strictness of accountability Role clarity Avoidance Perceived as strict. HCC role not clear. CCAC Internal Most organizations perceived as modification strict or somewhat strict. Half perceived HCC and CCAC role clarity, the other partially or not clear. Compromise Perceived as strict but fair HCC role clear. Defiance Perceived as strict but fair. HCC and CCAC role clear (one exception). See Appendix 6A, Table 6A-7 for full data set. For the most part all participants find MSAA sanctions to be strict, and given that most responses to the MSAA are compliance or internal modification they may suggest that perceived strictness influences organizational propensity for compliance. Many of these organizations (notably CSA 9 and 10) are also financially dependent on the LHIN and also voiced concerns/stress about loss of funding. CSA 1 finds sanctions to be strict but nevertheless engages in avoidance; this could be because CSA 1 was not financially dependent on the LHIN, which may overshadow the impact of the perceived strictness of the demand. It may be that dependency is related to the impact of perceived strictness. With regard to CCAC contracts, organizations that perceive CCAC sanctions to be strict tend towards internal modification (compliance behaviour), while those who perceive sanctions as fair or reasonable engage in non-compliance behaviours such as compromise and defiance. These findings support proposition 4a that organizations who perceive strict penalties for noncompliance will tend to comply. If we examine role clarity there is some support for proposition 4b when we look at responsiveness to the MSAA. However, the proposition does not hold with regard to CCAC contracts. Although most participants identified that the role of the HCC agency under a CCAC contract is clear, the organization still engaged in non-compliance behaviours such as compromise and defiance. It may be that role clarity is not enough to support organizational compliance to CCAC contracts as suggested by proposition 4b. 169 6.3.4.5 Professional norms Proposition 4c: Organizations will be more likely to comply with external demands that rely on professional norms (i.e. regulations stipulated by a professional body). As discussed in Chapter 4, the MSAAs and CCAC contracts rely differently on professional norms in order to support accountability, with CCAC contracts relying much more heavily on professional norms than the MSAA. Proposition 4c then would suggest that we would see much higher compliance to the CCAC contract as compared to the MSAA. There is actually greater compliance to the MSAA than the CCAC contracts, suggesting that reliance on professional norms may not be important to ensuring organizational compliance. 6.3.4.6 Summary of how control affects responsiveness Organizations that perceive accountability requirements as strict are more likely to comply with MSAAs and CCAC contracts. Role clarity is only found to moderately influence organizational compliance with MSAAs and is found to have no affect on organizational response to CCAC contracts. Reliance on professional norms was not found to affect organizational response. 6.3.5 CONTEXT: Organizational resources and culture An organization’s access to resources and cultural context are expected to have an impact on how an organization responds to external demands. 6.3.5.1 Additional resources The affect of an organization’s access to resources on their response to MSAAs and CCAC contracts is tested in Chapter 5 by looking at organizational access to full-time employees and organizational size. We can also look at whether the organization requires additional resources to meet external demands to determine whether the need for additional resources will affect responsiveness. Participants identified a number of additional resources that are required in order to meet accountability requirements of the MSAAs and CCAC contract. These resources include: Financial: An identified need for additional financial resources in order to meet accountability demands. Financial needs include costs associated with travel to meetings, accreditation requirements and reporting (such as the cost of audited financial statements): 170 “Costs have sort of increased maybe with some of these additional accountability requirements in terms of being resource-intensive for the active monitoring of all the performance indicators and improvement initiatives. Costs related to say accreditation which was stated in one of the MSAA agreements that we are accredited community support program. So there are additional costs to achieving that and resources required to achieve that.” (CSA 4-1) “…for the CCAC we’re expected to be accredited to a body, hm, and right now we are actually going through the [] of the process to being accredited to CARF Canada, hm, a lot of other service providers use the Accreditation Canada body and that definitely requires a lot of extra time and resources on the part of the staff and as well as consulting services, that is one thing that we spend a lot of money on.” (CSA 12) Human resources: Participants specifically identified the need for additional human resources to meet accountability requirements. This may involve the hiring of new staff, retraining staff or refocusing the work of existing staff to work exclusively on reporting and monitoring. “We’ve always had a bookkeeper whose responsibility really was just general bookkeeping and we used Simply Accounting and it was fairly straightforward. When the new reporting requirements came down we couldn’t hire somebody who was familiar with, not only the reports but the new software that we were required to use. So we had to take the person who was spending very little time doing the books to almost her entire focus now is on administrative and she had to be retrained.” (CSA 9) “Then in terms of knowledge resources obviously there’s an ongoing need for staff training to ensure that we are able to meet the expectations whether it’s a staff competency point of view, or when policies and processes change within the CCAC that we are able to be flexible enough that we can modify our own processes and change that very quickly to be able to comply with those.” (CSA 7) “I would agree [that we need additional resources] because some branches require additional human resources from an administrative perspective to ensure for example records management is meeting the required indicators.” (CSA 7) Time: Participants identified the requirement of additional time to meet accountability requirements of the MSAAs and CCAC contracts. This may include the time to attend meetings, general administration (such as answering emails) or do reporting. “[I only have] thirty hours a week and every time we have a meeting I would be losing ten or twelve client hours. The meeting will be six hour plus six hours travel for the total meeting. One week there would be sixty five e-mails in for me that included pages and pages of stuff to go through .Hm, so, there were travel, there were e-mail and there is cost of travel so, we will looking at that point of view. We 171 are the smallest agency living furthest away. We looked at doing telephone conferencing on different things, you know, that a lot of time that wasn’t offered.” (CSA 1) “But I would say time for sure would be a resource challenge in meeting some of these reporting requirements. It’s using the existing resources that we have in order to complete these tasks and they can be resource-intensive I guess for that person’s time.” (CSA 4-1) Technology: Additional technology or IT requirements are required to meet demands. Technology and IT can be used to gather data, but in most instances, it is required to report data back to the LHINs and CCACs. “So we’ve had contracts since the beginning but having said that our IT technology quality risk resources have been expanding and needing to expand enormously over the last I’d say since the late 1990’s maybe. Just a huge burgeoning of resources dedicated to quality performance indicators, decision support, risk management, all that kind of stuff….contract management.” (CSA 8) One participant also found that there is a need for technologies, such as personal digital assistants, to simply keep up with the demands of the sector: “One of the biggest pieces is technology and as a not-for-profit, even at my own organization it’s a bit tough. We definitely have competitors that have invested for instance in BlackBerries or some type of PDA with frontline staff so that there is a way that we can communicate with our frontline staff like those PSWs that are going from client home to client home and better access them. I think that’s definitely a build into the business, not even just for us, any health system provider that’s going to be operating, you really need to be able to communicate in a secure manner with other providers.” (CSA 4-2) Other participants did not see a need for additional requirements, but instead felt that home and community care organizations always face a lot of requirements as part of their business: “…is becoming such a part of routine that we built it in, we know that the fourth week of October is going to be a crazy week of getting LHIN reports done and everything else wait for that time period.” (CSA 3) “There are always continual changes that we have to keep looking at and rebuilding to meet the requirements of the contract and to do it more efficiently. We are always looking at those aspects. That never ends.” (CSA 4-3) The LHIN representatives and urban CCAC representative did not see the accountability requirements as too onerous and felt that their demands fit into the existing demands placed on 172 home and community care agencies from other funders like the United Way or from municipal bodies. Conversely, the rural CCAC representative was well aware of the additional resource demands required to meet accountability requirements of CCAC contracts. This participant felt that organizations are likely to feel that, given fiscal constraints, organizations cannot be compensated for the additional work they are required to do: “Because we haven’t been going to market for a long time, and now we are in a constraint in terms of what we can pay them, that’s what they tell us. It takes additional resources for them to do that and they don’t feel they are compensated for that.” (Rural CCAC) 6.3.5.2 Examining the proposition related to access to resources Proposition 5a. Organizations with better access to resources will be more likely to comply with accountability requirements. Examining perceived additional resource requirements sheds additional light on why organizational size may not have the expected affect on organizational compliance. In terms of the MSAA, small organizations that are compliant or engage in internal modification also reported that few additional resources are required (see Appendix 6A, Table 6A-8). With regard to CCAC contracts most organizations are large, or a branch of a large organization and nearly all reported requiring additional resources to meet demands. While the proposition is wellsupported with regard to MSAAs it is difficult to determine whether there is support with regard to CCACs since almost all organizations are fairly well resourced. 6.3.5.3 Organizational culture As discussed in Chapter 2, it is expected that organizational culture can play a role in how an organization responds to external demands (Gelfand et al., 2004). Specifically, it is expected that in order for an accountability requirement to be seen as legitimate, the organization upon whom the demand is placed must see the requirement as conforming to their perception of where responsibility lies: with the individual or the collective. Rather than simply individual versus collective responsibility, the interviews revealed that the responsibility for the delivery of high quality services could be seen as either an individual, organizational, or collective responsibility. 1. Individual: Responsibility for quality care lies with the frontline service providers. Only one participant suggested this is the case; however, they stated a collective responsibility with the frontline providers being the “primary” in charge of assuring quality care: 173 “The primary has to be frontline staff. They are the ones that are doing the most interaction, but the frontline staff can’t do it without the supports that we can help to provide, whether it’s providing additional training, whether it’s providing the resources for staff to do it. Ideally management then sits back and does that supporting role, that frontline staff need to do. They are the first contact point.” (CSA 13) 2. Organization: Responsibility for quality care lies with the organization as a whole. “[Responsibility for quality lies with] the organization as a whole, I mean I’m ultimately responsible for delivering on the quality. I do have, hm, one of my managers who have quality within her portfolio.” (CSA 10) 3. Collective: Responsibility for quality care lies with the organization and the frontline providers together. “We have an absolute mantra here which is everybody is responsible for quality. So the frontline providers know that they are responsible for quality. We are open to their ideas. That they are responsible for the quality of the care they provide and the quality of their relationship with the client. They are responsible for upgrading their skills. We are responsible to let them know if they need to. We are responsible for implementing larger quality improvement projects. They have to tell us if they see something out there that doesn’t look right and that they think we need to improve. We all work on quality. We’ve had a quality and patient safety culture push for a good ten years now and we let everyone know. It starts with you and it continues through the rest of us.” (CSA 8) 6.3.5.4 Examining the propositions related to organizational culture Proposition 5b. Organizations will be more likely to adhere to accountability requirements that are aligned with their cultural context. The language of the MSAA and CCAC contracts tends to focus on assigning responsibility to the organization as a whole; however, CCAC contracts also clearly lay out responsibilities of individual service providers in terms of what services they need to be able to provide. This would suggest that CCAC contracts tend to support combined responsibility of the organization and individual provider, while the MSAA focuses mainly on the organizations’ responsibility for services as a whole. The proposition does not hold for CCAC contracts given that organizations engaged in noncompliance behaviours despite cultural contextual alignment between organizations and CCAC contracts. There is some support for the proposition with regard to the MSAA (see Appendix 6A, Table 6A-9). 174 6.3.5.5 Summary of how context affects responsiveness Organizations with better access to resources were more likely to comply with both MSAAs and CCAC contracts. Organizations’ cultural context did not strongly affect their responsiveness to accountability demands. 6.3.6 Examining all organizational factors Examining all organizational factors together can help paint a picture of what compliant and noncompliant organizations generally look like. Table 6-6 provides an overview of organizational characteristics aligned with different responses to MSAAs and CCAC contracts. Organizational characteristics associated with compliance to MSAAs include larger size, financial dependence, low stakeholder conflict, no impact on autonomy, perceived strictness of demand, role clarity and alignment of quality culture. This finding offers support to many of the propositions guided by Oliver’s theory of organizational responsiveness. The propositions are not as strongly supported with regard to CCAC contracts. The only important factors with regard to responsiveness to CCAC contracts are organizational size and dependence, in that large organizations with multiple CCAC contracts are able to engage in defiance behaviours since they are not financially dependent on one single CCAC contract to survive. This affords the organizations greater power, allowing them to defy the external demand. 175 Table 6-6: Organizational characteristics associated with responses to MSAAs and CCAC contracts. Response Size Dependence and flexibility of demand Stakeholder conflicts and demands Perceived impact on autonomy Perceived strictness of accountability Role clarity Organizational quality culture alignment MSAA Compliance Med. Financially dependent on the MSAA but consider demand flexible. Reported low stakeholder conflict No impact on autonomy Perceived demand as strict Quality culture aligned with MSAA Internal modification SmallMed Reported stakeholder conflict and additional resource demands from multiple stakeholders Small No impact on autonomy (one exception that perceived impact on administrative autonomy). Not specified. Mostly perceived demand as strict. Compromise Not specified. HCC role clear. Quality culture not aligned with MSAA Avoidance Small Either the organization as a whole or specific funded programs are financially dependent on the MSAA. Most consider demand flexible with regard to meeting targets Specific funded programs dependent on MSAA, consider MSAA flexible with regard to meeting targets. Not financially dependent, do not consider MSAA flexible HCC role was clear. One organization reported the LHIN role was not clear. Most reported HCC and LHIN roles were clear. Impact on administrative autonomy Perceived as strict. HCC role not clear. Quality culture not aligned with MSAA CCAC Internal modification MedLarge Reported stakeholder conflict and additional resource demands Impact on autonomy to deliver services. Most organizations perceived as strict or somewhat strict. Half perceived HCC and CCAC role clarity, the other partially or not clear. Quality culture mostly aligned with CCAC contract. Compromise Large Perceived as strict but fair HCC role clear. Large (incl. Branch) Reported stakeholder conflict and additional resource demands Reported stakeholder conflict and additional resource demands No impact on autonomy. Defiance Organization, programs or branch financially dependent on CCAC funding. Consider CCAC flexible with regard to targets. Branches dependent. Consider CCAC flexible with regard to targets. Organizations, branches and programs dependent on CCAC funding; however, receive CCAC funding from multiple CCACs on multiple contracts across Ontario. Consider CCAC flexible with regard to targets. Impact on autonomy to deliver services. Perceived as strict but fair. HCC and CCAC role clear (one exception). Quality culture aligned with CCAC contract. Quality culture aligned with CCAC contract. Stakeholder conflict and additional resource demand of multiple stakeholders No stakeholder conflict reported Quality culture partially aligned with MSAA 176 6.4 The problem with indicators A significant problem identified by interview participants was that performance indicators included in both the MSAA and CCAC contracts do not sufficiently capture what participants felt were the important aspects of the services they delivered. Participants found that both the MSAA and CCAC contracts tend to focus on process indicators, but do not capture health outcome indicators that they felt reflected high quality home and community care services: “ ...[MSAA indicators do] not take into any consideration what the effect you may have on this person, health wise, staying at home longer, staying at the hospital, staying at the long term care … what effect it would have, you know, on the caregivers because that’s a really an unseen populations. So, all we are doing is just tracking numbers and then the numbers don’t really have a huge impact.” (CSA 3) “We don’t do a lot of outcome measurements. I don’t think there are any actually related to client outcomes or achieving the client goals... Outcome, although difficult, goal achievement and outcome would be very important to ensure that we are using the CCAC dollars appropriately.” (CSA 7) Even CCAC and LHIN representatives identified that important outcome indicators are missing from the agreements and contracts: “A great example is, by having CSS services in place, how long do we delay somebody from having to go into a long-term care home or delay them from having to go to a hospital? CSS services, has it reduced the number of times somebody goes to the ER? We don’t have access to that data and that would be ideal performance indicators. That would be an outcome indicator.” (Rural LHIN) “The outcome measures are things like satisfaction with the service. Was the personal care that we are providing, is it increasing the person’s independence? Those are harder to measure.” (Urban CCAC) Participants also felt that the MSAA misses key indicators around staff satisfaction, system integration (how sectors work together), client quality of life, cost savings associated with home and community care (i.e. hospital deferral), health promotion indicators, and medication management. Another key concern for respondents was that some indicators do not accurately take into consideration contextual factors. One example is geographic location of the service provider that affects the time it takes to do a visit, and is reported as number of visits rather than time per visit. 177 Participants also noted that the MSAAs and CCAC contracts use performance indicators on aspects of service delivery that they do not control: “One thing that we are supposed to report which is turnover rate, I find to be a real irritant to me. They are talking about staff turnover rate. As far as I’m concerned the community support services sector always had lower wages. We are just not supported well here in this sector. So because of that we sometimes lose people to other positions and there’s just such a discrepancy in what we can pay. So that contributes to the turnover rate, which is outside the agency’s ability to change. I don’t think the turnover rate is something that we should be even looking at now or the way that it’s looked at needs to be carefully considered.” (CSA 6) “I think when we are looking at CCACs, when you look at… probably an overarching theme would be the human resource labour shortage for support workers. Continuity is definitely something that is important to capture in terms of providing services to the client but the targets that are established by the CCACs sometimes do not reflect the reality of the service providers in the ability to find staff to meet the targets. Same with the ability to accept referrals. As the service volumes increase and increase from CCACs, when we are experiencing severe human resource challenges there’s a bit of a disconnect there.” (CSA 4-1) A final concern around indicators, specifically CCAC indicators, was that some indicators actually compete against each other; so, if an organization wants to meet targets in one area, they may have to sacrifice meeting targets in another: “…sometimes we don’t meet target because target competes with each other, for instance, sometimes we compromise continuity because we want to take a referral. Those are indicators but they compete against each other… A referral will come in, in the evening because the client has been discharged from hospital stay. We will send the evening nurse… or somebody that could go. Anybody that could go because we want to get the client in but on and on-going basis that client might be on service, Tuesday, Wednesday, Thursday, for example, pick up by another primary team but that does initial evening nurse won’t be on…So by taking that initial referral because we don’t want to decline it, putting someone in that home, we disadvantaged ourselves because now that client is only going to get one trial visit.” (CSA 5) Although we may expect the perception of the accuracy and appropriateness of performance indicators to which an organization is held to account may influence responsiveness, in this particular sample all respondents reported that the MSAA and CCAC contract performance indicators do not accurately reflect their perception of high quality home and community care services. For this sample then, we cannot determine whether perceived inadequacy of performance indicators affects organizational responsiveness. What this does demonstrate is that the performance indicators in the MSAAs and CCAC contracts do not adequate capture the 178 quality of home and community care services. Thus, while an organization may be compliant with the MSAA or CCAC contract, this does not necessarily indicate that the agency is delivering high quality care. 6.5 Unintended consequences Research Question 4: What are the potential impacts of accountability frameworks on home care service delivery? As discussed in Chapter 2, accountability requirements and performance measurement may lead to perverse outcomes and unintended consequences. Interview participants revealed a number of unintended consequences of the accountability requirements attached to LHIN MSAAs and CCAC contracts. One positive unintended consequence identified by participants is that the MSAA and CCAC contracts increased focus on quality across their organizations (by frontline staff, boards of directors, and broader organization): “To focus on everything you do and, you know, go through everything and that’s good. We think, at least here, we always been quality centre here. Always been quality focus. [The MSAA] focus us probably a little bit more like [other interviewee] said and make us more aware of things that we probably could do better or differently, hm.” (CSA 2) “I think that the fact that we report on quality indicators quarterly and monthly to the CCAC is known from top to bottom in the organization. They see their team reports. They get competitive between the teams about who is going to perform better. So that whole awareness of quality constantly being monitored and watched and responded to and trying to get ahead of it, be proactive, all that awareness runs throughout the organization. If I was trying to engender that much focus on quality by myself as the director of quality, I think it would probably be a little bit harder.” (CSA 8) A few participants cited shifting frontline staff time away from client care and towards reporting as an unintended consequence of the MSAAs and CCAC contracts. While some participants merely saw this as an unfortunate side effect of the agreements and contracts, this shift of time was one of the main reasons why CSA 1 cancelled their MSAA, returned the funding and plan to never go back to the MSAA. The participant identified that meeting requirements took too much time away from clients: “…if I’m wasting 12 hours in a meeting, [and] a drive, it’s gone. It’s 12 hours that are not being given to my client.” (CSA 1) 179 A final unintended consequence of the MSAA in particular is the impact on innovation. Some participants identified that they are not comfortable innovating around service delivery as that could impact on performance targets. One participant felt that many organizations under the MSAA would not take that risk: “There is very few people that are going to, take a lot of risk, in this kind of environment. I don’t think, I don’t think we are going to take too many risk.” (CSA 10) “The MSAA, they are so criteria-based, you hit the mark, or you didn’t. They don’t allow that developmental learning to go on… And they are very clear to me. If I don’t hit my targets, it has implications on me receiving the funding again.” (CSA 13) 6.6 Summary of qualitative findings This chapter explored HCC organizational responses to MSAAs and CCAC contracts. It is found that organizations engage in compliance, internal modification, compromise, avoidance and defiance behaviours, with the majority of organizations engaging in internal modification. Internal modification is a response that was not theorized but emerged from the interview data. This response demonstrates that HCC agencies are willing to make changes to their organizations in order to meet accountability demands of the MSAAs and CCAC contracts. This chapter also explored all 13 propositions related to cause, constituents, content, control and context in relation to organization responses to MSAA and CCAC contracts. Organizational size (in relation to MSAA only), financial dependence, and perceived strictness of demands all increased the likelihood that organizations would comply with MSAAs and CCAC contracts. Perceived conflict with competing demands decreased likelihood that organizations would comply with MSAAs and CCAC contracts. Table 6-7 summarizes findings with regard to propositions related to organizational responsiveness. Table 6-7: Summary of findings with regard to propositions. Proposition Cause Proposition 1. Larger organizations will be more likely to comply with accountability requirements. LHIN MSAA CCAC contract Supported Not supported Constituents Proposition 2a: Organizations are more likely to comply Supported Supported 180 Proposition with accountability requirements from stakeholders upon whom they are highly dependent for funding. LHIN MSAA CCAC contract Perceived conflict between demands impacts on responsiveness. Supported Supported Additional resource demands due to multiple accountability demands impacts on responsiveness. Supported Supported Content Proposition 3a. Organizations are more likely to comply Indeterminate with accountability requirements if they align with their organizational goals. Indeterminate Proposition 3b. Organizations will engage in compromising responses to accountability tools that are not aligned with organizational goals during the development and implementation stages of accountability requirements. Indeterminate Indeterminate Proposition 3c. Organizations will be less likely to comply with accountability requirements that infringe on their autonomy. Supported Weak support Proposition 3d. Organizations will be more likely to comply with accountability requirements that are perceived as inevitable, despite their impact on organizational autonomy. Supported Weak support Supported Supported Proposition 4b: Organizations will be more likely to comply with accountability requirements that have clearly defined roles and responsibilities for the accountee. Moderately supported Not supported Proposition 4d: Organizations will be more likely to comply with external demands that rely on professional norms (i.e. regulations stipulated by a professional body). Not supported Not supported Supported Indeterminate Control Proposition 4a. Organizations will be more likely to comply with accountability requirements that are perceived to carry strict penalties for noncompliance. Context Proposition 5a: Organizations with better access to 181 Proposition resources will be more likely to comply with accountability requirements. LHIN MSAA CCAC contract Proposition 5b. Organizations will be more likely to adhere to accountability requirements that are aligned with their cultural context. Moderately supported Not supported Most interesting were the additional themes that emerged in the interviews. One common theme across all respondents was the perception that performance indicators in the MSAA and CCAC contracts do not adequately reflect the quality component of home and community care services. Participants reported that indicators do not adequately capture outcomes relating to clients, contextual factors, and economic impacts. They also reported a number of unintended consequences related to the MSAA and CCAC contracts including an increased focus on quality at all levels in the organization (from frontline staff to boards of directors), shifting staff time away from client care and towards reporting, and reduced incentives for innovation (in relation to the MSAA only). 182 Chapter 7 Analysis, discussion and conclusions 7 Introduction Chapters 4, 5, and 6 presented research findings from the document analysis and environmental scan, survey, and key informant interviews respectively. This chapter analyzes and discusses the findings in relation to the literature presented in Chapter 2 and additional literature that helps provide a rich analysis. The discussion is organized into four sections to reflect the four research questions presented in Chapter 1: Research question #1: What accountability frameworks are currently in place for home and community care agencies in Ontario and how do the characteristics of these frameworks vary? Research question #2: What is the array of realized organizational responses to accountability requirements? Research question #3: How do responses vary as a function of organizational factors? Research question #4: What are the potential impacts of accountability frameworks on home care service delivery? First, research question #1 is explored using the findings presented in Chapter 4 in relation to the political science literature around policy instruments and New Public Management (NPM) approaches to public policy and administration. Next, research question #2 and #3 are explored using findings presented in Chapters 4, 5, and 6 in relation to organizational behaviour, political science and accountability literature. This portion of the analysis constitutes the mixed-methods aspect of this research as it pulls together findings from quantitative and qualitative data to explore propositions and draw conclusions. Next, research question #4 is explored using findings from Chapters 4, 5, and 6 in relation to performance measurement and accountability literature and literature around best-practices in home and community care. Finally, this chapter offers a discussion of findings in light of the literature, identifies practical implications of the findings, overview strengths and weaknesses of the study, and suggests directions for future research. 183 7.1 Accountability frameworks in place: Research question 1 analysis Chapter 4 discusses how home and community care agencies are subject to a variety of accountability requirements that can be regulatory (government legislation), expenditure-based (grants, funding, contracts), exhortative (from clients, families, volunteers and communities), or a combination of all three (accreditation). In Chapter 4 the characteristics of these tools are outlined by asking “to whom, for what, and at what cost,” and finds that government bodies, in particular provincial governments, tend to rely on regulatory and expenditure policy instruments to hold HCC agencies to account for services delivered. Regulation and expenditure instruments are more substantial levers of control as compared to exhortative instruments that are relatively non-coercive (Doern & Phidd, 1983) and weak (Howlett & Ramesh, 1995), or self-regulation (which is also associated with accreditation, see Chapter 4). As this study focuses on organizational responsiveness to accountability instruments used by government, this section will focus on regulatory and expenditure policy instruments and the political incentives to use such accountability tools for this sector. Regulatory policies are the only mandatory accountability requirements imposed on HCC agencies. These policies carry a number of advantages: 1) they help reduce the need for information regarding subject’s preferences; 2) they can help remove undesirable behaviour; 3) they are efficient, predictable, and can be less costly than other instruments; and 4) they are often politically appealing (Howlett & Ramesh, 1995). Among the disadvantages of regulatory instruments are that they can promote economic inefficiency, inflexibility and can inhibit innovation. Furthermore, there may be costs associated with enforcement, and it is not possible to set regulations for all undesirable activities (Ibid). The last two disadvantages are particularly concerning as governments may not actively enforce regulations which can lead to undesirable behaviour, as discussed below. The regulations in place do not cover specific aspects of the delivery of home and community care service; leaving room for agencies to engage in activities or behaviours that can lead to inefficiencies and higher costs, or poor quality of care to clients and their families. Many community care services that seniors rely on such as home support, transportation, meals-onwheels, and friendly visiting are delivered by unregulated workers, such as PSWs and volunteers. 184 Given the low measurability of these services (see Chapter 1) and few outcome measures being used (found and discussed in Chapter 6), these services may be vulnerable to poor quality delivery. As one interview respondent reports, community care services are not measured for quality: “The problem with [the reporting is that it is] very quantitative. Very little on quality and, you know, we measure quality by how long people are staying with us... [Community support services have] always been [able] to keep people at home and save money on ER, on hospital and so on… They are not measuring [quality] because I don’t think they been able to find yet a way to measure it.” (CSA 2) In addition to the broad government legislation there is also legislation and regulations that are linked specifically to funding for home and community care services (see Chapter 4). These forms of legislation and regulations capture more specific aspects of home and community care services; however, they only cover organizations that are designated as HSPs and/or organizations receiving LHIN funding. Thus, a significant number of organizations, in particular home care organizations, are not covered by regulations that control the provision of HCC services, although home care workers who are also professionals (e.g. nurses, dietitians, social workers) are covered by the Regulated Health Professions Act, 1991 regardless of funding. The government also uses expenditure policy instruments to hold home and community care agencies to account for services -- an example of government using “treasure” to influence behaviours and activities and to gain information (Hood, 1983). Expenditure instruments carry a number of advantages including encouraging certain activities, allowing for flexibility, supporting innovation (in instances where the government allows funded bodies to choose their own “appropriate responses”), and potentially reducing costs (Howlett et al., 2009). Expenditure instruments also tend to be politically acceptable (Howlett & Ramesh, 1995), and are particularly attractive in light of the NPM vision of government as “steering” rather than “rowing” (Thomas, 1998). As discussed in Chapter 4, funding instruments are most often used in instances where the state has little or no role in the provision of goods or services (Howlett, 2000). Funding instruments thus allow the government to set overarching policy objects (“steering”) while letting organizations who receive funding engage in the delivery of services. However, organizations may need to adhere to standards around the delivery of those services (for example, policies and regulations attached to funding mentioned above). 185 Despite the number of advantages and political appeal of expenditure instruments, these tools may be difficult to establish, require high information costs, and may be redundant (in instances where the activity would have occurred without any funding) (Hood & Margetts, 2007; Howlett & Ramesh, 1995). Additionally, as expenditure tools are “fair weather” policy instruments they are often only effective in a climate where there is societal consensus (Hood, 1983; Hood & Margetts, 2007). In the event that societal consensus is lost, government funding for these services may be reduced; subsequently removing one of the accountability tools in place for the home and community care sector. Home and community care may be particularly vulnerable to a potential loss of funding because the sector is not covered under the Canada Health Act, 1985 leaving it to the discretion of each province to fund these services (see discussion in Chapter 1). Expenditure tools often come along with a set of conditions to ensure that funding is spent as intended (Hood & Margetts, 2007). Formalized performance reporting systems are particularly important as they often enhance the strength of accountability relationships (Bergsteiner & Avery, 2009). Performance reporting is also considered a pillar of government management improvement efforts guided by NPM reforms (Clark & Swain, 2005). Chapter 4 found that reporting requirements attached to expenditure tools are the main way in which organizations are held to account to government agencies providing funding. These reporting requirements are examples of governments drawing on their “authority” to ensure their expenditure will have the expected outcomes (Hood & Margetts, 2007). Home and community care agencies under LHIN MSAAs and CCAC contracts have to submit multiple financial and performance reports as part of the accountability requirements to receive funding (see Chapter 4). Many of the costs associated with these reports (such as IT infrastructure and human resource time) are incurred by home and community care organizations under agreements and contracts. Chapter 6 shows that smaller agencies, in particular, have to dedicate a significant amount of their administrative time to meeting reporting requirements. Such intensive diversion of resources from services to administrative reporting is particularly problematic for organizations under MSAAs that permit only 7% of LHIN MSAA funding to be used for administrative costs (down from 12% since 2011).23 23 Information provided by a key informant during interviews. 186 The financial burden of reporting is exacerbated for agencies with multiple funders, particularly when each funder demanded a different financial and/or performance reporting formats. For example, Chapter 6 finds that organizations not only have multiple reporting requirements, but often need to report similar data in different ways to different funders, representing a significant burden for agencies that have to redirect frontline staff time away from client care towards reporting. Smaller, more poorly resourced organizations find reporting requirements to be particularly burdensome. 7.1.1 Politically driven accountability policy: Research question 1 analysis summary In general, the delivery of home and community care services is more tightly controlled when agencies are receiving government funding; otherwise they are subject only to mandatory laws and a variety of voluntary tools to which organizations may or may not wish to adhere. In the wake of the NPM movement that suggests governments should be in the business of driving policy rather than delivering services, the incentive is to use expenditure policy instruments that rely on performance measurement techniques, which may or may not reflect quality service delivery (see discussion in Chapter 2). The use of expenditure-based accountability methods that rely on performance measurement techniques for home and community care services in Ontario can thus be understood to be politically driven. The findings presented in this thesis suggest that contract-based accountability, informed by NPM principles, is the dominant accountability approach for government funded home and community care agencies in Ontario. 7.2 Organizational responses to accountability requirements: Research question 2 analysis As outlined in Chapter 2, Oliver’s (1991) model of organizational responsiveness identifies five potential organizational responses to external demands: acquiescence, compromise, avoidance, defiance and manipulation. For this study Oliver’s conception of responses was broken into two categories, compliance and non-compliance. Survey and interview data presented in Chapters 5 and 6 respectively revealed that home and community care organizations in Ontario engage in responses that are similar to those theorized by Oliver: compliance, and non-compliance behaviours (including compromise, avoidance and defiance). An additional response not 187 theorized by Oliver but found in this study is termed Internal modification. The following section discusses each of the responses found in survey and interview data. 7.2.1 Compliance In the survey analysis, compliance is defined as organizations that hold contracts/agreements, have previously held contracts/agreements, and who plan to apply to contracts/agreements in the future. Qualitative data reveals that compliance is perceived as including a number of additional behaviours including meeting reporting requirements, not experiencing sanctions and the organization’s perception of its own compliance. Organizations with previously held contracts would have to have had to lose contracts for reasons other than sanctions (e.g. contract/agreement termination due to loss of funding) to be considered compliant. As anticipated, no other forms of acquiescence theorized by Oliver (habit, imitation) were identified by interview participants. Rather, a different form of compliance behaviour not included in the original theoretical model was identified in Chapter 6. Qualitative data analysis revealed that sub-contracting and partnering behaviours previously theorized as compromise behaviours were actually behaviours intended to improve compliance with accountability demands of MSAAs and CCAC contracts. While Oliver (1991) suggests that compromise behaviours are an exertion of organizational power in order to modify external demands, behaviours of sub-contracting and partnerships in the context of this study are examples of organizations making internal organizational changes in order to comply with those demands. Including partnering and sub-contracting as compliance behaviours for the survey analysis is not only useful for operational purposes, but aligns with findings from the qualitative data. Organizations also engaged in other behaviours that were intended to support compliance including adopting new policies and procedures, increasing the business-focus of the organization, and making changes to human resource roles and responsibilities. This study uses the term “internal modification” to describe these forms of compliance behaviours in this study. These findings suggest that organizations not only passively complied with external demands as suggested by Oliver’s model, but that they would actively make organizational changes in order to comply with those demands. Similarly, Modell (2001), in his study on responsiveness of one large Norwegian hospital to adopting performance measurement tools, found that acquiescence behaviours can comprise more active responses than Oliver had 188 suggested. Based on his findings, Modell asserted, “Oliver might have over-emphasized the passivity of acquiescence as a response where more complex, interwoven rationalities for the adoption of structural attributes emerge” (p.458). Oliver’s model can be extended to include more active forms of compliance. 7.2.2 Non-compliance behaviours Non-compliance behaviours were originally theorized to include compromise/manipulation, avoidance and defiance behaviours. Qualitative data analysis presented in Chapter 6 revealed that the compromise/manipulation response is most aligned with negotiation behaviours. Negotiation is the only instance in which home and community care organizations can exert some power in order to modify the external demand. In the case of home and community care agency responsiveness to MSAAs and CCAC contract accountability requirements, this behaviour can be called “negotiation” in order to simplify the taxonomy. While negotiation was identified as a possible response, few organizations in the interview sample reported that negotiation occurs at the organizational level; and when it does, it is mainly around the CAPS and RFP processes for the LHIN MSAA and CCAC contracts respectively. These negotiations are centered on service prices and performance targets that are to be included in contracts and agreements. Most interview respondents identified that the actual content of the agreements and contracts are non-negotiable at the organizational level. These forms of negotiations are examples of the “bargaining” tactic defined by Oliver as involving the “effort of the organization to exact some concessions from an external constituent in its demands or expectations” (1991, p.154). Most interview participants reported that negotiation occurs at higher levels between the Ontario MOHLTC and OACCAC and representatives from the HCC sector such as OCSA. These original negotiations helped to create agreement/contract templates, including the accountability requirements (such as reporting requirements and standardized performance measures) that are used for all agreements and contracts. Oliver’s original model focuses on organizations that deal with external demands more directly than is occurring in the home and community care sector in which organizations are represented by their associations. The home and community care sector thus represents a different external environment than is originally considered by Oliver and likely explains why Oliver’s compromise behaviours are minimal in the home and community 189 care context. This study’s findings suggest the need to expand Oliver’s original framework to include different organizational environments (such as the presence of associations that represent organizations) because environment affects potential responses. In addition to negotiation behaviours, organizations also engage in avoidance behaviours. In Chapter 5, the only non-compliance behaviour that could be operationalized using survey data was the avoidance behaviour which is demonstrated by an organization identifying that they did not plan to apply for LHIN MSAA or CCAC contracts. Qualitative findings presented in Chapter 6 also identified avoidance as a potential response, although only one organization in the sample engaged in this behaviour. The avoidance response found in this study reflects the “escape” tactic of avoidance in which an organization “exit[s] the domain within which pressure is exerted” (Oliver 1991, p.155). Oliver considers avoidance to be a passive behaviour. Findings from Chapter 6 revealed that organizations engaged in defiance behaviours towards CCAC contracts. Defiance is considered to be a more active response than avoidance (Oliver, 1991). The defiance response can be understood not only by the organization’s response itself, but also by the consequences of that response. Interview participants confided that almost all organizations engaged in some level of non-compliance with regard to meeting targets or missing reports, although most participants did not consider these behaviours alone as actively dismissing requirements. However, when the missed targets or reports persisted over a period long enough to trigger harsher sanctions such as a financial penalty or loss of contract/agreement, interview participants then conceded that their organizations were actively dismissing accountability requirements. The form of defiance found in this study is most aligned with low-level resistance tactic which Oliver (1991) defines as “dismissal” in which organizations ignore the rules or values of external demands in instances where “internal objectives diverge or conflict…with institutional values or requirements” (p. 156). 7.2.3 Compliance and non-compliance behaviours of home and community care agencies: Research question 2 analysis summary This research found that organizations are likely to engage in both compliance and noncompliance behaviours towards LHIN MSAAs and CCAC contracts. Organizations engaged in more active forms of compliance than originally theorized in Oliver’s model. The internal modification response is characteristic of organizations with very little power to change external 190 demands to the point that they need to alter organizational structure and practice to meet the demand. Although Oliver suggests manipulation is a possible organizational response to external demands (see Chapter 2) this study uncovered no instances of manipulation as organizational responses to MSAAs or CCAC contracts. Rather, the responses aligned with previously theorized responses to accountability demands put forward by Frink and Klimoski (2004) who suggest that organizations may engage in conformity, negotiation, rejection and selective attention in response to accountability demands. Based on these findings, a modified model of Oliver’s responses to institutional pressures can be constructed to reflect HCC organizational responses to LHIN MSAAs and CCAC contracts. The following model includes whether the response is active or passive and the level of resistance with regard to non-compliance behaviours. The level of resistance associated with noncompliance responses is based on Oliver’s original theoretical model, as resistance was not explicitly gathered in this study. The model also includes the “external environment” that was found to influence the negotiation response. ! Low resistance Selfadvocate vs. Association advocacy High resistance ! Figure 7-1: Model of HCC organizational responses to LHIN MSAA and CCAC contracts. While this model focuses on home and community care agencies to specific accountability demands, this model could be applied to other organizations as well. By including active and passive forms of resistance and the organizational environment this model addresses the limitations of Oliver’s model identified in this study. 191 7.3 Organizational factors that affect responsiveness: Research question 3 analysis This section explores the factors that were found to affect responsiveness to MSAAs and CCAC contracts. To simplify analysis, the discussion is separated into the five factors identified in the theoretical model. 7.3.1 CAUSE As outlined in Chapter 2, cause refers to a set of expectations, rational, or intended objectives that underlie an environmental pressure on organizations. The cause concept suggests that an organization is more likely to comply with a demand that will improve its fitness to its environment. Larger organizations will tend to feel more pressure to comply as they are more visible (Proenca et al., 2000). The relationship between size and response leads to the following proposition: Proposition 1. Larger organizations will be more likely to comply with accountability requirements. This proposition was examined using both quantitative and qualitative data. For this study size was operationalized as total revenue (see Appendix 5-B). Logistic regression of survey data revealed that for every unit increase in size an organization is 2.346 times (95% CI 0.959, 5.734) more likely to comply with LHIN MSAAs (see Chapter 5). Interview data also suggested support for the proposition with regard to LHIN MSAAs (see Chapter 6). Findings from this study are consistent with other studies that have found that larger not-for-profit organizations (Calabrese, 2011), and private and public sector organizations (Goodstein, 1994) are more likely to comply with external demands as compared to smaller organizations. These findings are predictable in that we would expect larger organizations with better access to resources (Banaszak-Holl et al., 1996) to be more able to comply with external demands. Less predictable, however, is that organizational size was not found to affect compliance to CCAC contracts in either the quantitative or the qualitative analysis. As discussed in Chapter 1, the organizational “response” to CCAC contracts was more a reflection of the characteristics of organizations holding contracts since the moratorium on RFPs nearly 10 years ago. This may explain why organizational size was not a significant factor in organizations being awarded CCAC contracts. While this finding was not expected, a study in Australia also found that even 192 large, well-resourced organizations failed to adhere to even basic requirements of governmentimposed financial reporting standards in both the first and second year of implementation (Carlin & Finch, 2010).24 As well, Johnston and Warkentin (2008) discovered that organizational size did not affect healthcare organizations’ propensity to comply with the Health Insurance Portability and Accountability Act, 1996 in the United States. The findings in my study may also support the contention that larger organizations have greater access to resources as compared to smaller ones (Banaszak-Holl et al., 1996), which in turn will enhance their power (Bjoe & Whetten, 1981) to countervail external demands. For example, McKay (2001) found that organizations with greater power could engage in manipulation responses to the Ontario Environmental Bill of Rights more readily than low power organizations that were only able to comply. Small organizations with low power were less able to push back against external demands than their large, more powerful, counterparts, potentially requiring them to make significant organizational changes to meet demands (for example engaging in internal modification). In other words, size was an indication of power to resist external demands as opposed to the resource capacity to fulfill external demands; organizational power may be an important predictor of organizational responsiveness to external demands more so than simply size. For example, in this study one of the smallest organizations in the interview sample was able to engage in avoidance because it had access to a source of power in the form of other resources (like funders and volunteers). 7.3.2 CONSTITUENTS The “constituents” factor recognizes that organizations are likely to have multiple stakeholders who may impose varying, sometimes conflicting, demands on an organization that will affect how organizations respond to external demands. As found in Chapter 4, HCC agencies faced multiple accountability demands from provincial, federal and municipal governments, funders and donors, clients and their families, and their community. Chapter 2 had advanced three propositions in relation to the “constituents” factor. The first is related to resource dependence: 24 Organizations included in this study were a sample of 50 large Australian listed firms from a variety of sectors including: health and allied health, financial, food/beverage/retail, materials, media and commercial, and utilities/energy/construction. 193 Proposition 2a: Organizations are more likely to comply with accountability requirements from stakeholders upon whom they are highly dependent for funding. Findings from Chapter 5 demonstrated that financial dependence increased the likelihood of compliance to CCAC contracts by 1.036 times (95% CI 1.013, 1.059). Support for this proposition for CCAC contracts is not surprising, especially given that organizations that comply with CCAC contracts have been receiving funding under those contracts for over a decade. In Chapter 6, qualitative data also demonstrated that high dependence influences the propensity to comply with CCAC contracts. There are disparate findings between quantitative and qualitative findings with regard to the influence of dependence on organizational response to the MSAA. The quantitative data did not support the proposition while the qualitative data did. The survey found that 44% of organizations receiving 81-100% of their funding from LHINs demonstrated a noncompliance/avoidance response, specifically identifying that they would not apply for a LHIN MSAA in the future. One possible explanation is that the costs of compliance with accountability demands may outweigh the benefits of receiving funds from the LHIN. Accountability requirements from the LHIN can increase overhead costs (see discussion in Chapter 6), which can affect organizational funding from other sources particularly for not-for-profit organizations. Calabrese (2011) found that donors to not-for-profit organizations may reduce funding to these organizations if they appear to have excessive overhead. Not-for-profit organizations may opt to avoid the MSAA in order to reduce overhead costs associated with complying with the MSAA as a means to generate more support for donor sources which tend to carry fewer accountability costs (see Chapter 4 discussion on costs associated with exhortation tools such as those imposed by funders). The following two propositions related to the “constituents” factor highlight the influence of multiple competing demands from different stakeholders on organizational response: Proposition 2b. Organizations that have multiple dependencies on different stakeholders with differing accountability requirements are less likely to have the same response to all requirements. Proposition 2c. When differing accountability requirements from different stakeholders are not well aligned, organizations are less likely to have the same response to all requirements. 194 Survey findings demonstrated that an increased numbers of stakeholders did not affect the likelihood that an organization would comply or compromise with MSAAs. There may not be an impact because these different stakeholders do not place significant additional demands on an organization, or because the different demands are well aligned. As well organizations may see the LHIN as their most important stakeholder. Thus additional stakeholders would have little bearing on their compliance behaviour. Organizations with multiple stakeholders responded most positively to the stakeholder they perceived to be most important (Camara, M., Chamorro, E., & Moreno, A., 2009). In contrast, increased numbers of stakeholders, particularly accreditor stakeholders, did affect an organization’s likelihood to comply with CCAC contracts. The influence of accreditors on compliance is understandable given that many CCAC contracts require organizations under contract to be accredited (see Chapter 4), hence, the positive association found between accreditors and compliance with CCAC contracts. Interview data presented in Chapter 6 did not provide sufficient information about how organizations responded to other demands beyond the MSAAs and CCAC contracts. Qualitative findings however did shed light on whether perceived conflict and number of identified stakeholders affected responsiveness. Interview findings suggested that organizations that engaged in non-compliance behaviours to the MSAA also perceived conflict among stakeholder demands. Furthermore, organizations that engaged in non-compliance behaviours reported they required additional resources to meet multiple accountability demands. While this finding suggests some support for the propositions, a full exploration of these propositions would require future in-depth examination of different stakeholders holding an organization to account. 7.3.3 CONTENT Oliver’s theoretical framework suggests that goal alignment, pressure on autonomy and perceived inevitability are likely to influence organizational responsiveness. Qualitative data was used to explore four propositions in relation to the content factor. Goal alignment was not found to affect responsiveness leading to the rejection of the following propositions: Proposition 3a. Organizations are more likely to comply with accountability requirements if they align with their organizational goals. 195 Proposition 3b. Organizations will engage in compromising responses to accountability tools that are not aligned with organizational goals during the development and implementation stages of accountability requirements. Qualitative data supported propositions regarding autonomy and perceived inevitability: Proposition 3c. Organizations will be less likely to comply with accountability requirements that infringe on their autonomy. Proposition 3d. Organizations will be more likely to comply with accountability requirements that are perceived as inevitable, despite their impact on organizational autonomy. Qualitative data demonstrated that organizations that complied or internally modified with regard to LHIN MSAAs did not find that the MSAA diminished their organizational autonomy. However, the impact on autonomy was mitigated by financial dependence. Organizations that were highly financially dependent on CCACs engaged in internal modification despite reporting that the contract decreased organizational autonomy. The findings of this thesis suggest that there may be a need to reconsider how perceived inevitability is operationalized. Originally inflexibility was operationalized as an indicator of inevitability, because inflexibility was seen as a detriment to non-compliance behaviours like negotiation. However, participants reported that their organizations found it easier to comply with accountability requirements when the LHINs and/or CCACs are flexible with regard to meeting performance targets. Flexibility around accountability requirements can potentially improve organizational compliance by providing organizations with the time to make necessary changes to meet requirements. Strike (1998) argues that flexible accountability may be necessary to take into account the pluralistic nature of society. In discussing accountability in the education sector in the US, he argues for high level, broad accountability standards that address public interest but allow for local-contextual differences across jurisdictions. A similar argument could be made for the home and community care sector in which local contextual factors make compliance with accountability standards challenging, if at all possible (see indicators and unintended consequences findings in Chapter 6). 196 7.3.4 CONTROL The “control” factor focuses on the amount of control an external demand can exert over an organization. Propositions related to this factor were tested using only qualitative data. Proposition 4a. Organizations will be more likely to comply with accountability requirements that are perceived to carry strict penalties for noncompliance. Proposition 4b: Organizations will be more likely to comply with accountability requirements that have clearly defined roles and responsibilities for the accountee. Proposition 4c: Organizations will be more likely to acquiesce to external demands that rely on professional norms (i.e. regulations stipulated by a professional body). The influence of perceived strictness on responsiveness was mitigated by financial dependence. For example, CSA 1 perceived demands as strict but did not depend highly on the MSAA and was able to engage in avoidance behaviours. Additionally, organizations that engaged in defiance to CCAC contracts perceived demands as strict; however, they were not financially dependent on the CCAC contracts to survive. While the interview data speaks to the impact of perceived strictness, we can infer that the level of coerciveness of the external demand may also have affected organizational responsiveness. The MSAAs and CCAC contracts are examples of expenditure policy tools commonly considered to be only moderately coercive (Doern & Phidd, 1983). However, they may be perceived as more highly coercive in instances where organizations are dependent for funding. This perception is reflected in the findings as interview respondents tended to discuss the strictness of accountability demands in terms of the potential loss of funding (see Chapter 6). Role clarity was not found to affect responsiveness to the LHIN MSAA and CCAC contracts, thus proposition 4b is not supported, despite the contention by scholars that role clarity has been found to be an important factor in strong accountability relationships (Bergsteiner & Avery, 2009; Thomas, 1998). It is possible that the issue is not with role clarity but rather with the direction of the accountability relationship. While most respondents felt their roles were clear, not all respondents felt that the LHIN and CCAC roles were clear, suggesting that the LHIN MSAA and CCAC contracts primarily served as uni-directional rather than bi-directional accountability tools. In their discussion of citizen engagement, Abelson and Gauvin (2004) suggest that bi-directional accountability structures are important to relationship building, which 197 enhances accountability. The LHIN MSAA and CCAC contracts’ emphasis on one-way accountability could thus be undermining the accountability relationship, leading to noncompliance behaviours. Proposition 4c is not supported by the data (see Chapter 6). Pawlson and O’Kane (2002) argue that reliance on professionalism as an accountability tool is based on old views in which there is blind trust of health care professionals (in particular physicians). As the market accountability becomes increasingly dominant, Pawlson and O’Kane assert that professionalism will need to adapt to increasing demands for quality improvement and performance measurement for accountability. Regardless of the declining effectiveness of professionalism as an accountability tool (see Tuohy, 2003), it is possible that provider-level accountability does not affect organizational level accountability, explaining why proposition 4c is not supported in this study. 7.3.5 CONTEXT The “context” factor of the framework presented in Chapter 2 refers to the environmental context within which external pressures are exerted on target organizations. Key contextual factors expected to affect organizational responsiveness to accountability are an organization’s access to resources (financial and human) and an organization’s individualist or collectivist culture. Two propositions are put forward with regard to the context factor: Proposition 5a. Organizations with better access to resources will more likely comply with accountability requirements. Proposition 5b. Organizations will more likely comply with accountability requirements that aligned with their cultural context. These propositions are not supported by the survey and interview results presented in Chapters 5 and 6. With regard to proposition 5a, survey data revealed only weak support for the proposition with regard to organizational compliance to LHIN MSAAs and was not supported at all with regard to compliance to CCAC contracts. Qualitative data shed some light on these unexpected findings. Chapter 6 shows that the perception of the need for additional resources possibly mitigated the influence of access to resources. The qualitative data showed that, in relation to MSAAs, small organizations that engaged in compliance reported that little or no additional resources were needed to meet requirements. As was the case with the quantitative data, qualitative data did not support the proposition for CCAC contracts. 198 These findings suggest that instead of encouraging compliance, access to resources seems to discourage compliance to CCAC contracts. Organizations that were well-resourced and not fully dependent on CCACs to survive could afford to engage in defiance behaviours. They had sufficient capacity to withstand a few lost contracts. As previously stated, this finding suggests that the well-resourced organizations have greater power with which to countervail external demands (Bjoe & Whetten, 1981). Carlin and Finch (2010) also found that well-resourced organizations can avoid financial reporting requirements; non-compliance is more indicative of organizations’ unwillingness to meet demands rather than their inability to meet demands. Proposition 5b is not supported by the data, suggesting that cultural context is not an important factor in organizational responsiveness. It is possible that Gelfand et al.’s (2004) contention of the impact of individualism and collectivism, originally discussed at the intra-organizational level, does not translate to the inter-organizational level examined in this study. 7.3.6 Dependency and size, key factors in organizational responsiveness: Research question 3 analysis summary As theorized by Oliver (1991) and suggested by resource dependence theory, an organization’s dependence on funders is a strong determinant of organizational responsiveness. While autonomy, perceived strictness, size and access to resources have an impact on responsiveness, these factors are all mitigated by level of dependence. Organizations that are large and less financially dependent on the LHIN and CCAC are able to push back on accountability demands. The only organizations that are able to fully defy demands are the largest organizations that have multiple CCAC contracts. In these cases the financial penalty or loss of only one or two contracts would not have a significant effect on the broader organization. Organizations that were smaller, more poorly resourced, and highly dependent on LHINs or CCACs either complied or internally modified their organizations to meet requirements so that they could continue to receive funding. This strategy was more often used by organizations under MSAAs that tended to be smaller as compared to organizations under CCAC contracts. Organizations that are dependent on LHINs and CCACs and that required additional resources to meet accountability demands of the MSAAs and CCAC contracts had to modify their organizational structure or practices to meet demands. Interview participants tended to see some 199 internal organizational modifications as positive, they saw other modifications, in particular the shifting of staff time away from care and towards reporting, as detrimental to the quality of care. Study findings suggest that responsiveness is influenced primarily by the degree of organizational dependence and access to resources. Dependence and access to resources can be conceptualized as existing on a scale from low to high. From the quantitative and qualitative findings a model of responsiveness is constructed which assigns varying levels of dependence and access to resources to the five organizational responses to LHIN MSAAs and CCAC contracts found in this study. This model is illustrated in figure 7.2. +Low dependence High dependence Low dependence Compliance+ Low access to resources + Low dependence High access to resources High dependence Internal+modification+ Low access to resources + Low dependence High access to resources High dependence Compromise+ Low access to resources + Low dependence High access to resources High dependence Avoidance+ Low access to resources + Low dependence High access to resources High dependence Defiance+ Low access to resources High access to resources + Figure 7-2: Organizational characteristics associated with responses to LHIN MSAAs and CCAC contracts. 200 The model illustrates the level of dependency (the blue line) and access to resources (the red line) on organizational responsiveness ranging from low dependence and access to resources on the left to high dependence and access to resources on the right. The X denotes the level of dependence or access to resources associated with each organizational response. The affect of perceived strictness and autonomy are not depicted in this model as these factors are overshadowed by financial dependence. Access to resources represents organizational size in this model. It should also be noted that not all behaviours are associated with the response to LHIN MSAAs and CCAC contracts. No organizations were found to engage in avoidance to CCAC contracts and no organizations were found to be in defiance of LHIN MSAAs. A notable finding pertains to internal modification and avoidance responses. While qualitative data suggested that low dependence is associated with avoidance, the quantitative data found that some highly dependent organizations also engaged in avoidance behaviours. This finding is reflected in Figure 7-2 through the moving X denoting that varying levels of dependence may be associated with avoidance to LHIN MSAAs. This moving X is also intended to demonstrate that large, medium and small organizations all engaged in internal modification behaviours. 7.4 Unintended consequences and potential effects of accountability on home and community care service delivery: Research question 4 analysis In addition to examining organizational responsiveness to accountability demands, this study also examined how accountability potentially affects home and community care service delivery. Qualitative data sheds light on this issue by identifying negative and positive unintended consequences of accountability and performance measurement. This section explores the influence of expenditure-based accountability frameworks imposed through LHIN MSAA and CCAC contracts on the delivery of home and community care services. 7.4.1 Negative unintended consequences of accountability and performance measurement Accountability and performance measurement practices can lead to perverse outcomes and unintended consequences such as increased costs, biased reports, gaming and other strategic behaviours, veiled performance, and dis-incenting innovation and professionalism (Clark & 201 Swain, 2005; De Bruijn, 2007; De Vries, 2007; Townley, 2005). This study found that in order to meet accountability demands organizations often shifted frontline staff time away from client care and towards reporting. This diversion of resources represents an increase in time costs associated with meeting accountability requirements which is a negative effect of accountability (De Vries, 2007). Interview participants reported that frontline staff would sometimes use their own time to fulfill reporting requirements. As interview participants pointed out, such additional reporting requirements increase the workload for home and community care workers, particularly for PSWs, who are amongst the lowest paid within the health care sector, and further discourages labour retention in that sector (see Chapter 6, section 6.4). Additional reporting burden and time requirements may persuade staff to leave the home and community care sector for better hours and better pay in another health care sector, thereby exacerbating the existing human resource problem. Interview participants also reported that meeting accountability requirements reduces the incentive to engage in innovative practices. Some participants felt that their organizations could not take the “risk” associated with innovative practices which could potentially lead to missed performance targets and subsequent potential loss of funding. This finding supports Townley’s (2005) argument that performance measures can “constrain behaviour to the extent that new or innovative methods or practices are eschewed for fear that measures may not be reached” (p. 567), and Brandsen et al.’s (2000) critique of rigid accountability demands that discourage innovative practice. Nonetheless, some accountability requirements, such as the “back-office integration” requirement for some LHIN MSAAs, have been adopted and could be considered innovative. However, most interview participants did not consider this requirement as innovative, with some even considering it a hindrance to effective service delivery. In addition to the negative unintended consequences of accountability, there were also a number of issues with performance indicators. Participants reported that indicators do not adequately capture important aspects of service quality (such as health outcome measures), staff satisfaction, system performance (such as system cost savings associated with keeping people at home with community care supportive services), client quality of life, independence, autonomy, and health promotion activities. Focusing on some indicators to the detriment of others represents the problem of “tunnel vision” associated with performance measurement (Townley, 2005). Of particular concern to participants were instances in which organizations were accountable for 202 performance targets that they could not control. Shortt and Macdonald (2002) suggest that organizations can only be answerable when they have the necessary resources and power to meet their obligations. Participants also reported that indicators did not adequately take contextual factors (like geographic location and human resource availability) into consideration and often unfairly represented the care being delivered. Ignoring contextual factors in performance measures is similar to De Bruijn’s (2007) concept of veiled performance, in which measures do not adequately reflect causal connections between actions and performance at a micro level. Although De Bruijn sees veiled performance as the result of aggregating data at a macro level, this study reveals that this problem can also occur when contextual factors, which influence performance, are overlooked. 7.4.2 Positive unintended consequences: Supporting best-practices in home and community care As discussed in Chapter 2, supporting best practices in home and community care service delivery could be considered a positive unintended consequence of accountability. According to Health Canada, three factors support home and community care’s central goal of helping individual’s age-in-place (Health Canada, 2010): targeting appropriate care for older people at different level of care needs, providing case management to integrate care, and supporting caregivers. Neither the MSAA nor CCAC contracts include provisions regarding targeting at-risk seniors. It is possible that the LHINs and CCACs engage in targeting at a high-level in terms of the types of services that are contracted; however, data at that level is beyond the scope of this study. There are however, provisions in both the MSAA and CCAC contracts that can affect the integration of care and caregivers. Integrated care can be supported when strategies are put in place to address funding, administration, organization, service delivery and clinical practice (Kodner & Spreeuwenberg, 2002. See Box 2.1 in Chapter 2). CCAC contracts and LHIN MSAAs both have provisions that support only some domains associated with integrated care specifically around organizational and service delivery domains. CCAC contracts require organizations to develop and follow care plans and institute transition plans when clients change service packages, service deliverers, or are discharged from service. Care plans developed by service providers must also include 203 descriptions of how services will be integrated with other service providers where necessary (Services Schedules, Section 2.1.3(2)). The MSAA has minimal requirements with regard to case management; however, it has many provisions regarding supporting multidisciplinary/interdisciplinary teamwork. For instance, the MSAA asks service providers to engage with other providers in other sectors to increase partnership and support the overall LHIN goal of “an integrated health system that provides access to high quality health services” (CAPS Guidelines). Additionally, MSAA indicators include system perspective indicators that aim to support integration of services. However, there are currently no community support sector specific indicators around integrating services (see Appendix 4-B). While the MSAAs and CCAC contracts address some aspects of integrated care, they only address a few of the domains and related strategies associated with integrated care suggested by Kodner & Spreeuwenberg (see Chapter 2). The strong emphasis on case management under CCAC contracts is an important aspect of integrated care as it can potentially foster strong linkages to external support and community groups (Jones, 2007), and can help ensure there is seamless integration and navigation of services across care sectors (Hollander & Prince, 2002). However, case management alone does not cover all aspects of integrated care. The emphasis on integration at a more system/organizational level under the MSAA is encouraging, but it is not clear how organizations under the MSAA are held to account for the request for increased partnership and integration. Furthermore it is not clear how these strategies would overcome the many barriers to integration such as coordinating and working across different sectors and funding streams (Kodner & Spreeuwenberg, 2002; Williams et al., 2009a) and managing the differences in service approaches in different sectors (Kodner & Spreeuwenberg, 2002). Document analysis revealed that CCAC contracts include provisions that address caregivers. However, these provisions focus mainly on ensuring that organizations under contract see the caregiver as a potential proxy to the client in instances when consultation or feedback is required. While recognizing the role of caregivers is important, these provisions could potentially add to the burden on caregivers who may be expected to provide evaluation feedback on the home care worker or be the primary contact in a complaints process. 204 The LHIN MSAAs include caregiver experiences in their performance indicators (as part of the “person experience” performance dimension); however, as in the case of integration of services, there are currently no sector specific indicators that address caregiver needs under the MSAA (see Appendix 4-B). It is possible that organizations hold a LHIN MSAA for the delivery of respite services for caregivers, in which case the MSAA directly supports caregivers. While caregivers are acknowledged in both the CCAC contract and MSAA, there are no provisions that ensure organizations engage in supportive strategies for caregivers such as providing resources and education, or doing assessments (Riess-Sherwood et al., 2002). 7.4.3 Dis-incentive innovation and shifting care-time away from clients: Research question 4 analysis summary Accountability frameworks are found to dis-incent innovation and shift care-time away from clients due to high financial and time costs associated with meeting demands. Furthermore, performance indicators in MSAAs and CCAC contracts are not considered to be sufficient indicators of quality home and community care services. Organizations may be reporting on performance, but this is not necessarily leading to higher quality home and community care services. As discussed in Chapter 2, performance does not necessarily refer to quality; thus, including performance accountability as part of a framework will not guarantee quality service delivery. MSAAs and CCAC contracts do not pose a direct barrier to factors that support best-practices in home and community care service delivery, but they also do not directly support those factors. In the case of caregiver support, the MSAAs and CCAC contracts may represent an additional burden as caregivers may be expected to fill out forms and provide feedback. The MSAAs and CCAC contracts represent a lost opportunity to hold home care service and community care service agencies to account for supporting integrated care, supporting caregivers, and engaging in targeting strategies through CCAC contracts and MSAAs. 7.5 Discussion Existing accountability processes are highly political and value embedded. While it is politically advantageous to rely on expenditure policy instruments and performance management as a means to support accountability, these tools do not necessarily support more effective and 205 efficient service delivery as may be expected. Downloaded costs to the sector can reduce staff time with clients and potentially burnout frontline staff. Holding organizations to performance targets can discourage innovation. Importantly, performance measures themselves do not capture key aspects of quality in home and community care service delivery and fail to take contextual factors into consideration. Furthermore, these tools do not adequately support known bestpractices in home and community care service delivery such as providing older people care that is appropriate for their level of needs, integrated care delivery, and support for caregivers. Particularly noteworthy is the negative impact on small organizations that are highly dependent on LHIN and CCAC funding. Not only will these organizations have fewer resources to manage the downloaded costs of accountability (staff and technology) they are also less likely to have the power to push back on requirements. Standardized accountability tools like the MSAA and CCAC contracts are not responsive enough to contextual factors and allow large, well-resourced organizations to pick and choose which contracts to comply and not comply with; while small, resource-dependent organizations need to make internal changes to meet demands. While it is important to have strong accountability mechanisms in place to hold organizations to account for the public funding they receive, it is equally important to be aware of how these tools could be affecting an organization’s ability to deliver services to clients. The effect of accountability on small, poorly resourced organizations may be different in a rural versus an urban setting. While the study findings do not show differences in rural and urban organizational responsiveness to accountability demands, geographic location could affect market contestability, subsequently influencing organizational power. As discussed in Chapter 1, the home and community care sector is generally considered to be a highly contestable service in which organizations can easily move in and out of the market (Preker et al., 2000). Contestability may be reduced in geographic areas where few providers can be profitable due to small 25 population density. This is what Vining and Globerman (1999) term as “location specificity.” Instances of location specificity have been shown to reduce the strength of accountability sanctions (Van Slyke, 2006). Van Slyke (2006) found that public managers in rural settings could not terminate contracts in part because “there was not another in-county provider” (p.171). 25 The small population density reduces demand and keeps the market small so other organizations do not want to enter the market to compete. 206 In these instances contract and agreement based accountability tools are almost unenforceable affording even small organizations power to circumvent accountability demands. Our analysis suggests that existing standardized expenditure accountability tools are insufficient; but would other accountability tools be better suited to the home and community care sector? As discussed in Chapter 1, the home and community care sector is conducive to a government “buy” approach to service delivery (Preker et al., 2000). Instances of government “buy” options such as these required additional regulations in order to appropriately hold the entire sector to account (Preker et al., 2000). An argument may be made for governments to “make” these services to assure across the board accountability of the sector, as was done in Saskatchewan (Saskatchewan Ministry of Health, 2010). Although here too, accountability may be vulnerable to local and regional pressures that could undermine quality measures. An expansion of regulations that ask home and community care service agencies to be accountable for high quality services could help to address the accountability gaps identified by this research, while supporting the “steering” role the government has chosen. Nunes, Rego, and Brandão (2009) argue for an expansion of healthcare regulation as a means for public authorities to “supervise and control” behaviours and activities (p. 259). Nunes et al. (2009) “suggest that in publicly financed healthcare systems regulation can be regarded as sustained and focused control exercised by a public agency over health activities with the goal of balancing equity and efficiency, complying with specific quality standards” (p. 259). Regulation not only serves to enhance supervision of health systems, but also addresses market failures, such as service scarcity (Nunes et al., 2009), that could occur in the home and community care sector which could render expenditure-based accountability tools unenforceable. As previously stated, enhanced regulation will not necessarily cover all potential behaviours (Howlett & Ramesh, 1995) and can come up against strong opposition due to increasing costs, increasing bureaucratic burden, and impeding innovation among other criticisms (Walshe & Shortell, 2004). Another potential approach would be to expand professionalization of the sector to bring more frontline service delivery staff under a regulatory framework like that for nurses and other professional health care workers. Professionalization creates a form of self-regulation in instances where a professional body regulates its members or a form of regulation in instances of governmental regulated acts. Although reliance on professionalism did not affect organizational 207 level responsiveness in this study, increased professionalism could influence individual level accountability and ensure a high standard of work. Evetts (2006) suggests that professionalism is increasingly used as a discourse in order to encourage specific occupational changes. Evetts defines the professionalism discourse as “the ways in which occupational and professional workers themselves are accepting, incorporating and accommodating to the concepts of ‘profession’ and particularly ‘professionalism’ in their work” (p.523). Essentially, Evetts suggest that by providing individuals with the discourse of professionalism they would be more likely to act “professionally” in their day-to-day work. Professionalizing PSWs and other home and community care staff could thus facilitate desired behaviour at the frontline level. A shift towards professionalism may also address the low measurability and observability issues characteristic of street-level bureaucracies (Lipsky, 1980) like the home and community care sector since frontline staff will behave in a professional manner once they have internalized a professionalism discourse. Unfortunately professionalising PSWs is a challenging prospect. A set of competencies and standards would have to be identified and rolled out to colleges and universities that train personal support workers. Additionally there would need to be a body in place that would oversee these standards and ensure compliance by training centers and students. Not only is this prospect challenging and expensive it may be difficult to set standards for many of the services offered by personal support workers, in particular Instrumental Activities of Daily Living or (IADLs) such as meal prep and housekeeping. Some could further argue that professionalising PSWs may lead to displacing IADLs in favour of more traditional professional activities such as physiotherapy and occupational therapy; which would not support accountability for personal support work at all, but rather shift services away from IADLs which are important for supporting seniors in their homes. 7.6 Practical implications This study findings suggest that there are a series of trade-offs that need to be considered in choosing appropriate accountability policies. Current expenditure-based accountability policies allow for standardized accountability requirements, support a quality culture at the organizational level, and account for financial and some performance accountability. However, these tools do not account for differing organizational environments, do not adequately capture quality, and can 208 be unenforceable. What is required is a set of bottom-line criteria for home and community care service delivery. Home and community care agencies should be held to account for, at the very least, the delivery of quality services that meet the goals of those services. In the instance of senior care, this would be to support seniors as they age in their home or the community setting they choose. Contracts and agreements could potentially support the delivery of quality service delivery; however, work needs to be done on how performance is measured in order to better reflect quality. Currently, the CCAC level is moving forward on improving performance measures in the home and community care sector. The result of this work will hopefully include more outcome measures and measures that capture important contextual factors. The trade-off here is that not all agencies can be covered under a contract and agreement model, but at the very least this proposal will ensure that publicly funded services meet quality care standards and support best-practices. Accountability requirements also need to address contextual factors that can potentially render requirements unenforceable for some agencies and overly burdensome for others. This study found that small, highly dependent and poorly resourced organizations (in highly contestable markets) struggled to comply with accountability requirements; while large, well-resourced and less dependent organizations were able to circumvent accountability requirements. A case could be made for allowing for case-by-case modifications to accountability requirements based on the size and resource availability of home and community care agencies rather than relying on standardized requirements, allowing for requirements that do not disproportionately burden small organizations, while being ineffective at holding large organizations to account. Ensuring targets and reporting requirements are manageable with the funds and resources available to the organization may be a useful approach. Additionally, policy makers could consider including additional accountability measures for larger organizations, such as making organizational level performance information publicly available. Finally, attention should be paid to the possibility of professionalization for home and community care workers, in particular PSWs, while paying special attention to the possible challenges of doing so listed above. Expanding professionalization could address the accountability gaps for organizations not under government funding by ensuring individual level accountability of front-line staff. Professionalization would also be a politically attractive tool as 209 it downloads most accountability costs onto professional bodies and supports the NPM notion of private service delivery. Unfortunately this approach would not necessarily include the many volunteers that deliver home and community care services. Furthermore, this form of regulation “does not always achieve the goal of an effective supervision of professional practice” (Nunes et al., 2009, p.258). The potential for shifting PSW work towards professional services (discussed above) would also have to be addressed. Professionalization, however, be a good start towards enhanced accountability for the sector. 7.7 Limitations There are a few limitations of this study that need to be addressed. First, findings from this study are not necessarily generalizable outside Ontario as other jurisdictions may use different policy instruments to hold home and community care agencies to account. The inclusion of more rural and urban regions in Ontario as well as the inclusion of different types of home and community care organizations should improve generalizability across Ontario. Second, because there are fewer for-profit than not-for-profit agencies delivering home and community care services in Ontario (see Chapter 5) there were few for-profit providers included in the study. Additional representation from for-profits, particularly in the interviews, could have elicited additional information not collected here. Finally, the relatively low-survey response rate rendered some regressions impossible and could be concerning. However, low response rates are expected for organizational level surveys, and response rates for the survey exceeded minimal levels identified in the literature (see Chapter 5). 7.8 Strengths and contribution This study has several strengths. First, the use of mixed-methods allowed for a more in-depth exploration of research questions than a single method would have allowed. Quantitative findings pointed to some key trends, while qualitative findings were integral to help understand and explain the unexpected and surprising findings from the survey. Second, the study includes both accountor and accountee perspectives in the analysis, ensuring that that both perspectives of the accountability relationship are represented. Finally, by examining the intersection between accountability frameworks and organizational behaviour, this study offers a new perspective on accountability that has not previously been fully explored in the literature. 210 Findings from this study made important contributions to both accountability theory and organizational behaviour theory. This study discovered a previously unidentified organizational response to external demands, namely, the internal modification response that can be incorporated into future accountability studies. Furthermore, the study demonstrated the value of examining health care accountability at the organizational level by revealing important organizational factors that influence responses to accountability frameworks. 7.9 Future research Study findings suggest potential areas for further study. For example, future research around organizational responsiveness to accountability requirements could yield novel insights with a case study approach to allow for more in-depth analysis of several theories that could not be captured in this study. A case study approach would allow for a deeper analysis of how organizations respond to different accountability requirements from different stakeholders, and thereby shed additional light on how organizations manage multiple accountability requirements. This case study would involve an in-depth exploration of all stakeholder accountability requirements and relationships of a single organization. Such an approach would help elaborate on findings around the “constituents” organizational factor in relation to responsiveness to external demands. A case study approach could also elaborate on findings around the influence of informal norms on responsiveness. This study was unable to determine the affect of informal norms-based interactions between accountors and accountees on responsiveness as these types of interactions were, in themselves, forms of accountability. Given the potential influence of trust and relationships on accountability (see discussion in Chapter 2 on citizen engagement) informal interactions could potentially have a significant influence on responsiveness to accountability demands. It would also be beneficial to examine inter-organizational interaction as a means to enhance accountability down to the level of front line workers. Future research should also consider linking responsiveness to quality data. Although there are few outcome indicators at the organizational level for the home and community are sector, there are some tools in place, such as the interRAI home care assessment tool, which assess patient level outcome data (Morris, Fries, Bernabei, Steel, Ikegami, Carpenter, Gilgen, DuPasquier, Frijters, Henrard, Hirdes, Belleville-Taylor, Berg, Bjökgren, Gray, Hawes, Ljunggren, 211 Nonemaker, Phillips, & Zimmerman, 2009). Organizational responses to accountability could be linked to patient level outcome data to determine whether there are correlations between responses and outcomes, potentially allowing for an analysis of the links between responses and quality of care. 7.10 Conclusion Existing accountability frameworks in place for the home and community care sector do not cover all organizations that deliver these services, and expenditure-based tools that cover organizations delivering publicly funded services are overly burdensome for some organizations, insufficient for others, and do not adequately support quality care. Organizational level factors should be taken into consideration when constructing accountability frameworks as a means to elicit desirable responses and avoid unintended consequences. 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Retrieved from http://www.ryerson.ca/crncc/knowledge/related_reports/pdf/HMRU_caregiver_report_2010. pdf 227 Appendix 3-A: Documents and their sources Type of Document Laws Name Source Business Corporations Act (1990) http://www.elaws.gov.on.ca/html/statutes/english/elaws_statu tes_90b16_e.htm http://www.elaws.gov.on.ca/html/statutes/english/elaws_statu tes_90c38_e.htm http://www.elaws.gov.on.ca/html/statutes/english/elaws_statu tes_90a35_e.htm http://www.elaws.gov.on.ca/html/statutes/english/elaws_statu tes_90o01_e.htm http://www.elaws.gov.on.ca/html/source/regs/english/2011/el aws_src_regs_r11191_e.htm Corporations Act (1990) Auditor General Act (1990) Occupational Health and Safety Act (1990) Accessibility for Ontarians with Disabilities Act (2005) Home and Community Care Services Act, 1994 Community Care Access Corporations Act, 2001 Local health System Integration Act, 2006 Health Insurance Act, 1990 Commitment to the Future of Medicare Act, 2004 Personal Health Information Protection Act, 2004 Health Care Consent Act, 1996 Health Protection and Promotion Act, 1990 Substitute Decisions Act, 1992 Policies Ministry of Health and LongTerm Care Appeal and Review Boards Act, 1998 Assisted Living Services in Supportive Housing Policy (1994). Date Accessed 08-022012 08-022012 08-022012 08-022012 08-022012 http://www.elaws.gov.on.ca/html/statutes/english/elaws_statu tes_94l26_e.htm http://www.elaws.gov.on.ca/html/statutes/english/elaws_statu tes_01c33_e.htm http://www.elaws.gov.on.ca/html/statutes/english/elaws_statu tes_06l04_e.htm 09-012012 http://www.elaws.gov.on.ca/html/statutes/english/elaws_statu tes_90h06_e.htm http://www.elaws.gov.on.ca/html/statutes/english/elaws_statu tes_04c05_e.htm 09-012012 http://www.elaws.gov.on.ca/html/statutes/english/elaws_statu tes_04p03_e.htm http://www.elaws.gov.on.ca/html/statutes/english/elaws_statu tes_96h02_e.htm http://www.elaws.gov.on.ca/html/statutes/english/elaws_statu tes_90h07_e.htm http://www.elaws.gov.on.ca/html/statutes/english/elaws_statu tes_92s30_e.htm http://www.elaws.gov.on.ca/html/statutes/english/elaws_statu tes_98m18_e.htm http://www.southwestlhin.on.ca/uploadedFiles/P ublic_Community/Health_Service_Providers/Se rvice_Accountability_Agreements/Community/ 09-012012 09-012012 09-012012 09-012012 09-012012 09-012012 09-012012 09-012012 09-012012 228 Community Support Services Complaints Policy (2004) 3%20LTC%20Supportive%20Housing%20Impl ementation%20Guidelines%20Assisted%20Livi ng%20-%20Dec%201994.pdf http://www.torontocentrallhin.on.ca/Page.aspx?i d=5622 13-062011 Attendant Outreach Service Policy Guidelines and Operational Standards (1996) Policy and Guidelines for Screening of Community Personal Support Workers (2003) Community Financial Guidelines (2011) Supply Chain Guideline (2009) Government grants LHIN MSAA documents CAPS documents Policies and procedures applicable at places of work Ontario Trillium Foundation Grant Information OTF Reporting Forms for Multi-year Grants Reporting Forms for Capital Grants Report Forms for Single-year Grants Additional Capital one-year financial table Additional Capital one-year outcomes table New Horizons for Seniors Program (HRSDC) New Horizons docs: Capital assistance funding Community participation and leadership funding New Horizons Program – building capacity workshop (Ontario seniors’ secretariat) MSAA Template April 2011 CSS 2011-2014 Schedules Health System Indicator Initiative 2011-14 MSAA Indicators Final Approval of agency checklist 2011-14 CAPS Provincial Orientation Session (Jan 4 2011) List of All HSP providers in Ontario CAPS Guidelines 2011-14 Final CAPS Guidelines CAPS User Guide http://www.trilliumfoundation.org/en/ http://www.trilliumfoundation.org/cms/en/html/ grantees/granteesreporting_materials.aspx?menuid=35 10-012012 13-062011 http://www.hrsdc.gc.ca/eng/community_partner ships/seniors/index.shtml http://www.trilliumfoundation.org/cms/en/html/ grantees/granteesreporting_materials.aspx?menuid=35 10-012012 13-062011 NOTE: No longer available online http://www.torontocentrallhin.on.ca/Page.aspx?i d=3960&ekmensel=e2f22c9a_72_262_3960_1 LHIN Key Informant 12-062011 15-042011 LHIN Key Informant 15-042011 http://www.torontocentrallhin.on.ca/Page.aspx?i d=3960&ekmensel=e2f22c9a_72_262_3960_1 13-062011 229 CCAC contract documents CCAC contract prequalification documents CCAC RFP documents Health System Indicator Initiative LHIN Indicator Framework Background Guide MSAA Indicator Technical Specifications Contract Templates: Form of Agreement - Coding General Conditions - Coding Schedule 1 – Special Conditions - Coding Schedule 2 – Pricing and Compensation - Coding Schedule 3 – Dietetic Services Schedule 3 – Nursing Services Coding Schedule 3 – OT Services Schedule 3 – Personal Support and Homemaking Services Coding Schedule 3 – PT Services Coding Schedule 3 – Social Work Services Schedule 3 – SLP Services Schedule 4 – Performance Standards - Coding 2011 Revisions to 2007 contract templates (power point) Prequalification Documents: Instructions to Applicants Q&A Document Data Sheet Template – Equipment and Equipment Related Supplies Data Sheet Template – Infusion Data Sheet – Medical Supplies Data Sheet – Nursing Data Sheet – Personal Support Data Sheet- Therapy List of all Prequalified Service Providers, Feb 28 2011, public version RFP Templates: Generic FAQ Document RFP – Equipment and Supplies SE Template Review Schedule A – RFP Data Sheet Schedule B – Proposal Submission Form Schedule C – Equipment and Supplies Schedule E – Proposal Streaming Rules Schedule F – Site Visit http://www.ccacont.ca/Content.aspx?EnterpriseID=15&Languag eID=1&MenuID=1073 13-062011 http://www.ccacont.ca/Content.aspx?EnterpriseID=15&Languag eID=1&MenuID=1059 13-062011 http://www.ccacont.ca/Content.aspx?EnterpriseID=15&Languag eID=1&MenuID=105 13-062011 230 Accreditation Canada CARF Standards Council of Canada Information on accreditation program Information on accreditation program Information on accreditation program http://www.accreditation.ca/en/ http://www.carf.org/ http://www.scc.ca/en/programsservices/interested-in-accreditation-how-toapply 10-012012 10-012012 11-012012 231 Appendix 3-B: Survey version, pre-piloting Organizational characteristics/structure 1. What services does your organization deliver (check all that apply) In each case check all geographic locations/regions where these services are delivered Service Provided Nursing Personal care PT OT SLT Social Work Dietetic services Respite Homemaking Adult day programs Meals on Wheels Friendly visiting Security checks Transportation Local Across one CCAC/ LHIN region Across multiple CCAC/ LHIN region Across Ontario Across multiple provinces Across Canada Internationally Not provided 232 Home help Home Assisted Living/ Supportive housing Retirement living facility Other: (please list) 2. In 2009/2010 fiscal year how many total client hours of service did you provide (for all services)? a. What % of those client hours are for home care? (approximate is fine): b. What % of those client hours are for community care? (approximate is fine): 3. In the 2009/2010 fiscal year how many staff did you employ? **Please note, we recognize that staff may have different professional backgrounds then their current role at your organization. Please just list staff numbers in relation to their primary role/function at your organization not based on their education. Staff Nurses Physiotherapists Occupational therapists Speech-language pathologists Personal support workers Social workers Dietians Administrative staff No. Fulltime equivalent (FTEs) No. of Fulltime: No. with at least 30 guaranteed hours/week No. of Parttime: No. with 16-29 guaranteed hours /week No. of Parttime: No. with ≤ 15 guaranteed hours /week 233 Recreation Gerontologist Other (please specify) 4. In 2009/2010 fiscal year how many volunteers did you have working with your organization? a. How many have direct client contact? Funders and partners 5. What was your total revenue for the 2009/2010 fiscal year? a. Please list your 2009/2010 fiscal year revenue sources? (check all that apply) Y/N Funder Amount or proportion (approximate is fine) Fee-for-service (non-government funded, individual pay) Co-payments (subsidized by government funding) CCAC service contract LHIN service agreement (MSAA) LHIN one-time-funding Other one-time government grants (list all that apply) Ministry of Health and Long-Term care service agreement Other Ontario Ministry contract (please list all ministries) Donations Other (please specify) b. Approximately what percentage (proportion) of your revenues are related to home care service delivery (see Table 1 for services included in “home care”)? 234 c. Approximately what percentage (proportion) of your revenues are related to community service delivery (see Table 1 for services included in “community services”)? 6. Please check all networks and associations with whom you are a member: Check all that apply Ontario Home Care Association (OHCA) Ontario Community Service Association (OCSA) Community Navigation Access Program (CNAP) (TC LHIN) Doorways to Care (DWTC) (TC LHIN) SMILE support program (SE LHIN) Home at Last program (province wide) Community Care for Seniros (SE LHIN) The Prince Edward County Community Care for Seniors Association (SE LHIN) Other (please list all that apply) Service Contracts and Grant Funding 7. The following question has to do with whether your organization has ever applied for government service contracts or agreements to deliver home care services and/or community care services or government grants to support home care service delivery and programs and/or community care service delivery and programs run a. Has your organization applied for grants, agreements and/or contracts to deliver home care services and or community care services from (please check all applicable options for each contract and/or grant): Contracts/ Agreements/ grants Ontario Trillium Foundation Grant Yes, applied and currently hold Yes, applied previously and successful Yes, applied No, but never unsuccessful applied 235 New Horizons for Seniors Program Grant Ministry of Health and Longterm Care service agreement LHIN service agreement (MSAA) CCAC home care service contract Veterans Affairs service agreements First Nations service agreements Others: b. For cases where you have won contracts, agreements or grants indicate whether you partnered with anyone (check all that apply): Contracts/ Agreements/ grants Yes, partnered Ontario Trillium Foundation Grant New Horizons for Seniors Program Grant Ministry of Health and Long-term Care service agreement LHIN service agreement (MSAA) CCAC home care service contract Veterans Affairs service agreements First Nations service agreements Others: c. In 2009/2010 did you sub-contract any services delivered under grants, agreements, or contracts? If so, which services are sub-contracted? In 2009/2010 did you provided subcontracted services for another organization receiving grants, agreements or contracts? If so, which services were you sub-contracted to deliver? 236 Contracts/ Agreements/ grants Yes, subcontracted to other organization Service(s), subcontracted. List all that apply Yes, was subcontracted to deliver service(s) Service(s) delivered under sub-contract. List all that apply Ontario Trillium Foundation Grant New Horizons for Seniors Program Grant Ministry of Health and Long-term Care service agreement LHIN service agreement (MSAA) CCAC home care service contract Veterans Affairs service agreements First Nations service agreements Others: d. If the opportunity arose in the next year, would your organization plan to apply for any of the following service contracts, agreements or grants for home and community care service delivery Contracts/ Agreements/ grants Ontario Trillium Foundation Grant New Horizons for Seniors Program Grant Ministry of Health and Long-term Care service agreement LHIN service agreement (MSAA) Yes, plan to apply No, do not plan to apply Don’t know/ have not decided 237 CCAC home care service contract Veterans Affairs service agreements First Nations service agreements Others: Accountability 8. Do you produce an annual report? Y/N. a. If yes, is it publicly available? Y/N 9. Is your organization accredited with any of the following organizations? Accreditor Yes, No, but in currently the accredited accreditation process No, but plan on seeking accreditation in the next year No, do not plan on seeking accreditation Accreditation Canada (previously Canadian Council on Health Services Accreditation, CCHSA) CARF International – Aging Services/ CARFCCAC CARF Canada Standards Council of Canada (ISO) Other: Follow-Up Part of this study will be trying to understand nuances about approaches to accountability. Would you be willing to share your experiences with us? Y/N a. If yes, please provide an email address (or phone number) where you can be reached. Name: Contact Info: Tel: E-mail: 238 Appendix 3-C: Survey feedback forms for pilots Information and Introduction Consent forms for studies related to the CIHR funded “Approaches to Accountability” project. Project Lead: Dr. Raisa Deber Dept. Health Policy, Management and Evaluation University of Toronto Dear Sir or Madame: Accountability has multiple definitions. Most simply, it means having to be answerable to someone, for meeting defined objectives. Accountability is a key component of many current reform efforts, both in Canada, and internationally. It is becoming increasingly important to clarify both what is meant by the term, and which approaches to achieving it might work where. The Partnership for Health System Improvement (PHSI) on Approaches to Accountability features collaboration among an accomplished interdisciplinary team, working in partnership with senior policy makers across multiple health care sub-sectors, to clarify what is known about best practices to achieve accountability under various circumstances. We have assembled a research team, including Raisa Deber, Ross Baker, Jan Barnsley, Andrea Baumann, Whitney Berta, Adalsteinn Brown, Tony Culyer, Mark Dobrow, Brenda Gamble, Nancy Kraetschmer, Audrey Laporte, Louise Lemieux-Charles, Janet Lum, Heather Manson, Eric Nauenberg, Robert Schwartz, A. Paul Williams,and Walter Wodchis. Our Lead Decision Making Partner is the Ontario Ministry of Health and LongTerm Care. Other Decision Making Partners include: Canadian Healthcare Association, Canadian Homecare Association, Canadian Medical Association, Cancer Care Ontario, City of Toronto Division of Long Term Care Homes and Services, College of Family Physicians of Canada, College of Nurses of Ontario, Council of Academic Hospitals of Ontario, Dalla Lana School of Public Health, Ontario Ministry of Health Promotion, Ontario Association of Non-profit Homes and Services for Seniors, Ontario College of Family Physicians, Ontario Community Support Association, Ontario Long Term Care Association, at least two Local Health Integration Networks (Mississauga Halton, Toronto Central), Quality Management ProgramLaboratory Services (Ontario Medical Association), Toronto Central Community Care Access Centre, UOIT, and VON Canada. For further information, please contact our team: Carolyn Steele Gray ([email protected]) & Dr. Raisa Deber ([email protected]). We greatly appreciate your consideration to participate in this sub-study. Sincerely, Carolyn Steele Gray, MA, PhD candidate Dr. Raisa Deber, Professor Dept. Health Policy, Management and Evaluation University of Toronto 239 Pilot study – Participation Request “Approaches to Accountability” sub-study: Accountability in the Home and Community Care Sector Primary Investigator: Carolyn Steele Gray, MA., PhD candidate. Thesis Supervisor: Raisa Deber, PhD Committee Members: Whitney Berta, PhD; Janet Lum, PhD Department of Health Policy Management and Evaluation University of Toronto The purpose of this project is to explore organizational responses to accountability in the home and community care sector in Ontario. Specifically, we are interested in how community service agencies that deliver home and community care services have responded to contract-based accountability requirements imposed by Local Health Integration Networks and Community Care Access Centres. This sub-study is part of the larger “Approaches to Accountability” project outlined in the introductory letter attached. The sub-study is led by Carolyn Steele Gray, a doctoral student with the Department of Health Policy, Management and Evaluation; it will satisfy the dissertation research requirement for the doctoral program. We are seeking Community Support Service organizations that deliver care in the Toronto Central and/or South East LHIN regions to help us pilot a brief survey which will be used as part of the first phase of this research. This survey is intended to gather information for the first phase of this research and will help identify case study subjects, in this case community service organizations, which will be examined in the second phase of this research. Before sending out to all organizations we require feedback on the survey with regard to the following: 1. How long did the survey take to fill out (not including the time to respond to feedback form questions)? 2. Were questions worded in a way that was understandable? 3. Were questions easy to answer? 4. Did answering any of the questions make you feel uncomfortable? 5. Was the consent form understandable and acceptable? As a pilot participant you will be asked to fill out the online survey, including signing the consent form. You will also be asked to fill out the attached feedback while taking the survey. You may fill out the feedback form on your computer and return the form via email to Carolyn Steele Gray at [email protected] , or you may write your thoughts by hand and return it through the mail (a self-addressed stamped envelope with be provided). We anticipate the entire process of taking the survey and filling out the feedback form with take between 30 and 45 minutes. After returning your feedback forms we may ask you for a brief follow-up phone conversation to clarify your comments if needed; the follow-up phone call will take between 15 and 30 minutes. This research has received ethics approval through the University of Toronto Health Services Research Ethics Board. Please note your responses will not be included in the overall study – and will only be used for pilot purposes at this time. Your participation is integral to this research and would be greatly appreciated. If you have any questions or concerns, please don’t hesitate to contact Carolyn Steele Gray. Sincerely, Carolyn Steele Gray, MA, PhD candidate Dr. Raisa Deber, Professor & Dr. Whitney Berta, Professor Dept. Health Policy, Management and Evaluation, University of Toronto Dr. Janet Lum Ryerson University 240 On-line survey feedback form Please fill out the following form while you take the online survey. We ask that you type your answers and take as much room to answer each question as required. 1. Was the consent form understandable? Y/N a. If NO, why not? 2. Was the consent form acceptable? Y/N a. If NO, why not? 3. [For each question pilots were asked to answer three questions: 1. What!is!this!question!asking?!Was!it!clear?!(i.e.!was!the!meaning!of!this!question! immedicately!understandable!or!did!you!have!to!think!it!over!for!a!while)?! 2. Was this question easy to answer? (i.e. could you answer the question from memory, did it require that you look up information or do any calculations)! 3. Did this question make you feel uncomfortable? (i.e. do you have concerns about sharing this information about your organization)! ! These!questions!were!asked!in!a!table!format.]! 4. Approximately how long did the survey take you to fill out (excluding the time it took to fill out this feedback form)? 5. Do you have any additional comments or feedback about the survey that you would like to share? Thank you for taking the time to provide your feedback. 241 Appendix 3-D: Pilot feedback The following changes were made to the survey based on pilot feedback: 1. Remove question on client hours: There were too many challenges associated with answering this question accurately and it did not add much value because revenue can be used as an indicator of organizational size. This question was replaced with a question regarding how service units are counted (hours vs. visits). 2. Change question regarding volunteers: It was not clear what type of volunteers we were asking about so we asked respondents to separate service volunteers from fundraising volunteers. 3. Add definitions throughout survey: a. The definition of home and community care services provide at the beginning of the survey needed to be included on all pages of the survey to help improve clarity. b. The meaning of “partnerships, sub-contracting and mergers” was unclear. We added the following definitions to the survey based on pilot feedback: i. Collaboration: Agencies working together on a program but receive money separately. A non-legal partnership. ii. Partnerships: Providing services together and receiving funding together. A legal, contract-based, partnership. iii. Memberships: Having a membership in an association; may include paying membership fees or meeting specific criteria for membership in the association iv. Mergers: Two or more organizations combining to become one organization. v. Sub-contracting: Assigning some obligations of an existing contract to another party. Or being assigned some obligations of an existing contract from another party. 4. Managing multiple sources of information: Pilot respondents identified that, for some organizations, different people from one organization would be required to answer different parts of the survey. An overview letter was included to identify that the survey could be sent to multiple individuals who could answer different parts of the survey. The primary investigator would be responsible for aggregating the data. It was discussed whether a PDF survey would be more suitable; however, all respondents indicated that they preferred the online format. 242 Appendix 3-E: Introductory letter Introductory Email Good afternoon, We are asking for your help for a project which is exploring organizational responses to accountability in the home and community care sector in Ontario. Specifically, we are interested in how community service agencies that deliver home and community care services have responded to contract-based accountability requirements imposed by Local Health Integration Networks and Community Care Access Centres. The sub-study is led by Carolyn Steele Gray, a doctoral student with the Department of Health Policy, Management and Evaluation; it will satisfy the dissertation research requirement for the doctoral program. This sub-study is part of a larger Partnership for Health System Improvement (PHSI) on Approaches to Accountability which features collaboration among an accomplished interdisciplinary team, working in partnership with senior policy makers across multiple health care sub-sectors, to clarify what is known about best practices to achieve accountability under various circumstances. The project is funded by the Canadian Institutes for Health Research (CIHR) and matching contributions from some of our partners. The project includes lead decision making partners in the Ontario Ministry of Health and Long-Term Care as well as other decision making partners. For this sub-study these partners include: the Canadian Homecare Association, the Ontario Community Support Association, the Ontario Long Term Care Association, and at least two Local Health Integration Networks (Mississauga Halton and Toronto Central). For a full list of our partners and more information on the PHSI please contract Valerie Rackow at [email protected]. Today we are asking for your participation in an online survey which will take between 15 and 30 minutes. The survey is intended to gather information about community support service organizations who deliver home and community care services in Ontario. The survey will seek information regarding: services delivered and location(s) delivered; number of staff and volunteers employed; revenue and funders; memberships, partnerships and collaborations; and service contracts, service agreements and grant funding. The survey can either be filled out by one individual or multiple individuals in the organization who are likely to have the information required; please forward the survey to individuals whom you believe would be most able to answer questions. To ensure we understand the nuances of accountability relationships, we will also conduct several in-depth case studies. The survey accordingly includes one question asking whether your organization might be willing to participate. Regardless of your desire to participate in the case study portion, we hope you will click on the link below to access the survey: http://www.askitonline.com/survey/accountabilityhomeandcommunity/ Please submit surveys by August 1st 2011. If you have any questions or concerns please contact Carolyn Steele Gray at [email protected] 243 We greatly appreciate your help. Good policy requires understanding what is happening; ensuring that we reflect a broad set of organizations is critical. Carolyn Steele Gray, MA, PhD candidate Dr. Raisa Deber, Professor Dept. Health Policy, Management and Evaluation University of Toronto Committee Members: Dr. Janet Lum, Ryerson University & Dr. Whitney Berta, University of Toronto. Consent Form “Approaches to Accountability” sub-study: Accountability in the Home and Community Care Sector Primary Investigator: Carolyn Steele Gray, MA., PhD candidate. Thesis Supervisor: Raisa Deber, PhD Committee Members: Whitney Berta, PhD; Janet Lum, PhD Department of Health Policy Management and Evaluation University of Toronto Purpose of the Research: The purpose of this project is to explore organizational responses to accountability in the home and community care sector in Ontario. Specifically, we are interested in how community service agencies that deliver home and community care services have responded to contract-based accountability requirements imposed by Local Health Integration Networks and Community Care Access Centres. This sub-study is part of the larger “Approaches to Accountability” project outlined in the introductory letter attached. The sub-study is led by Carolyn Steele Gray, a doctoral student with the Department of Health Policy, Management and Evaluation; it will satisfy the dissertation research requirement for the doctoral program. What you will be asked to do in the research: You are being asked to fill out a brief survey as part of the first phase of this research. This survey is intended to gather information for the first phase of this research and will help identify case study subjects, in this case community service organizations, which will be examined in the second phase of this research. At the end of the survey you will also be asked whether you’d be willing to participate as a case study in the second phase of this research. This survey will take between 20-30 minutes to complete. Risks and Discomforts: We do not foresee any physical risks or discomforts arising from your participation in the research. There may be questions asked in the survey that you may find difficult to answer, or simply do not wish to answer. In that event you are free skip those questions in the survey. Potential benefits of the research and benefits to you: Potentially, this study has broad implications for the development and implementation of accountability tools in the home and community care sector. Identifying how organizations have responded to agreement and contract-based accountability tools and identifying what, if any, organizational factors play a role in those responses can be instructive to policy makers when modifying accountability requirements in an effort to elicit desirable organizational responses. Your survey responses will be a critical part of the analysis. 244 Voluntary participation: Your participation in the study is completely voluntary and you may choose to withdraw from the study at any time. Your decision not to participate, or to withdraw, will not affect your relationship with the researchers, the University of Toronto, or any other group associated with this project. Withdrawal from the study: You can withdraw from the study at any time, for any reason. If you wish to withdraw from the study, however, we ask that you inform the primary investigator, Carolyn Steele Grey, on or before April 30th 2012 before submission of her dissertation for review. Your decision to withdraw from the study will not affect your relationship with the researchers, the University of Toronto, or any other group associated with this project. Confidentiality: Your survey responses will be assigned an identifier and stripped of identifying information prior to analysis so that your confidentiality and anonymity can be protected to the fullest extent possible. Identifying information will be kept in a separate and secure file accessibly only to Carolyn Steele Gray. Your identity will not be associated in any way to the data transferred from your survey to the dataset analyzed for this study. Survey responses will be stored on a password protected and encrypted computer in a locked room for 7 years. You may authorise the use of your name and organization for inclusion in the study if you choose to waive your confidentiality. Questions about the research? If you have any questions about the research in general or about your role in the study, please feel free to contact the principal investigator Carolyn Steele Gray by email ([email protected]). This research has been approved by the University of Toronto, Office of Research Ethics, Research Ethics Board and by the Toronto Central Community Care Access Centre Research Advisory Committee. If you have any questions or concerns, please feel free to contact us, or Research Ethics Manager, Daniel Gyewu in the Office of Research Ethics at the University of Toronto ([email protected]). Legal Rights and Signatures: I _______________________________, consent to participate in the “Accountability in the Home and Community Care Sector” study conducted by Carolyn Steele Gray, a doctoral student with the Department of Health Policy, Management and Evaluation. I have understood the nature of this project and wish to participate. I am not waiving any of my legal rights by signing this form. My signature below indicates my consent _______________________________ ________________________________ Participant Date _______________________________ ________________________________ Investigator Date 245 Appendix 3-F: Interview guides with introductory letter and consent forms CCAC Information and Introduction Consent forms for studies related to the CIHR funded “Approaches to Accountability” project. Project Lead: Dr. Raisa Deber Dept. Health Policy, Management and Evaluation University of Toronto Dear Sir or Madame: Accountability has multiple definitions. Most simply, it means having to be answerable to someone, for meeting defined objectives. Accountability is a key component of many current reform efforts, both in Canada, and internationally. It is becoming increasingly important to clarify both what is meant by the term, and which approaches to achieving it might work where. The Partnership for Health System Improvement (PHSI) on Approaches to Accountability features collaboration among an accomplished interdisciplinary team, working in partnership with senior policy makers across multiple health care sub-sectors, to clarify what is known about best practices to achieve accountability under various circumstances. We have assembled a research team, including Raisa Deber, Ross Baker, Jan Barnsley, Andrea Baumann, Whitney Berta, Adalsteinn Brown, Tony Culyer, Mark Dobrow, Brenda Gamble, Nancy Kraetschmer, Audrey Laporte, Louise Lemieux-Charles, Janet Lum, Heather Manson, Eric Nauenberg, Robert Schwartz, A. Paul Williams,and Walter Wodchis. Our Lead Decision Making Partner is the Ontario Ministry of Health and Long-Term Care. Other Decision Making Partners include: Canadian Healthcare Association, Canadian Homecare Association, Canadian Medical Association, Cancer Care Ontario, City of Toronto Division of Long Term Care Homes and Services, College of Family Physicians of Canada, College of Nurses of Ontario, Council of Academic Hospitals of Ontario, Dalla Lana School of Public Health, Ontario Ministry of Health Promotion, Ontario Association of Non-profit Homes and Services for Seniors, Ontario College of Family Physicians, Ontario Community Support Association, Ontario Long Term Care Association, at least two Local Health Integration Networks (Mississauga Halton, Toronto Central), Quality Management Program-Laboratory Services (Ontario Medical Association), Toronto Central Community Care Access Centre, UOIT, and VON Canada. For further information, please contact our team: Carolyn Steele Gray ([email protected]) & Dr. Raisa Deber ([email protected]). We greatly appreciate your consideration to participate in this sub-study. Sincerely, Carolyn Steele Gray, MA, PhD candidate Dr. Raisa Deber, Professor Dept. Health Policy, Management and Evaluation. University of Toronto 246 Informed Consent for Organizations & Key Informants - CCACs “Approaches to Accountability” sub-study: Accountability in the Home and Community Care Sector Primary investigator: Carolyn Steele Gray, MA., PhD candidate Thesis Supervisor: Raisa Deber, PhD Committee Members: Whitney Berta, PhD; Janet Lum, PhD Department of Health Policy Management and Evaluation. University of Toronto Purpose of the Research: The purpose of this project is to explore organizational responses to accountability in the home and community care sector in Ontario. Specifically, we are interested in how community service agencies that deliver home and community care services have responded to contract-based accountability requirements imposed by Local Health Integration Networks and Community Care Access Centres. This study is part of the larger “Approaches to Accountability” project outlined in the introductory letter attached. This study is being completed to satisfy the thesis component of Carolyn Steele Gray’s doctoral degree in Health Policy in the Department of Health Policy Management and Evaluation in the University of Toronto. What you will be asked to do in the research: You are being asked to help provide information as part of the case study methodology used for the second phase of this research. This may include: a) document analysis: the provision of relevant documents pertaining to your activities with an emphasis on Community Care Access Centre contracts, accreditation, and/or performance indicators. No individual client or individual staff information will be gathered as part of this study; b) key informant interviews: You will also be asked a series of questions that pertain to CCAC services delivery contracts. You will be sent interview questions before the interview. Although additional follow-up questions may be asked for clarification. Interviews will take between 30 and 60 minutes, depending on how much information is available in documents provided. Every effort will be made to gather information from documents in order to reduce the time required for the interview. Confidentiality: Your answers will be tape recorded to facilitate transcription, but your identity will not be attached to your responses. All transcripts will use only the identification number assigned to you, the identifying information will be stored separately. Recordings and transcriptions will be stored on a password protected and encrypted computer in a locked room for 7 years. Any additional documents you provide that are not publicly available and/or are sensitive in nature will also be stored electronically in a password protected and encrypted computer, or in hard copy in a locked cabinet. Documents will also be stored in a locked room for 7 years. Should you agree to allow us to use quotations in the analysis, we will first send you a transcript of what quotes we plan to use for your approval. You will have the option of a) whether we can use the quotes and/or b) whether we can identify you organization. Risks and Discomforts: We do not foresee any physical risks or discomforts from your participation in the research. There may be questions asked that you may find difficult to answer or simply do not wish to answer. In that event you are free to refuse to answer any question. Potential benefits of the research and benefits to you: This study has potentially broad implications for the development and implementation of accountability tools in the home and 247 community care sector. Identifying how organizations have responded to contract-based accountability tools and identifying what, if any, organizational factors play a role in those responses can help policy makers modify contracts in order to elicit desirable organizational responses. Your thoughts and concerns around accountability in the home and community care sector will be a critical part of the analysis. Voluntary participation: Your participation in the study is completely voluntary and you may choose to stop participating at any time. Your decision not to volunteer will not affect your relationship with the researchers, the University of Toronto, or any other group associated with this project. Withdrawal from the study: You can stop participating in the study at any time, for any reason, if you so decide. If you decide to be removed from the study, however, you must inform the investigator on or before April 30th 2012 before submission of the thesis for review. Your decision to stop participating, or to refuse to answer particular questions, will not affect your relationship with the researchers, the University of Toronto, or any other group associated with this project. Questions about the research? If you have any questions about the research in general or about your role in the study, please feel free to contact the principal investigator Carolyn Steele Gray by email ([email protected]). This research has been approved by the University of Toronto, Office of Research Ethics, Research Ethics Board and by the Toronto Central Community Care Access Centre Research Advisory Committee. If you have any questions or concerns, please feel free to contact us, or Research Ethics Manager, Daniel Gyewu in the Office of Research Ethics at the University of Toronto ([email protected]). Legal Rights and Signatures: I _______________________________, consent to participant in the “Accountability in the Home and Community Care Sector” study conducted by Carolyn Steele Gray. I have understood the nature of this project and wish to participate. I am not waiving any of my legal rights by signing this form. My signature below indicates my consent _______________________________ ________________________________ Participant Date _______________________________ ________________________________ Investigator Date 248 CCAC Interview Guide ** Prior to interview an email will be sent to the interviewee with a list of the questions s/he will be asked. I. Opening: “Thank you for agreeing to meet with me today.” “Is it okay for me to tape this interview?” CONFIDENTIALITY: - Your participation in this interview is completely voluntary and you may choose to stop it at any time. Your name or any identifying information will not appear in any report or publication of this research unless you give consent or it is otherwise publicly available. Your interview transcripts and recording will be safely stored on a password protected computer and only research staff will have access to this information. Confidentiality will be provided to the fullest extent possible by law “I would be happy to send you a transcript of the interview, for you to correct or amend as needed.” “All questions today will be with regard to CCAC contracts held with Community Service Agencies (CSAs) delivering home care services.” “Remember, there are no right answers to any of these questions, I just want to talk with you and learn from your experience.” Introductory Questions: LHIN 1. Just to start us off, what is your role at the CCAC? II. Regarding the MSAAs: LHIN 2. How are you involved with CCAC contracts? LHIN 3. How are CSA’s held to account for services under contracts? LHIN 4. Do organizations require additional resources to meet requirements? 249 a. If so, do you provide these resources or do organizations need to access them on their own? Measurability LHIN 5. In your opinion, do performance indicators in the contract capture the important aspects of home care services delivered by CSA’s under CCAC contracts? Please elaborate. LHIN 6. What activities do you think are important to be measured but are not currently being measured? a. Why are these activities not being measured? Observability LHIN 7. How often are the frontline staff of CSA’s directly supervised by CCAC staff? a. Would this be desirable? Complexity/Embeddedness: LHIN 8. Do organizations rely on any external health care sectors or professionals in order to meet contract requirements? If so in what way? Organizational factors LHIN 9. Are CCAC contracts flexible? If so, in what ways? LHIN 10. Do you feel that CSA and CCAC responsibilities are clearly stated in CCAC contracts? LHIN 11. How often does the CCAC interact with CSA’s who hold CCAC contracts? a. What is the primary purpose of these interactions? Impacts of accountability frameworks LHIN 12. In your opinion, do you think CCAC contracts have resulted in any unintended consequences (i.e. organizational changes, staff behaviours, etc…). Please elaborate. Organizational responses LHIN 13. Do you feel like organizations meet all accountability requirements stipulated in the contract? If not, in what ways to they not meet requirements? LHIN 14. a. b. c. Are contracts negotiated? If so in what ways? How is consensus reached? Do you feel this process leads to a better/worse agreement? LHIN 15. Do you feel sanctions for non-compliance with CCAC contracts are strict? 250 LHIN 16. Generally, how do you feel CSA organizations have responded to CCAC contracts? (i.e. do they find them reasonable? Have some organizations avoided contracts? Has there been more partnering between organizations to meet CCAC requirements?) Identifying case studies LHIN 17. As part of this interview we are hoping to identify CSA organizations of interest. Thinking to some of the responses from the previous question can you identify four or five organizations who have exhibited one of the following responses to CCAC contracts: a. Full compliance with agreements over sustained period of time b. Bargaining or negotiating terms of the agreement either prior to entering the agreement c. Changing types of services delivered and/or populations served d. Merging with other organizations or partnering to deliver agreements e. Avoiding MSAAs, possibly after having already had previous agreements with the LHIN. Information and Introduction Consent forms for studies related to the CIHR funded “Approaches to Accountability” project. Project Lead: Dr. Raisa Deber Dept. Health Policy, Management and Evaluation University of Toronto Dear Sir or Madame: Accountability has multiple definitions. Most simply, it means having to be answerable to someone, for meeting defined objectives. Accountability is a key component of many current reform efforts, both in Canada, and internationally. It is becoming increasingly important to clarify both what is meant by the term, and which approaches to achieving it might work where. The Partnership for Health System Improvement (PHSI) on Approaches to Accountability features collaboration among an accomplished interdisciplinary team, working in partnership with senior policy makers across multiple health care sub-sectors, to clarify what is known about best practices to achieve accountability under various circumstances. We have assembled a research team, including Raisa Deber, Ross Baker, Jan Barnsley, Andrea Baumann, Whitney Berta, Adalsteinn Brown, Tony Culyer, Mark Dobrow, Brenda Gamble, Nancy Kraetschmer, Audrey Laporte, Louise Lemieux-Charles, Janet Lum, Heather Manson, Eric Nauenberg, Robert Schwartz, A. Paul Williams,and Walter Wodchis. Our Lead Decision Making Partner is the Ontario Ministry of Health and Long-Term Care. Other Decision Making Partners include: Canadian Healthcare Association, Canadian Homecare Association, Canadian Medical Association, Cancer Care Ontario, City of Toronto Division of Long Term Care Homes and Services, College of Family Physicians of Canada, 251 College of Nurses of Ontario, Council of Academic Hospitals of Ontario, Dalla Lana School of Public Health, Ontario Ministry of Health Promotion, Ontario Association of Non-profit Homes and Services for Seniors, Ontario College of Family Physicians, Ontario Community Support Association, Ontario Long Term Care Association, at least two Local Health Integration Networks (Mississauga Halton, Toronto Central), Quality Management Program-Laboratory Services (Ontario Medical Association), Toronto Central Community Care Access Centre, UOIT, and VON Canada. For further information, please contact our team: Carolyn Steele Gray ([email protected]) & Dr. Raisa Deber ([email protected]). We greatly appreciate your consideration to participate in this sub-study. Sincerely, Carolyn Steele Gray, MA, PhD candidate Dr. Raisa Deber, Professor Dept. Health Policy, Management and Evaluation University of Toronto LHIN Informed Consent for Organizations & Key Informants – LHINs “Approaches to Accountability” sub-study: Accountability in the Home and Community Care Sector Primary investigator: Carolyn Steele Gray, MA., PhD candidate Thesis Supervisor: Raisa Deber, PhD Committee Members: Whitney Berta, PhD; Janet Lum, PhD Department of Health Policy Management and Evaluation. University of Toronto Purpose of the Research: The purpose of this project is to explore organizational responses to accountability in the home and community care sector in Ontario. Specifically, we are interested in how community service agencies that deliver home and community care services have responded to contract-based accountability requirements imposed by Local Health Integration Networks and Community Care Access Centres. This study is part of the larger “Approaches to Accountability” project outlined in the introductory letter attached. This study is being completed to satisfy the thesis component of Carolyn Steele Gray’s doctoral degree in Health Policy in the Department of Health Policy Management and Evaluation in the University of Toronto. What you will be asked to do in the research: You are being asked to help provide information as part of the case study methodology used for the second phase of this research. This may include: a) document analysis: the provision of relevant documents pertaining to your activities with an emphasis on Local Health Integration Network community care agreements, accreditation, and/or performance indicators. No individual client or individual staff information will be gathered as part of this study; b) key informant interviews: You will also be asked a series of questions that pertain to LHIN community care service agreements (Multi-Service 252 Accountability Agreements, MSAAs). You will be sent interview questions before the interview. Although additional follow-up questions may be asked for clarification. Interviews will take between 30 and 60 minutes, depending on how much information is available in documents provided. Every effort will be made to gather information from documents in order to reduce the time required for the interview. Confidentiality: Your answers will be tape recorded to facilitate transcription, but your identity will not be attached to your responses. All transcripts will use only the identification number assigned to you, the identifying information will be stored separately. Recordings and transcriptions will be stored on a password protected and encrypted computer in a locked room for 7 years. Any additional documents you provide that are not publicly available and/or are sensitive in nature will also be stored electronically in a password protected and encrypted computer, or in hard copy in a locked cabinet. Documents will also be stored in a locked room for 7 years. Should you agree to allow us to use quotations in the analysis, we will first send you a transcript of what quotes we plan to use for your approval. You will have the option of a) whether we can use the quotes and/or b) whether we can identify you organization. Risks and Discomforts: We do not foresee any physical risks or discomforts from your participation in the research. There may be questions asked that you may find difficult to answer or simply do not wish to answer. In that event you are free to refuse to answer any question. Potential benefits of the research and benefits to you: This study has potentially broad implications for the development and implementation of accountability tools in the home and community care sector. Identifying how organizations have responded to contract-based accountability tools and identifying what, if any, organizational factors play a role in those responses can help policy makers modify contracts in order to elicit desirable organizational responses. Your thoughts and concerns around accountability in the home and community care sector will be a critical part of the analysis. Voluntary participation: Your participation in the study is completely voluntary and you may choose to stop participating at any time. Your decision not to volunteer will not affect your relationship with the researchers, the University of Toronto, or any other group associated with this project. Withdrawal from the study: You can stop participating in the study at any time, for any reason, if you so decide. If you decide to be removed from the study, however, you must inform the investigator on or before April 30th 2012 before submission of the thesis for review. Your decision to stop participating, or to refuse to answer particular questions, will not affect your relationship with the researchers, the University of Toronto, or any other group associated with this project. Questions about the research? If you have any questions about the research in general or about your role in the study, please feel free to contact the principal investigator Carolyn Steele Gray by email ([email protected]). This research has been approved by the University of Toronto, Office of Research Ethics, Research Ethics Board and by the Toronto Central Community Care Access Centre Research Advisory Committee. If you have any questions or concerns, please feel free to contact us, or Research Ethics Manager, Daniel Gyewu in the Office of Research Ethics at the University of Toronto ([email protected]). 253 Legal Rights and Signatures: I _______________________________, consent to participant in the “Accountability in the Home and Community Care Sector” study conducted by Carolyn Steele Gray. I have understood the nature of this project and wish to participate. I am not waiving any of my legal rights by signing this form. My signature below indicates my consent _______________________________ ________________________________ Participant Date _______________________________ ________________________________ Investigator Date LHIN Interview Guide ** Prior to interview an email will be sent to the interviewee with a list of the questions s/he will be asked. I. Opening: “Thank you for agreeing to meet with me today.” “Is it okay for me to tape this interview?” CONFIDENTIALITY: - Your participation in this interview is completely voluntary and you may choose to stop it at any time. Your name or any identifying information will not appear in any report or publication of this research unless you give consent or it is otherwise publicly available. Your interview transcripts and recording will be safely stored on a password protected computer and only research staff will have access to this information. Confidentiality will be provided to the fullest extent possible by law “I would be happy to send you a transcript of the interview, for you to correct or amend as needed.” 254 “All questions today will be with regard to LHIN Multi-Service Accountability agreements held with Community Service agencies delivering community care services.” “Remember, there are no right answers to any of these questions, I just want to talk with you and learn from your experience.” Introductory Questions: LHIN 1. Just to start us off, what is your role at the LHIN? II. Regarding the MSAAs: LHIN 2. How are you involved with MSAA agreements? LHIN 3. How are CSA’s held to account for services under the agreement? LHIN 4. Do organizations require additional resources to meet requirements? a. If so, do you provide these resources or do organizations need to access them on their own? Measurability LHIN 5. In your opinion, do performance indicators in the agreement capture the important aspects of community services delivered by CSA’s under LHIN agreements? Please elaborate. LHIN 6. What activities do you think are important to be measured but are not currently being measured? a. Why are these activities not being measured? Observability LHIN 7. How often are the frontline staff of CSA’s directly supervised by LHIN staff? a. Would this be desirable? Complexity/Embeddedness: LHIN 8. Do organizations rely on any external health care sectors or professionals in order to meet service agreement requirements? If so in what way? Organizational factors LHIN 9. Are MSAA’s flexible? If so, in what ways? LHIN 10. Do you feel that CSA and LHIN responsibilities are clearly stated in MSAA agreements? LHIN 11. How often does the LHIN interact with CSA’s who hold MSAA’s? a. What is the primary purpose of these interactions? Impacts of accountability frameworks 255 LHIN 12. In your opinion, do you think LHIN agreements have resulted in any unintended consequences (i.e. organizational changes, staff behaviours, etc…). Please elaborate. Organizational responses LHIN 13. Do you feel like organizations meet all accountability requirements stipulated in the agreement? If not, in what ways to they not meet requirements? LHIN 14. a. b. c. Are agreements negotiated? If so in what ways? How is consensus reached? Do you feel this process leads to a better/worse agreement? LHIN 15. Do you feel sanctions for non-compliance with the MSAA are strict? LHIN 16. Generally, how do you feel CSA organizations have responded to the MSAAs? (i.e. do they find them reasonable? Have some organizations avoided MSAAs? Has there been more partnering between organizations to meet MSAA requirements?) Identifying case studies LHIN 17. As part of this interview we are hoping to identify CSA organizations of interest. Thinking to some of the responses from the previous question can you identify four or five organizations who have exhibited one of the following responses to MSAA agreements: a. Full compliance with agreements over sustained period of time b. Bargaining or negotiating terms of the agreement either prior to entering the agreement c. Changing types of services delivered and/or populations served d. Merging with other organizations or partnering to deliver agreements e. Avoiding MSAAs, possibly after having already had previous agreements with the LHIN. HOME AND COMMUNITY CARE ORGANIZATIONS Information and Introduction Consent forms for studies related to the CIHR funded “Approaches to Accountability” project. Project Lead: Dr. Raisa Deber Dept. Health Policy, Management and Evaluation University of Toronto Dear Sir or Madame: Accountability has multiple definitions. Most simply, it means having to be answerable to someone, for meeting defined objectives. Accountability is a key component of many current reform efforts, both in Canada, and internationally. It is becoming increasingly important to clarify both what is meant by the term, and which approaches to achieving it might work where. The Partnership for Health System Improvement (PHSI) on Approaches to Accountability features collaboration among an accomplished interdisciplinary team, working in partnership 256 with senior policy makers across multiple health care sub-sectors, to clarify what is known about best practices to achieve accountability under various circumstances. We have assembled a research team, including Raisa Deber, Ross Baker, Jan Barnsley, Andrea Baumann, Whitney Berta, Adalsteinn Brown, Tony Culyer, Mark Dobrow, Brenda Gamble, Nancy Kraetschmer, Audrey Laporte, Louise Lemieux-Charles, Janet Lum, Heather Manson, Eric Nauenberg, Robert Schwartz, A. Paul Williams,and Walter Wodchis. Our Lead Decision Making Partner is the Ontario Ministry of Health and Long-Term Care. Other Decision Making Partners include: Canadian Healthcare Association, Canadian Homecare Association, Canadian Medical Association, Cancer Care Ontario, City of Toronto Division of Long Term Care Homes and Services, College of Family Physicians of Canada, College of Nurses of Ontario, Council of Academic Hospitals of Ontario, Dalla Lana School of Public Health, Ontario Ministry of Health Promotion, Ontario Association of Non-profit Homes and Services for Seniors, Ontario College of Family Physicians, Ontario Community Support Association, Ontario Long Term Care Association, at least two Local Health Integration Networks (Mississauga Halton, Toronto Central), Quality Management Program-Laboratory Services (Ontario Medical Association), Toronto Central Community Care Access Centre, UOIT, and VON Canada. For further information, please contact our team: Carolyn Steele Gray ([email protected]) & Dr. Raisa Deber ([email protected]). We greatly appreciate your consideration to participate in this sub-study. Sincerely, Carolyn Steele Gray, MA, PhD candidate Dr. Raisa Deber, Professor Dept. Health Policy, Management and Evaluation University of Toronto Informed Consent for Organizations & Key Informants - Community service agencies “Approaches to Accountability” sub-study: Accountability in the Home and Community Care Sector Primary investigator: Carolyn Steele Gray, MA., PhD candidate Thesis Supervisor: Raisa Deber, PhD Committee Members: Whitney Berta, PhD; Janet Lum, PhD Department of Health Policy Management and Evaluation. University of Toronto Purpose of the Research: The purpose of this project is to explore organizational responses to accountability in the home and community care sector in Ontario. Specifically, we are interested in how community service agencies that deliver home and community care services have responded to contract-based accountability requirements imposed by Local Health Integration Networks and Community Care Access Centres. This study is part of the larger “Approaches to Accountability” project outlined in the introductory letter attached. This study is being 257 completed to satisfy the thesis component of Carolyn Steele Gray’s doctoral degree in Health Policy in the Department of Health Policy Management and Evaluation in the University of Toronto. What you will be asked to do in the research: You are being asked to participate in a key informant interview used for the second phase of this research. You will be asked a series of questions that pertain to your organization, services delivered, stakeholder relationships, budgets and funding and about your local CCAC service delivery contracts and Local Health Integration service agreement. Even if you have never held a CCAC contract of LHIN service agreement your participation would still be desired. You will be sent interview questions before the interview, although additional follow-up questions may be asked for clarification. Interviews will take between 45 and 60 minutes. Every effort will be made to gather information from publicly available documents in order to reduce the time required for the interview. Confidentiality: Your answers will be tape recorded to facilitate transcription, but your identity will not be attached to your responses. All transcripts will use only the identification number assigned to you, the identifying information will be stored separately. Recordings and transcriptions will be stored on a password protected and encrypted computer in a locked room for 7 years. Any additional documents you provide that are not publicly available and/or are sensitive in nature will also be stored electronically in a password protected and encrypted computer, or in hard copy in a locked cabinet. Documents will also be stored in a locked room for 7 years. Should you agree to allow us to use quotations in the analysis, we will first send you a transcript of what quotes we plan to use for your approval. You will have the option of a) whether we can use the quotes and/or b) whether we can identify you organization. Risks and Discomforts: We do not foresee any physical risks or discomforts from your participation in the research. There may be questions asked that you may find difficult to answer or simply do not wish to answer. In that event you are free to refuse to answer any question. Potential benefits of the research and benefits to you: This study has potentially broad implications for the development and implementation of accountability tools in the home and community care sector. Identifying how organizations have responded to contract-based accountability tools and identifying what, if any, organizational factors play a role in those responses can help policy makers modify contracts in order to elicit desirable organizational responses. Your thoughts and concerns around accountability in the home and community care sector will be a critical part of the analysis. Voluntary participation: Your participation in the study is completely voluntary and you may choose to stop participating at any time. Your decision not to volunteer will not affect your relationship with the researchers, the University of Toronto, or any other group associated with this project. Withdrawal from the study: You can stop participating in the study at any time, for any reason, if you so decide. If you decide to be removed from the study, however, you must inform the investigator on or before April 30th 2012 before submission of the thesis for review. Your decision to stop participating, or to refuse to answer particular questions, will not affect your relationship with the researchers, the University of Toronto, or any other group associated with this project. 258 Questions about the research? If you have any questions about the research in general or about your role in the study, please feel free to contact the principal investigator Carolyn Steele Gray by email ([email protected]). This research has been approved by the University of Toronto, Office of Research Ethics, Research Ethics Board and by the Toronto Central Community Care Access Centre Research Advisory Committee. If you have any questions or concerns, please feel free to contact us, or the Research Ethics Manager, Daniel Gyewu in the Office of Research Ethics at the University of Toronto ([email protected]). Legal Rights and Signatures: I _______________________________, consent to participant in the “Accountability in the Home and Community Care Sector” study conducted by Carolyn Steele Gray. I have understood the nature of this project and wish to participate. I am not waiving any of my legal rights by signing this form. My signature below indicates my consent _______________________________ ________________________________ Participant Date _______________________________ ________________________________ Investigator Date Interview Guide – Community Service Agency ** Prior to interview an email will be sent to the interviewee with a list of the questions s/he will be asked. I. Opening: “Thank you for agreeing to meet with me today.” “Is it okay for me to tape this interview?” CONFIDENTIALITY: - Your participation in this interview is completely voluntary and you may choose to stop it at any time. Your name or any identifying information will not appear in any report or publication of this research unless you give consent or it is otherwise publicly available. 259 - Your interview transcripts and recording will be safely stored on a password protected computer and only research staff will have access to this information. Confidentiality will be provided to the fullest extent possible by law “I would be happy to send you a transcript of the interview, for you to correct or amend as needed.” “Remember, there are no right answers to any of these questions, I just want to talk with you and learn from your experience.” Introductory Questions: CSA 1. Just to start us off, what is your role in this organization? CSA 2. What services does your organization provide? CSA 3. Who are your primary customers (seniors, children with disabilities, etc…)? II. If currently holding a CCAC and/or LHIN service contract: CSA 4. How are you involved with the contracting of services with the CCAC and/or LHIN? CSA 5. What services are contracted by the CCAC and/or LHIN? CSA 6. Do you provide services outside of the CCAC contract and/or LHIN agreement? If so, what percentage of your revenue comes from the CCAC contract and/or LHIN agreement? CSA 7. How are you held to account for contracted services with the CCAC and/or LHIN? CSA 8. Does your organization require additional resources to meet requirements? a. If so, do you provide these resources or does the organization need to access them on their own? Measurability CSA 9. Do performance indicators in the contracts capture the important aspects of the services you deliver? Elaborate. CSA 10. Are there any other indicators that you collect internally that are not reported to the CCAC and/or LHIN as part of your performance indicators? CSA 11. What activities do you think are important to be measured but are not currently being measured? a. Why are these activities not being measured? Observability CSA 12. How often are the frontline staff directly supervised? 260 Complexity/Embeddedness: CSA 13. Do you rely on any other health care sectors or professionals outside of your organization in order to deliver your services? If so in what way? Organizational responses CSA 14. Do you feel like your organization meets all accountability requirements stipulated in the contract or agreement? Specify. CSA 15. a. b. c. Were either the contracts or agreements negotiated? If so in what ways? How was consensus reached? Do you feel this process lead to a better/worse agreement? CSA 16. Has your organization experienced any sanctions due to non-compliance with contracts or agreements? a. What were the sanctions for? b. How were you sanctioned? CSA 17. Has your organization changed the way it delivers services since winning a contract with the CCAC or since winning an agreement with the LHIN? a. If so, in what ways has your organization changed? b. Do you feel these changes infringe on your autonomy as an organization? Organizational factors CSA 18. Is your organization dependent on the CCAC contract to survive? CSA 19. Is your organization dependent on the LHIN service agreement to survive? CSA 20. Do you have other stakeholders, outside of the CCAC or LHIN, to whom you are held accountable to? a. If so in what ways are you held to account? Elaborate for each stakeholder. b. What is the nature of each of these relationships? (funders, accreditors, etc..) c. Are these demands in conflict with each other? If so in what ways? CSA 21. Do you feel that you have to comply fully with the contract and/or agreement, or do you feel that it is flexible? a. If flexible, in what ways? CSA 22. Are your responsibilities clearly stated in the contract and/or agreement? CSA 23. Do you feel sanctions for non-compliance are strict? CSA 24. How often do you interact with the CCAC and/or LHIN? a. What is the primary purpose of these interactions? CSA 25. Who in your organization is responsible for the quality of service – is it the individual providers or the organization as a whole? 261 CSA 26. Have accountability requirements resulted in any unintended consequences (i.e. organizational changes, staff behaviours, etc…) III. If previously held a CCAC service contract and/or LHIN agreement: CSApc 4. How were you involved with the contracting of services with the CCAC and/or LHIN? CSApc 5. What services were contracted by the CCAC and/or LHIN? CSApc 6. Did you provide services outside of the CCAC contract and/or LHIN agreement? If so, what percentage of your revenue comes from the CCAC contract and/or LHIN agreement? CSApc 7. How were you held to account for contracted services with the CCAC and/or LHIN? CSApc 8. Does your organization require additional resources to meet requirements? a. If so, do you provide these resources or does the organization need to access them on their own? Measurability CSApc 9. Did performance indicators in the contract or agreement capture the important aspects of the services you deliver? Elaborate. CSApc 10. Were there any other indicators that you collect internally that are not reported to the CCAC or LHIN as part of your performance indicators? CSApc 11. What activities do you think are important to be measured but were not being measured? a. Why are these activities not being measured? Observability CSApc 12. How often are the frontline staff directly supervised? Complexity/Embeddedness: CSApc 13. Do you rely on any other health care sectors or professionals outside of your organization in order to deliver your services? If so in what way? Organizational responses CSApc 14. Did you feel like your organization met all accountability requirements stipulated in the contract and/or agreement? Specify. a. If not, what made it difficult to meet requirements? b. Did these challenges play a role in your decision to no longer compete for CCAC contracts or LHIN agreements? CSApc 15. Were contracts and/or agreements negotiated? a. If so in what ways? b. How was consensus reached? 262 c. Do you feel this process lead to a better/worse agreement? CSApc 16. Did your organization experienced any sanctions due to non-compliance with CCAC contracts and/or LHIN agreements? a. What were the sanctions for? b. How were you sanctioned? CSApc 17. Did your organization have to change the way it delivered services when it held a CCAC contract and/or LHIN agreement? a. If so, in what changes were made? b. Do you feel these changes infringed on your autonomy as an organization? Organizational factors CSApc 18. Do you have other stakeholders, outside of the CCAC or LHIN, to whom you are held accountable to? a. If so in what ways are you held to account? Elaborate for each stakeholder. b. What is the nature of each of these relationships? (funders, accreditors, etc..) c. Are these demands in conflict with each other? If so in what ways? CSApc 19. Was the CCAC contract and/or LHIN agreement flexible? If so in what ways? CSApc 20. Were the organizations responsibilities clearly stated in the contract and/or agreement? CSApc 21. Did you feel sanctions for non-compliance were strict? CSApc 22. How often did you interact with the CCAC and/or LHIN? a. What was the primary purpose of these interactions? CSApc 23. Who in your organization is responsible for the quality of service – is it the individual providers or the organization as a whole? Impacts of accountability frameworks CSApc 24. Did the LHIN agreements result in any unintended consequences (i.e. organizational changes, staff behaviours, etc…) a. Have these been eliminated since the termination of the contract? II. If never held a CCAC and/or LHIN service contract: CSA 1. Have you ever competed for a CCAC contract of LHIN agreement? a. Why? Why not? b. If previously applied but unsuccessful: Why do you think you were unsuccessful? CSA 2. Would you compete for a CCAC contract or LHIN agreement in the future? a. Why? Why not? 263 Appendix 3-G: Final survey (written version of the online survey) Consent Form “Approaches to Accountability” sub-study: Accountability in the Home and Community Care Sector Primary Investigator: Carolyn Steele Gray, MA., PhD candidate. Thesis Supervisor: Raisa Deber, PhD Committee Members: Whitney Berta, PhD; Janet Lum, PhD Department of Health Policy Management and Evaluation University of Toronto Purpose of the Research: The purpose of this project is to explore organizational responses to accountability in the home and community care sector in Ontario. Specifically, we are interested in how community service agencies that deliver home and community care services have responded to contract-based accountability requirements imposed by Local Health Integration Networks and Community Care Access Centres. This sub-study is part of the larger “Approaches to Accountability” project outlined in the introductory letter attached. The sub-study is led by Carolyn Steele Gray, a doctoral student with the Department of Health Policy, Management and Evaluation; it will satisfy the dissertation research requirement for the doctoral program. What you will be asked to do in the research: You are being asked to fill out a brief survey as part of the first phase of this research. This survey is intended to gather information for the first phase of this research and will help identify case study subjects, in this case community service organizations, which will be examined in the second phase of this research. At the end of the survey you will also be asked whether you’d be willing to participate as a case study in the second phase of this research. This survey will take between 20-30 minutes to complete. Risks and Discomforts: We do not foresee any physical risks or discomforts arising from your participation in the research. There may be questions asked in the survey that you may find difficult to answer, or simply do not wish to answer. In that event you are free skip those questions in the survey. Potential benefits of the research and benefits to you: Potentially, this study has broad implications for the development and implementation of accountability tools in the home and community care sector. Identifying how organizations have responded to agreement and contract-based accountability tools and identifying what, if any, organizational factors play a role in those responses can be instructive to policy makers when modifying accountability requirements in an effort to elicit desirable organizational responses. Your survey responses will be a critical part of the analysis. Voluntary participation: Your participation in the study is completely voluntary and you may choose to withdraw from the study at any time. Your decision not to participate, or to withdraw, will not affect your relationship with the researchers, the University of Toronto, or any other group associated with this project. Withdrawal from the study: You can withdraw from the study at any time, for any reason. If you wish to withdraw from the study, however, we ask that you inform the primary investigator, 264 Carolyn Steele Grey, on or before April 30th 2012 before submission of her dissertation for review. Your decision to withdraw from the study will not affect your relationship with the researchers, the University of Toronto, or any other group associated with this project. Confidentiality: Your survey responses will be assigned an identifier and stripped of identifying information prior to analysis so that your confidentiality and anonymity can be protected to the fullest extent possible. Identifying information will be kept in a separate and secure file accessibly only to Carolyn Steele Gray. Your identity will not be associated in any way to the data transferred from your survey to the dataset analyzed for this study. Survey responses will be stored on a password protected and encrypted computer in a locked room for 7 years. You may authorise the use of your name and organization for inclusion in the study if you choose to waive your confidentiality. Questions about the research? If you have any questions about the research in general or about your role in the study, please feel free to contact the principal investigator Carolyn Steele Gray by email ([email protected]). This research has been approved by the University of Toronto, Office of Research Ethics, Research Ethics Board and by the Toronto Central Community Care Access Centre Research Advisory Committee. If you have any questions or concerns, please feel free to contact us, or Research Ethics Manager, Daniel Gyewu in the Office of Research Ethics at the University of Toronto ([email protected]). Legal Rights and Signatures: I _______________________________, consent to participate in the “Accountability in the Home and Community Care Sector” study conducted by Carolyn Steele Gray, a doctoral student with the Department of Health Policy, Management and Evaluation. I have understood the nature of this project and wish to participate. I am not waiving any of my legal rights by signing this form. My signature below indicates my consent _______________________________ ________________________________ Participant Date _______________________________ ________________________________ Investigator Date NOTE: This consent form will be loaded as the first page of the on-line survey, “signing” consent will take the form of clicking the option “Yes, I consent to participate.” Choosing “No, I do not consent to participate” will automatically end the survey. 265 As part of the “Approaches to Accountability” sub-study, Accountability in the Home and Community Care sector, we wish to identify organizational characteristics and responses to existing accountability requirements. The following survey seeks to capture key organizational variables of interest as well as information about existing or previous accountability relationships. In addition to producing findings for analysis, findings from this survey, along with findings from document analysis and an environmental scan, will help to identify organizations that will be included in case studies. Both home care services and community care services are identified throughout this survey. Home and community care services are identified based on Health Canada’s standards. You will be asked to refer to the following definitions throughout the survey: Home Care services: • Nursing • Personal Care (bathing, dressing and feeding) • Physiotherapy (PT) • Occupational therapy (OT) • Speech-language therapy (SLT) • Social work • Dietetic services • Respite • Homemaking (light housekeeping) Community Care services: • Adult day programs • Meals on Wheels • Friendly visitor programs • Security checks • Transportation • Home help (homemaking) • Home maintenance (minor home repair, snow shovelling, and lawn care) • Meal prep • Foot care You are asked below to name your organization in order for the investigator to add survey data to other databases that have been created based on publicly available information. This is simply to keep data together prior to analysis; once all data is gathered identifying information will be removed and your organization will be assigned an anonymous identifier prior to analysis as stipulated in the consent form. Name of Organization: Organizational characteristics/structure The following questions are related to the characteristics of your organization and its structure. 1. In what LHINs does your organization provide services? Please check all that apply: 266 • • • • • • • • • • • • • • Erie St. Clair South West Waterloo Wellington Hamilton Niagara Haldimand Brant Central West Mississauga Halton Toronto Central Central Central East South East Champlain North Simcoe Musckoka North East North West 2. What services does your organization deliver (check all that apply) In each case check all geographic locations/regions where these services are delivered Service Provided Nursing Personal care PT OT SLT Social Work Dietetic services Respite Homemaking Adult day programs Local Across one CCAC/ LHIN region Across multiple CCAC/ LHIN region Across Ontario Across multiple provinces Across Canada Internationally Not provided 267 Meals on Wheels Friendly visiting Security checks Transportation Home help Home maintenance Meal prep Foot care Other: (please list) 3. For services that are counted in “visits,” how many hours is approx. equivalent to one visits (e.g. 1 visit = 0.5 hours) 4. In the 2009/2010 fiscal year how many staff did you employ? **Please note, we recognize that staff may have different professional backgrounds then their current role at your organization. Please just list staff numbers in relation to their primary role/function at your organization not based on their education. Staff Nurses Physiotherapists Occupational therapists Speech-language pathologists Personal support workers No. Fulltime equivalent (FTEs) No. of Fulltime: No. with at least 30 guaranteed hours/week No. of Parttime: No. with 16-29 guaranteed hours /week No. of Parttime: No. with ≤ 15 guaranteed hours /week 268 Social workers Dietians Administrative staff Recreation Gerontologist Other (please specify) 5. In 2009/2010 fiscal year how many service volunteers did you have working with your organization? a. Service volunteers b. Fundraising volunteers c. How many of those service volunteers had direct client contact? Funders and partners 6. What was your total revenue for the 2009/2010 fiscal year? a. Please list your 2009/2010 fiscal year revenue sources? (check all that apply) Y/N Funder Amount or proportion (approximate is fine) Client fees, full cost Co-pays, subsidized CCAC service contract LHIN service agreement (MSAA) LHIN one-time-funding Province one time grant Federal one-time grant Other one time grant Donations Fundraising Other (please specify) 269 b. Approximately what percentage (proportion) of your revenues are related to home care service delivery (see earlier definition for services included in “home care”)? c. Approximately what percentage (proportion) of your revenues are related to community service delivery (see earlier definition for services included in “community services”)? Memberships In the following questions please identify all associations with whom you are a member. Memberships in associations may include the sharing of information, paying membership fees, attending meetings, and/or meeting specific criteria for membership. Meeting attendance may or may not be reserved to Annual General Meetings. 7. Please check all associations with whom you are a membe: Check all that apply Ontario Home Care Association (OHCA) Ontario Community Service Association (OCSA) Ontario Association of Nonprofit Homes and Services for Seniors (OANHSS) Ontario Geriatric Association (OGA) Ontario Hospital Association (OHA) Ontario Long-term Care Association (OLTCA) Association of Ontario Health Centres (AOHC) Other (please list all that apply) 8. In the following question please identify all Networks and Collaborations with which you are a member. Networks include groups of organizations who work together to plan and coordinate service provision so as to avoid duplication, identify gaps in services or help to develop awareness about home and community care programs and services available. Belonging to a network does not necessarily mean that member organizations are funded by the same source or are working together on the same contract or agreement. Collaborations include groups of organizations who work together to provide services, but who get funded by separate sources. Check all that apply Community Navigation Access Program (CNAP) (TC LHIN) Doorways to Care (DWTC) (TC LHIN) 270 SMILE support program (SE LHIN) Other (please list all that apply) Service Contracts and Grant Funding The following questions have to do with whether your organization has ever applied for government service contracts or agreements to deliver home care services and/or community care services or government grants to support home care service delivery and programs and/or community care service delivery and programs. 9. Has your organization applied for grants, agreements and/or contracts to deliver home care services and or community care services from (please check all applicable options for each contract and/or grant): Contracts/ Agreements/ grants Yes, applied and currently hold Yes, applied previously and successful Yes, applied No, but never unsuccessful applied Ontario Trillium Foundation Grant New Horizons for Seniors Program Grant LHIN service agreement (MSAA) CCAC home care service contract Veterans Affairs service agreements First Nations service agreements Others: a. For cases where you have won contracts, agreements or grants indicate whether you partnered with anyone. By partnership we mean that you provide services together with another organization and receive funding from the same source e.g. by means of formal agreement like a Memorandum of Understanding (MOU). (check all that apply): 271 Contracts/ Agreements/ grants Yes, partnered Ontario Trillium Foundation Grant New Horizons for Seniors Program Grant LHIN service agreement (MSAA) CCAC home care service contract Veterans Affairs service agreements First Nations service agreements Others: Sub-contracting is defined here as assigning some obligations of an existing contract, agreement or grant to another party/organization. In 2009/2010 did you sub-contract any services delivered under grants, agreements, or contracts? In 2009/2010 did you provided subcontracted services for another organization receiving grants, agreements or contracts? Use the following answer key to answer the question below: 1 = Yes, subcontracted to other organizations 2 = Yes, was subcontracted to deliver service(s) (online cannot get a list of services) Contracts/ Agreements/ grants Ontario Trillium Foundation Grant New Horizons for Seniors Program Grant LHIN service agreement (MSAA) CCAC home care service contract Yes, subcontracted to other organization Service(s), subcontracted. List all that apply Yes, was subcontracted to deliver service(s) Service(s) delivered under sub-contract. List all that apply 272 Veterans Affairs service agreements First Nations service agreements Others: b. If the opportunity arose in the next year, would your organization plan to apply for any of the following service contracts, agreements or grants for home and community care service delivery? Contracts/ Agreements/ grants Yes, plan to apply No, do not plan to apply Don’t know/ have not decided Ontario Trillium Foundation Grant New Horizons for Seniors Program Grant LHIN service agreement (MSAA) CCAC home care service contract Veterans Affairs service agreements First Nations service agreements Others: Accountability 10. Do you produce an annual report? Y/N. a. Does your annual report include financial statements? Y/N b. If you produce an annual report is it publicly available? i. Yes, it is available to anyone through our website ii. Yes, it is available to anyone on request iii. Yes, but it is only available to our shareholders iv. No, not available. 273 11. Is your organization accredited with any of the following organizations? Accreditor Yes, No, but in currently the accredited accreditation process No, but plan on seeking accreditation in the next year No, do not plan on seeking accreditation Accreditation Canada (previously Canadian Council on Health Services Accreditation, CCHSA) CARF International – Aging Services/ CARFCCAC CARF Canada Standards Council of Canada (ISO) National Quality Institute Other: Follow-Up Part of this study will be trying to understand nuances about approaches to accountability. Would you be willing to share your experiences with us? Y/N a. If yes, please provide an email address (or phone number) where you can be reached. Name: Contact Info: Tel: E-mail: 274 Appendix 4-A: Accreditation Canada, required organizational practices and CARF and ISO accreditation processes Source: Accreditation Canada (2011), p.2. 275 CARF accreditation process An organization can become accredited through CARF through the following process: 1. 2. 3. 4. 5. 6. 7. The organization consults with a CARF resource specialist The organization conducts a self-evaluation The organization submits an “intent to survey” CARF will invoice the organization for the survey fee CARF selects a survey team made up of a team of expert practitioners On-site survey is conducted by the team CARF makes accreditation decision that can be three-year, one-year, provisional, or nonaccreditation. For CARF-CCAC the decision can either be a five-year term or nonaccreditation 8. The organization submits a Quality Improvement Plan to CARF that identifies how it is addressing identified areas of improvement. 9. The organization must demonstrate ongoing commitment by submitting an annual Conformance to Quality report to CARF that documents any additional improvements. 10. CARF will maintain ongoing contact with the organization over the term of accreditation (CARF, 2012c). ISO accreditation process To receive ISO accreditation an organization must go through the following process: 1. Submit a application form including all required documents and fees 2. Go through a pre-assessment in which ISO reviews the application and requests any additional documents. 3. ISO conducts an on-site assessment in which areas of weakness are identified 4. The organization responds to any areas of non-conformity and does a follow-up with ISO 5. ISO prepares a final report which identifies whether they recommend accreditation. This is sent to the Standards Council of Canada for review prior to a final decision being made (Standards Council of Canada, 2012). 276 Appendix 4-B: MSAA indicator framework Source: LHIN Collaborative (2011) p.12 &14 of 21 Core Indicators 277 Appendix 5-A: Tables and figures Survey sample bias tables Table 5A-1: Survey respondents vs. non-survey respondents compared by organizational size Organizational Non-respondents Respondents size N=57 (column %) N = 16 (column %) Small 18 (31.58%) 2 (12.50%) Medium 30 (52.63%) 9 (56.25%) Large 9 (15.79%) 5 (31.25%) Frequency missing = 144 Table 5A-2: Survey respondents vs. non-respondents compared by services delivered Urban region Rural region % of Non- % ANOV % of Non- % ANOV respondent Respondents A p respondent Respondents Ap Services s deliver delivering value s deliver delivering value services services services services N = 138 N = 26 N = 55 N = 14 Home care services Nursing 24% 28% 0.6315 10% 21.4% 0.2601 Personal Care 41% 58% 0.1162 24% 50% 0.0613 PT 6% 12% 0.2891 12% 7.1% 0.6135 OT 4% 16% 0.0159 10% 14.3% 0.6559 SLT 3% 8% 0.2374 10% 7.1% 0.7505 Dietetics 1.5% 12% 0.0060 6% 7.1% 0.8783 Social work 9% 16% 0.3673 12% 7.4% 0.6135 Respite 18% 32% 0.1173 14% 14.3% 0.9787 Homemaking 38% 44% 0.5677 16% 28.6% 0.2942 Community care services Adult day 17% 50% 0.0001 14% 14.3% 0.9787 programs Meals on 11.4% 8% 0.6224 18% 35.7% 0.1614 Wheels Friendly 26% 48% 0.0250 24% 50% 0.0613 Visiting Transportation 30.3% 36% 0.5758 24% 42.9% 0.1706 Security check 13.6% 24% 0.1890 14.3% 21.4% 0.5266 Home help 6.8% 4% 0.5995 4% 0% 0.4551 Home 6.8% 4% 0.5995 8% 14.3% 0.4836 maintenance Meal prep 18.2% 20% 0.8312 6% 14.3% 0.3149 Congregate 10.6% 20% 0.1890 12% 21.4% 0.3777 dining Foot care 6.8% 24% 0.0072 14% 35.7% 0.0675 278 Supportive housing Long-term care Hospice Palliative care Caregiver support Education Recreation Crisis support Physician services Case management Outreach 18.2% 24% 0.5006 12% 0% 0.1788 6.8% 0% 0.1810 2% 7.1% 0.3361 3% 13.6% 13.6% 8% 16% 24% 0.2374 0.7568 0.1890 22% 12% 24% 14.3% 28.6% 28.6% 0.5335 0.1354 0.7320 23.5% 30.3% 8.3% 1.5% 16% 32% 12% 4% 0.4129 0.8670 0.5582 0.4086 34% 12% 8% 2% 50% 57.1% 14.3% 0% 0.2817 0.0002 0.4836 0.6007 15.2% 24% 0.2781 2% 7.1% 0.3361 9.9% 0% 0.1026 4% 0% 0.4551 Table 5A-3: Survey respondents vs. non-respondents compared by how many home care services they deliver; urban region. Number'of'home'care' services'delivered' 0!home!care!services! 1G3!home!care!services! 4G6!home!care!services! 7G9!home!care!services! Non3respondents' N'='132'(column' %)' 60!(45.45%)! 54!(40.91%)! 16!(12.12%)! 2!(1.52%)! Respondents' N'='25'(column' %)' 6!(24%)! 12!(48%)! 6!(24%)! 1!(4%)! Total'N' 66! 66! 22! 3! Missing = 7 Table 5A-4: Survey respondents vs. non-respondents compared by urban CCAC contracts, by organization in urban region Number of urban CCAC Non-respondents Respondents Total contracts N=138 (column N = 26 (column N %) %) 0 129 (93.48%) 18 (69.23%) 147 1 6 (4.35%) 5 (19.23%) 11 3 1 (0.72%) 2 (7.69%) 3 5 1 (0.72%) 0 1 7 1 (0.72%) 0 1 11 0 1 (3.85%) 1 Frequency missing = 1 Table 5A-5: Survey respondents vs. non-respondents compared by number of CCACs with whom organizations hold a contract Number of CCAC with Non-respondents Respondents Total whom orgs hold contracts N=181 (column N = 36 (column N %) %) 0 169 (93.37%) 26 (72.22%) 195 279 1-3 4-6 7-9 10-13 2 (1.10%) 5 (2.76%) 2 (1.10%) 3 (1.66%) 2 (5.56%) 2 (5.56%) 3 (8.33%) 3 (8.33%) 4 7 5 6 Table 5A-6: Survey respondents vs. non-respondents compared by organizations that are in the urban region that hold MSAAs, urban region Current status with MSAA Non-respondents Respondents Total N=70 (column N = 18 (column N %) %) Don’t hold MSAA 28 (96.55%) 5 (55.56%) 33 Hold MSAA 1 (3.45%) 4 (44.44%) 5 Frequency Missing = 126 Survey descriptive statistics tables Table 5A-7: Service delivery area of survey respondents Region N % Total N Erie St. Clair LHIN 11 10.47% South West LHIN 16 15.23% Waterloo Wellington LHIN 7 6.67% Hamilton Niagara Haldimand Brant LHIN 16 15.23% Central West LHIN 13 12.38% Mississauga Halton LHIN 18 17.14% Toronto Central LHIN 26 24.76% Central LHIN 18 17.14% Central East LHIN 15 14.29% South East LHIN 17 16.19% Champlain LHIN 21 20% North Simcoe Muskoka LHIN 9 8.57% North East LHIN 13 12.38% North West LHIN 5 4.76% Frequency missing = 9 Total N 105 105 105 105 105 105 105 105 105 105 105 105 105 105 Table 5A-8: Organizational size of survey respondents size Frequency Percent Cumulative Frequency large 17 14.91 17 medium 32 28.07 49 small 16 Frequency missing = 49 14.04 65 Table 5A-9: Services provided of survey respondents Service Locally Across Across Across Across Across Inter- Not Total Miss 280 Nursing PC PT OT SLP Diet SW Respite HMak ADP MoW FV Trans SC HH HMain MP Foot Other services Edu CD SH Rec CS CGsup 9 11.69% 36 41.86% 4 5.88% 4 6.15% 4 6.45% 10 14.71% 16 23.88% 25 32.47% 36 42.86% 33 42.86% 37 48.05% 40 51.28% 48 57.83% 41 54.67% 37 45.68% 27 36.48% 38 46.34% 31 41.33% Prov 1 multiple Region regions 2 8 2.6% 10.39% 10 16 11.63% 18.6% 3 5 4.41% 7.35% 3 2 4.62% 3.08% 4 3 6.45% 4.84% 4 3 5.88% 4.41% 10 8 14.93% 11.94% 12 12 15.58% 15.58% 10 17 11.9% 20.24% 11 0 14.29% 4 6 5.19% 7.79% 12 13 15.38% 16.67% 11 9 13.25% 10.84% 8 10 10.67% 13.33% 9 1 11.11% 1.23% 4 7 5.41% 9.46% 10 14 12.2% 17.1% 6 8 8% 10.67% Not-prov 17 (14.91%) 27 (23.68%) 17 (14.91%) 13 (11.4%) 15 (13.16%) 17 (14.91%) all regions 2 2.6% 1 1.16% 1 1.47% 1 1.54% 1 1.61% 2 2.94% 1 1.49% 3 3.9% 2 2.38% 0 multiple provinces 1 1.3% 3 3.49% 0 Canada national provided N 0 0 77 37 0 0 86 28 0 0 68 46 0 0 0 65 49 0 0 0 62 52 0 0 0 68 46 0 0 0 67 47 1 1.3% 3 3.57% 0 0 0 77 37 0 0 84 30 0 0 77 37 0 1 1.3% 1 1.28% 1 1.2% 1 1.33% 2 2.47% 1 1.35% 2 2.44% 1 1.33% 0 0 77 37 0 0 78 36 0 0 83 31 0 0 75 39 0 0 81 33 0 0 74 40 0 0 82 32 0 0 16 20.78% 11 12.79% 17 25% 17 26.15% 17 27.42% 18 26.47% 15 22.39% 9 11.69% 9 10.71% 11 14.29% 10 12.99% 7 8.97% 7 8.43% 10 13.33% 7 8.64% 11 14.86% 9 10.98% 9 12% 75 39 1 1.28% 0 0 14 17.28% 0 1 1.22% 1 1.33% 97 87 97 101 99 97 Table 5A-10: Number of organizations providing different home care service mixes Home'care' Nursing' PC' PT' OT' SLT' Dietetics' Social' Respite' Home' services' work' making' Nursing' 35! ! ! ! ! ! ! ! ! PC' 16! 60! ! ! ! ! ! ! ! PT' 8! 8! 12! ! ! ! ! ! ! OT' 5! 6! 7! 9! ! ! ! ! ! 281 SLT' Dietetics' Social'work' Respite'' Homemaking' 3! 9! 9! 9! 14! 6! 10! 21! 34! 51! 4! 10! 8! 3! 7! 5! 8! 7! 3! 4! 9! 5! 6! 5! 5! ! 16! 10! 4! 8! ! ! 30! 18! 19! ! ! ! 46! 35! ! ! ! ! 58! Table 5A-11: Number of organizations providing home care services [9 services total] Number'of'HC'services' 0' 1' 2' 3' 4' 5' 6' 7' 8' 9' delivered' Number'of'organizations' 26! 21! 19! 20! 16! 5! 2! 3! 0! 2! Table 5A-12: Number of organizations providing different community care service mixes CC' services' ADP' MOW' MP' CD' FV' SC' Trans' HH' HM' Foot' EDU' REC' CS' CG' Sup' Hos' Pal' LTC' SH' ADP' MOW' MP' CD' FV' SC' Trans' HH' HM' Foot' Edu' Rec' CS' CGsup' Hos' Pal' LTC' SH' Cman' Ref' 43! 17! 21! 10! 27! 24! 27! 21! 12! 19! 9! 5! 11! 11! 2! 1! 0! 7! 1! 4! ! 43! 27! 20! 32! 30! 39! 29! 26! 27! 7! 8! 9! 6! 1! 1! 0! 9! 1! 3! ! ! 56! 20! 40! 39! 40! 45! 27! 31! 10! 11! 11! 10! 1! 2! 1! 12! 3! 5! ! ! ! 27! 24! 23! 23! 21! 14! 15! 5! 10! 8! 5! 0! 1! 0! 6! 1! 3! ! ! ! ! 56! 42! 47! 41! 27! 31! 12! 11! 12! 12! 2! 2! 1! 9! 1! 5! ! ! ! ! ! 52! 40! 38! 27! 30! 11! 12! 13! 11! 2! 1! 1! 13! 2! 6! ! ! ! ! ! ! 61! 42! 32! 34! 9! 9! 12! 12! 1! 1! 1! 10! 2! 5! ! ! ! ! ! ! ! 61! 31! 31! 11! 11! 13! 10! 1! 2! 0! 13! 2! 5! ! ! ! ! ! ! ! ! 36! 26! 5! 7! 6! 4! 0! 1! 0! 8! 1! 2! ! ! ! ! ! ! ! ! ! 43! 7! 7! 7! 8! 1! 2! 1! 7! 2! 2! ! ! ! ! ! ! ! ! ! ! 17! 6! 3! 8! 0! 0! 0! 5! 3! 7! ! ! ! ! ! ! ! ! ! ! ! 13! 5! 4! 0! 0! 0! 5! 2! 3! ! ! ! ! ! ! ! ! ! ! ! ! 15! 5! 1! 1! 0! 5! 1! 2! ! ! ! ! ! ! ! ! ! ! ! ! ! 17! 2! 0! 0! 4! 4! 4! ! ! ! ! ! ! ! ! ! ! ! ! ! ! 2! 0! 0! 0! 0! 0! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! 2! 0! 1! 0! 0! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! 1! 0! 0! 0! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! 17! 2! 3! Table 5A-13: Number of organizations providing community care services [20 services total] Number'of'CC' 0' 1' 2' 3' 4' 5' 6' 7' 8' 9' 10' 11' 12' 13' 14' 15' 16' services' delivered' Number'of' 15! 10! 13! 9! 7! 11! 11! 9! 8! 4! 8! 3! 2! 3! 0! 0! 1! organizations' Table 5A-14: Percent of total employees broken down into full-time (FTE), parttime/casual (PTE/Ca), and service volunteers (Service V) used by survey respondents. Type of Percent of total employees Total N Missing employees 0 1-20% 20-40% 40-60% 60-80% 80100% FTE % 7 51 10 13 4 3 88 26 total PTE/Ca % 11 37 14 15 5 6 88 26 total Service V 20 7 9 8 12 32 88 26 % total C' Ma n' ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! 5! 2! Ref' ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! 7! 282 Figure 5A-1: Percent of total employees broken down into full-time (FTE), part-time/casual (PTE/Ca), and service volunteers (Service V) used by survey respondents. 60! 50! 0! 40! 1G20%! 20G40%! 30! 40G60%! 20! 60G80%! 80G100%! 10! 0! FTE!%!total! PTE/Ca!%!total! Table 5A-15: Organizations’ funding sources Funding 0% 121416181Source 20% 40% 60% 80% 100% User fees 11 30 11 3 2 3 Co-pay 38 12 4 2 2 0 CCAC 48 5 0 1 1 5 LHIN 11 9 2 14 9 16 L 1-time 45 12 1 0 0 1 Province 52 6 0 0 0 0 Federal 49 9 0 0 0 0 Onetime 46 13 0 0 0 0 Donations 22 36 0 0 1 0 Fundraise 36 18 1 1 0 0 UW 49 11 0 0 0 0 Municipal 50 9 0 0 0 0 Other 42 13 2 1 0 0 Service!V!%!total! Total N 60 58 60 61 59 58 58 59 59 56 60 59 58 Missing 54 56 54 53 55 56 56 55 55 58 54 55 56 Table 5A-16: Organizations’ revenue related to home care services (in quintiles) RevHC Frequency Percent Cumulative Cumulative Frequency Percent 0 27 47.37 27 47.37 1-20% 5 8.77 32 56.14 283 RevHC Frequency Percent Cumulative Cumulative Frequency Percent 20-40% 3 5.26 35 61.40 40-60% 4 7.02 39 68.42 60-80% 4 7.02 43 75.44 80-100% 14 24.56 57 100.00 Frequency Missing = 57 (5 organizations get 100% of their revenue from home care services) Table 5A-17: Organizations’ revenue related to community care services (in quintiles) RevCC Frequency Percent Cumulative Cumulative Frequency Percent 0 7 12.07 7 12.07 1-20% 12 20.69 19 32.76 20-40% 6 10.34 25 43.10 40-60% 4 6.90 29 50.00 60-80% 2 3.45 31 53.45 80-100% 27 46.55 58 100.00 Frequency Missing = 56 (24 organizations get 100% of their revenue from community care services) Table 5A-18: Organizations’ association memberships Association Members (% total Total N) N OHCA 6 (6.98%) 86 OCSA 63 (71.59%) 88 OANHSS 10 (11.49%) 87 OGA 4 (4.60%) 87 OHA 4 (4.55%) 88 OLTCA 0 88 AOHC 1 (1.14%) 88 ONPHA 8 (9.09%) 88 CHCA 3 (3.45%) 87 PSNO 6 (6.82%) 88 ONPH 7 (7.95%) 88 OHSRA 1 (1.14%) 88 OAILSP 6 (6.90%) 87 UW 8 (9.09%) 88 VolTor 6 (6.82%) 88 Missing 28 26 27 27 26 26 26 26 27 26 26 26 27 26 26 284 Other (number) 0 (n=66); 1 (n=13); 2 (n=5); 3 (n=2); 5 (n=1) 87 27 Table 5A-19: Organizations’ network memberships Association Members (%) Total N Missing Neighbourhood 3 (3.41%) 88 26 centre network, 15.79% of urban region* urban respondents CSA network, 7 (7.95%) 88 26 urban region* 36.84% of urban respondents DWTC 4 (4.55%) 88 26 SMILE 6 (6.82%) 88 26 CCsCap 8 (9.09%) 88 26 HAL 9 (10.23%) 88 26 OCC 2 (2.27%) 88 26 HF 4 (4.60%) 87 27 Transportation 3 (3.41%) 88 26 network, urban 15.79% of region* urban respondents CSA network, 4 (4.55%) 88 26 rural region (but in other regions as well) Other (number) 0 (n=64); 1 87 27 (n=11); 2 (n=1); 3 (n=1); 4 (n=6); 5 (n=2); 6 (n=2) * calculated for organizations in urban region only as these networks only exist in the urban region Table 5A-20: Organizations’ use of annual reports Produce an AR includes Annual report availability Tota Missin annual financial lN g Anyone Availabl Available Not report report via e by only to available website request shareholder s No = 22 No = 22 24 27 4 (4.94%) 26 81 33 (26.19%) (26.19%) (29.63%) (33.33%) (32.10%) Yes = 62 Yes = 60 (73.81%) (73.17%) 285 N=84 M=30 N=82 M=32 Table 5A-21: Organizations’ accreditation Accreditor Currently In the accredited accreditation process Accreditation 19 1 (1.22%) Canada (23.1%) CARF 2 (2.44%) 3 (3.66%) ISO 1 (1.22%) 1 (1.22%) NQI 1 (1.20%) 1 (1.20%) HAO 3 (3.61%) 1 (1.20%) Salvation 3 (3.61%) 1 (1.20%) Army Other 1 (1.20%) 1 (1.20%) accreditation Plan on seeking accreditation 3 (3.66%) Do not plan on seeking accreditation 59 (71.95%) Total N Missing 82 32 5 (6.10%) 0 0 0 0 72 (87.80%) 80 (97.56%) 81 (97.59%) 79 (95.18%) 79 (95.18%) 82 82 83 83 83 32 32 31 31 31 0 81 (97.59%) 83 31 Relationships between independent variables – factor analysis findings Figure 5A-2: Scree plot for principal component factor analysis Table 5A-22: Eigenvalues for factor analysis Eigenvalues of the Correlation Matrix: Total = 8 Average = 1 Eigenvalue Difference Proportion Cumulative 1 2.12050056 0.48395276 0.2651 0.2651 286 Eigenvalues of the Correlation Matrix: Total = 8 Average = 1 Eigenvalue Difference Proportion Cumulative 2 1.63654780 0.38363063 0.2046 0.4696 3 1.25291717 0.36781183 0.1566 0.6262 4 0.88510534 0.17175287 0.1106 0.7369 5 0.71335247 0.09793026 0.0892 0.8261 6 0.61542220 0.11710247 0.0769 0.9030 7 0.49831974 0.22048501 0.0623 0.9653 8 0.27783473 0.0347 1.0000 Table 5A-23: Four factor solution, factor analysis (unrotated) Factor Pattern Factor1 Factor2 Factor3 S_FPNFP 0.78693 0.08470 0.05362 S_CCAC 0.78064 0.23236 -0.32305 S_LHIN -0.64841 0.11432 0.44867 S_TotAsc -0.30248 0.73203 -0.01589 size 0.24395 0.70240 0.29931 S_TotNet -0.42001 0.55153 -0.36602 FTEPerc 0.37851 0.25632 0.74086 TotAcr 0.02670 0.40397 -0.41436 Table 5A-24: Four factor solution, factor analysis PROMAX rotation Factor Structure (Correlations) Factor1 Factor2 Factor3 S_CCAC 0.85723 0.03889 0.20602 S_FPNFP 0.70886 -0.24125 0.39767 S_LHIN -0.76321 0.14999 0.13323 S_TotNet -0.21248 0.76504 -0.11900 S_TotAsc -0.22856 0.72853 0.28297 TotAcr 0.20860 0.49725 -0.06094 287 Factor Structure (Correlations) Factor1 Factor2 Factor3 FTEPerc 0.07799 -0.22984 0.83083 size 0.15113 0.37310 0.71030 288 Appendix 5-B: Organizational size operationalization In order to determine the organizational size variable, the distribution of total revenue was examined. Univariate analysis of environmental scan data yielded the following findings for total revenues reported in the environmental scan: N=73; Missing = 144; Mean: 7,644,588; Median: 818,089; Interquartile range: 2,830,538 Quantiles (Definition 5) Quantile Estimate 100% Max 209448931 99% 209448931 95% 10208725 90% 6052975 75% Q3 3173141 50% Median 818089 25% Q1 342603 10% 110405 5% 78466 1% 57296 0% Min 57296 These findings would suggest a definition of small, medium and large organizations that is similar to the definition provided by OCSA which defines small, medium and large organizations as follows: • • • Small!organization!–!total!revenue!<!$500,000! Medium!organization!–!total!revenue!$500,000!G!$2,000,000!($5,000,000!for!CCAC! provider)! Large!organization!–!total!revenue!>!$2,000,000!($5,000,000!for!CCAC!provider)! A second univariate analysis was conducted for total revenue distribution with survey findings to determine whether the spread was similar. The analysis yielded the following findings: N=65; Missing = 49; Mean: 6,894,857.66; Median: 1,069,500; Interquartile range: 3,597,913 Quantiles (Definition 5) Quantile Estimate 100% Max 130000000 99% 130000000 289 Quantiles (Definition 5) Quantile Estimate 95% 19000000 90% 10000000 75% Q3 4000000 50% Median 1069500 25% Q1 402087 10% 215000 5% 168000 1% 30500 0% Min 30500 These findings would suggest a distribution that lies somewhere between the OCSA definition for LHIN and OCSA funded organizations. Given that the survey includes CCAC funded organizations, and based on the distribution found in the survey, the following definitions for small, medium and large organizations were used: • • • Small!organization!–!total!revenue!<!$400,000! Medium!organization!–!total!revenue!$400,000!G!$4,000,000!! Large!organization!–!total!revenue!>!$4,000,000!! 290 Appendix 5-C: Additional tables Comparing respondents and non-respondents Table 5C-1: Survey respondents vs. non-respondents compared by how many home care services they deliver, rural region Number'of'home'care' services'delivered' 0!home!care!services! 1G3!home!care!services! 4G6!home!care!services! 7G9!home!care!services! Non3respondents' N'='50'(column'%)' 28!(56%)! 17!(34%)! 4!(8%)! 1!(2%)! Respondents' N'='14'(column'%)' 7!(50%)! 5!(35.71%)! 1!(7.14%)! 1!(7.14%)! Total' N' 35! 22! 5! 2! Missing = 5 Table 5C-2: Survey respondents vs. non-respondents compared by how many home care services they deliver, urban region Number'of'community' care'services'delivered' 0!community!care!services! 1G7!community!care!services! 8G14!community!care! services! 15G21!community!care! services! Non3respondents' N'='132'(column'%)' 11!(8.33%)! 112!(84.85%)! 9!(6.82%)! Respondents' N'='25'(column'%)' 4!(16%)! 15!(60%)! 6!(24%)! Total' N' 15! 127! 15! 0! 0! 0! Missing = 7 Table 5C-3: Survey respondents vs. non-respondents compared by how many home care services they deliver, rural region Number'of'community' care'services'delivered' 0!community!care!services! 1G7!community!care!services! 8G14!community!care! services! 15G21!community!care! services! Non3respondents' N'='59'(column'%)' 6!(12.24%)! 39!(79.59%)! 4!(8.16%)! Respondents' N'='14'(column'%)' 2!(14.29%)! 8!(57.14%)! 4!(28.57%)! Total' N' 8! 47! 8! 0! 0! 0! Missing = 6 Table 5C-4: Survey respondents vs. non-respondents compared by association memberships Number of assoc. Non-respondents Respondents Total memberships N=181 (column %) N=36 (column %) N 0 74 (40.88 %) 7 (19.44%) 81 1 61 (33.7%) 13 (43.33%) 74 2 33 (18.23%) 9 (30%) 42 3 8 (4.42%) 4 (13.33%) 12 4 2 (1.1%) 3 (10%) 5 291 6 8 23 1 (0.55%) 1 (0.55%) 1 (0.55%) 0 0 0 1 1 1 Table 5C-5: Survey respondents vs. non-respondents compared by partnerships Number of partnerships Non-respondents Respondents Total N=181 (column %) N=36 (column %) N 0 166 (91.71%) 33 (91.67%) 199 1 5 (2.76%) 1 (2.78%) 6 2 1 (0.55%) 0 1 3 2 (1.1%) 0 2 4 1 (0.55%) 0 1 5 1 (0.55%) 0 1 10 0 1 (2.78%) 1 14 1 (0.55%) 0 1 19 1 (0.55%) 0 1 32 1 (0.55%) 0 1 43 1 (0.55%) 0 1 47 0 1 (2.78%) 1 58 1 (0.55%) 0 1 Table 5C-6: Survey respondents vs. non- respondents compared by rural CCAC contracts, by organizations in rural region Number of urban CCAC Non-respondents Respondents Total contracts N=53 (column %) N = 14 (column N %) 0 48 (90.57%) 12 (85.71%) 80 1 5 (9.43%) 0 9 2 0 1 (7.14%) 1 3 0 1 (7.14%) 1 Frequency Missing = 2 Table 5C-7: Survey respondents vs. non-respondents compared by organizations that hold MSAAs, rural region Current status with Non-respondents Respondents Total MSAA N=15 (column %) N = 5 (column %) N Don’t hold MSAA 13 (86.67%) 4 (80%) 17 Hold MSAA 3 (13.33%) 1 (20%) 3 Frequency Missing = 49 Table 5C-8: Survey respondents vs. non-respondents compared by NFP and FP status Organizational status Non-respondents Respondents Total N=163 (column %) N=35 (column %) N NFP 113 (69.32%) 28 (80%) 141 FP 50 (30.67%) 7 (20%) 57 Frequency Missing = 19 292 Table 5C-9: Survey respondents vs. non-respondents compared by use of volunteer staff Organizations that use Non-respondents Respondents Total volunteers N=82 (column %) N=25 (column %) N Do not use volunteers 27 (32.93%) 6 (24%) 33 Use volunteers 55 (67.07%) 19 (76%) 74 Frequency Missing = 110 Additional descriptive statistics tables Table 5C-10: Number of organizations in survey that employ full-time (FTE) part-time (PTE) and casual (Ca) human resources Types Number of employees of HR 0 Total 1-10 11-25 26-50 51101201500+ Missing staff N 100 200 500 Nurses FTE Nurses PTE Nurses Ca PTs FTE 69 14 3 0 0 0 0 0 87 27 77 8 2 0 0 0 0 0 87 27 81 3 3 0 0 0 0 0 87 27 81 5 1 0 0 0 0 0 PTs PTE PTs Ca OTs FTE OTs PTE OTs Ca SLP FTE SLP PTE SLP Ca PSW FTE PSW PTE PSW Ca 84 4 0 0 0 0 0 0 88 26 (1 purch.) 88 26 86 1 1 0 0 0 0 0 88 26 84 3 1 0 0 0 0 0 88 26 85 2 1 0 0 0 0 0 88 26 86 2 0 0 0 0 0 0 88 26 85 2 1 0 0 0 0 0 88 26 85 2 1 0 0 0 0 0 88 26 84 1 1 0 0 1 0 0 87 27 52 16 9 5 2 2 1 0 87 27 52 19 7 4 4 0 0 1 87 27 63 12 3 5 1 1 0 1 86 28 293 Diet FTE Diet PTE Diet Ca Admin FTE Admin PTE Admin Ca Rec FTE Rec PTE Rec Ca Ger FTE Ger PTE Ger Ca Other 82 5 0 0 0 0 0 0 26 0 88 1 purc. 88 83 5 0 0 0 0 0 86 1 0 0 0 0 0 0 87 27 22 53 10 1 0 1 0 0 87 27 60 25 2 0 0 0 0 0 87 27 79 8 0 0 0 0 0 0 86 28 66 20 2 0 0 0 0 0 88 26 75 11 2 0 0 0 0 0 88 26 82 4 0 0 0 0 0 0 86 28 84 2 1 0 0 0 0 0 88 26 88 0 0 0 0 0 0 0 88 26 87 0 0 0 0 0 0 0 87 27 47 30 6 1 0 1 0 1 86 28 26 Table 5C-12: Number of organizations in survey that rely on fundraising (Fund), and service volunteers. Types of volunteers Number of volunteers 0 1112651- 101- 201- 500+ Total Missin N g 10 25 50 10 200 500 0 Fund volunteers 56 7 9 5 4 3 0 1 85 29 Service 18 13 6 8 12 13 8 9 86 28 volunteers Direct contract service 25 10 7 7 14 8 9 5 85 29 volunteers Table 5C-13: Differences between reported revenues of survey respondents and what was found in the environmental scan. Org Survey response Environmental ID# Scan A028 130,000,000 5,329,435 A058 190,000,000 528,626 A085 6,400,000 3,173,141 A096 82,000,000 97,544,182 A099 1,022,043.00 815,733 294 A131 A153 A153A A174 A176 A202 A203 $536,088 128,000 (subdivision) 457,106 950,000 816,267 470,027 3,396,085 209,448,931 470,264 818,089 440,719 121,723,000 Table 5C-14: Organizations’ response to accountability Accountability Response Tool Ontario Trillium Yes, applied and currently hold Grant Yes, applied previously and successfully Yes, applied but unsuccessful No, never applied New Horizons Yes, applied and currently hold Grant Yes, applied previously and successfully Yes, applied but unsuccessful No, never applied LHIN MSAA Yes, applied and currently hold Yes, applied previously and successfully Yes, applied but unsuccessful No, never applied CCAC contract Yes, applied and currently hold Yes, applied previously and successfully Yes, applied but unsuccessful No, never applied Veterans Affairs Yes, applied and currently hold Yes, applied previously and successfully Yes, applied but unsuccessful No, never applied First Nations Yes, applied and currently hold Yes, applied previously and successfully Yes, applied but unsuccessful No, never applied Other grants Held United Way 17 (26.15%) Interim Federal 4 (6.15%) Health N Total N Missing 16 (24.62%) 65 19 (29.23%) 65 49 49 3 (4.62%) 15 (23.08%) 14 (22.58%) 15 (24.19%) 65 65 62 62 49 49 52 52 5 (8.06%) 15 (24.19%) 54 (83.08%) 8 (125.31%) 62 62 65 65 52 52 49 49 1 (1.54%) 3 (4.62%) 12 (20%) 4 (6.67%) 65 65 60 60 49 49 54 54 0 21 (35%) 15 (24.59%) 3 (4.84%) 60 60 61 62 54 54 53 52 1 (1.61%) 18 (29.03%) 1 (1.69%) 0 62 62 59 59 52 52 55 55 0 23 (38.98%) Not held 48 61 59 59 Total N 65 65 55 55 Missing 49 49 295 Municipal grant Other grants 17 (26.15%) 1 (n=10) 2 (n=5) 48 49 65 64 Table 5C-15: Organizations’ plans to apply to grants/contracts in the future Grant/agreement Plan to apply in the future Total Yes No Don’t Know N Ontario Trillium Grant 26 (31.71%) 49 (59.76%) 7 (8.54%) 82 New Horizons Grant 28 (33.73%) 45 (54.22%) 10 (12.05%) 83 LHIN MSAA 43 (51.81%) 36 (43.37%) 4 (4.82%) 83 CCAC contract 19 (22.89%) 61 (73.49%) 3 (3.61%) 83 Veterans Affairs 20 (24.10%) 59 (71.08%) 4 (4.82%) 83 First Nations 3 (3.61%) 73 (87.95%) 7 (8.43%) 83 Other (number of other 0 (n=74) 83 applications planned for 1 (n= 7) next year) 2 (n=1) 3 (n=1) 49 50 Missing 32 31 31 31 31 31 31 Table 5C-16: Organizations’ who partner to deliver services under grants/agreements Funding/agreement No. orgs who Total N Missing partnered Trillium 16 (19.28%) 83 31 New Horizons 10 (12.05%) 83 31 MSAA 23 (27.38%) 84 30 CCAC 10 (11.90%) 84 30 Veterans Affairs 5 (5.95%) 84 30 First Nations 0 83 31 Table 5C-17: Organizations’ who subcontracted to deliver services under grants/agreements Funding/agreement No. orgs who No. orgs who were Total subcontracted to subcontracted by N other organizations other organizations (%) (%) Trillium 0 2 (2.38%) 84 New Horizons 0 0 84 MSAA 4 (4.76%) 9 (10.71%) 84 CCAC 4 (4.76%) 3 (3.57%) 84 Veterans Affairs 0 0 84 First Nations 0 0 84 Other 1 (n=2) 2 (n=2) 84 (number of organizations 2 (n=1) who have subcontracts for other purposes) Missing 30 30 30 30 30 30 30 296 Appendix 6-A: Qualitative descriptive and data tables Table 6A-1: Organizational characteristics: size, status, location, contracts/agreements, services delivered and primary clientele Organization Size Status Urban/ Rural CCAC contract/ MSAA Previously held MSAA Holds 5 LHIN MSAAs Services delivered Community Home care care Hospice Friendly visiting ADP Home help Recreation Security check Transportation Friendly visiting CSA 1 Small NFP Rural CSA 2 Medium NFP Urban CSA 3 Small NFP Rural Holds 1 LHIN MSAA CSA 4 -1 Central organization Large NFP Across Ontario Holds 9 LHIN MSAAs and 13 CCAC contracts Personal support/ care Homemaking CSA 4 -2 Branch, medium NFP Rural - CSA 4-3 Branch, medium NFP Rural - Homemaking Personal support/ care Social work Personal support/ care Homemaking CSA 5 Large NFP Across Canada Holds many CCAC contracts and LHIN MSAAs Personal support/ care Homemaking Nursing ADP MOW CSA 5-1 Branch, medium NFP Rural Holds 2 CCAC contracts ADP MOW Transportation CSA 6 Small NFP Rural Holds 1 LHIN MSAA Personal support/ care Nursing Respite Nursing CSA 7 Large FP Across Canada & USA Holds many CCAC contracts ADP Home help Personal support/ care Dietetics Nursing OT PT SLT Home maintenance MOW Transportation Friendly visiting Home help MOW Transportation Friendly visiting MOW Transportation Primary clientele Seniors Seniors Adults with disabilities Focus on specific cultural group (Frenchspeaking clients) Seniors Adults with disabilities Seniors Adults with disabilities Children Seniors Adults with disabilities Children Seniors Adults with disabilities Children Seniors Children Seniors Adults with disabilities Children Seniors Adults with disabilities Seniors Children 297 CSA 8 Large NFP Across Ontario Holds 16 CCAC contracts across 8 CCACs Personal support/ care Dietetics Homemaking Nursing OT PT SLT Social work CSA 9 Medium NFP Rural Holds 1 LHIN MSAA CSA 10 Small NFP Rural CSA 11 Small NFP Urban Holds 1 LHIN MSAA Holds 1 LHIN MSAA Personal support/ care Personal support/ care CSA 12 Medium NFP Urban CSA 13 Medium NFP Urban Holds 1 CCAC contract and 1 LHIN MSAA Holds 1 LHIN MSAA Personal support/ care Homemaking Respite Social work Seniors Adults with disabilities Children Home help Home maintenance Security check Transportation Friendly visiting ADP Home help Recreation Transportation Friendly visiting Home help ADP Home help Home maintenance MOW Recreation Transportation Friendly visiting Seniors Adults with disabilities Seniors Children Seniors Adults with disabilities Children Seniors Adults with disabilities Children Seniors Adults with disabilities Children Focus on specific cultural group Table 6A-2: Participants characteristics - role and involvement in contracts/agreements Organization Role Involvement Urban CCAC Senior Director for Performance Report monitoring Management and Accountability Relationship management Procurement Managing accountees Rural CCAC Senior Director for Performance Procurement Management and Accountability Managing accountees Monitoring Urban LHIN Senior Consultant for Performance Report monitoring Management Managing accountees Rural LHIN Senior Consultant for Performance Reporting monitoring Optimization Indicator development Monitoring Negotiating CSA 1 Program coordinator N/A - No longer hold MSAA. Had been involved in: Reporting Managing contracts/ agreements CSA 2* 1) Executive director. Reporting 2) Assistant to the director Managing contracts/ agreements 298 CSA 3 CSA 4 -1 Central organization CSA 4 -2 Branch Executive director Policy analyst and contracts manager CSA 4-3 Branch Branch manager (rural region) CSA 5 Regional vice president and chief of practice. Administration manager Executive director CSA 5-1 CSA 6 Branch management (rural region) CSA 7* 1) Vice president of operations 2) Senior vice president of home health and business development CSA 8 CSA 9 Director of contract quality and risk management. Senior manager, privacy officer Executive director CSA 10 Executive director CSA 11 CSA 12 Director Program director CSA 13* 1) Director of research and public policy 2) Senior manager of community and volunteer engagement Preparing proposals Negotiate Managing contracts/ agreements Reporting Feedback Indicator development Managing contracts/ agreements Meetings Reporting Feedback Managing contracts/ agreements Meetings Preparing proposals Managing contracts/ agreements Reporting Feedback Indicator development Managing contracts/ agreements Negotiate Relationship management Feedback Managing contracts/ agreements Preparing proposals Managing contracts/ agreements Negotiate Preparing proposals Reporting Managing contracts/ agreements Negotiate Preparing proposals Negotiate Reporting Feedback Managing contracts/ agreements Preparing proposals Reporting Feedback Indicator development Negotiate * Two people were involved in the interview Table 6A-3: Organizational size in relation to organizational response to MSAAs and CCAC contracts Response Organizational size Organization(s) MSAA Compliance Small CSA 6 Medium CSA 9 Medium CSA 13 Internal modification Small CSA 11 Small CSA 3 Small CSA 10 Medium CSA 2 299 Compromise Avoidance CCAC Internal modification Compromise Defiance Large Branch Small Small CSA 4-1 CSA 4-2 CSA 11 CSA 1 Medium Large Large Large Branch Branch Large (FP) Branch Large Branch Branch Branch CSA 12 CSA 4-1 CSA 5 CSA 8 CSA 4-3 CSA 4-2 CSA 7 CSA 4-3 CSA 5 CSA 4-2 CSA 4-3 CSA 5-1 300 Table&6A)4:&Participant&reported&conflict&between&stakeholder’s&accountability&demands&in&relation&to&organizational&response&to&LHIN&MSAAs&and& CCAC&contracts& Response' Perceived'dependence' No.' Stakeholder'accountability'demands' Org.(s)' stakeholders' Perceived'conflict' Additional''resource'demand' ' ' MSAA$$$$$$$$$$$$$$$$$$$$On&LHIN& Compliance& Yes,&75%&funded& 3& No**& & CSA&9& Yes,&64%&funded& 5& No& & CSA&6& No,&15%&funded& 6& Yes*& Yes& CSA&13& Internal& Yes&100%&funded& 7& Yes& & CSA&10& modification& Yes,&80%&funded& 3& & & CSA&3& Yes,&50%&funded& 6& & & CSA&2& Programs&dependent,&68%&funded& 4& Yes*& Yes& CSA&11& Funded&services&dependent& 4& Yes& & CSA&4)1& No,&20%&funded& 3& Yes& & CSA&4)2& Compromise& Programs&dependent,&68%&funded& 4& Yes*& Yes& CSA&11& Avoidance& No,&20)30%&funded& 4& & & CSA&1& CCAC$$$$$$$$$$$$$$$$$$$$$On&CCAC& Internal& Yes,&85%&funded& 4& Yes*& Yes& CSA&8& modification& Yes,&80%&funded& 3& Yes& & CSA&4)2& Branch&dependent,&95%&funded&& 4& Yes& & CSA&4)3& More&dependent&than&on&LHIN& 4& Yes& & CSA&4)1& More&dependent&than&on&LHIN& 5& Yes& & CSA&5& No,&but&loss&of&fund.&would&impact&prog& 4& Yes& & CSA&12& Compromise& Branch&dependent,&95%&funded& 4& Yes& & CSA&4)3& Branch&dependent,&65)70%&funded& 3& No& Yes& CSA&7& Defiance& Yes,&80%&funded& 3& Yes& & CSA&4)2& Branch&dependent,&95%&funded&& 4& Yes& & CSA&4)3& Programs&dependent,&95)98%&&funded& 4& Yes*& Yes& CSA&5)1& More&dependent&than&on&LHIN& 5& Yes& & CSA&5& *Identified&conflicts&between&agreements,&but&also&stated&that&they&did&not&feel&demands&were&in&conflict&with&each&other.&&& **&but&they&noted&that&they&had&heard&of&other&organizations&who&had&experienced&conflict&between&accountability&demands&associated&with&the&MSAA&and&other&stakeholder& accountability&requirements& & & 301 Table&6A)5:&Goal&alignment&in&relation&to&organizations&response&to&MSAAs&and&CCAC&contracts& Response' Goal'alignment' Organization(s)' MSAA$ Compliance& Yes&(A)& CSA&13& No& CSA&6& N/A& CSA&9& Internal&modification& Yes&(A)& CSA&11& Yes&(Ac)& CSA&3& Yes&(A,&P)& CSA&10& Yes&(A,&Ac)& CSA&4)1& Yes&(A,&Ac)& CSA&4)2& No& CSA&2& Compromise& Yes&(A)& CSA&11& Avoidance& Yes&(P)& CSA&1& CCAC$ Internal&modification& Yes&(A,&Ac)& CSA&4)1& Yes&(A,&Ac)& CSA&4)2& Yes&(P)& CSA&5& Yes&(A)& CSA&12& Yes&(A,&Ac)& CSA&4)3& Yes&(A,&P)& CSA&8& Compromise& Yes&(A,&Ac)& CSA&4)3& Yes&(A,&Ac)& CSA&7& Defiance& Yes&(A,&Ac)& CSA&4)2& Yes&(P)& CSA&5& Yes&(A,&Ac)& CSA&4)3& Yes&(P)& CSA&5)1& N/A:&Organizational&mission/value&statement&not&available&for&comparison& A:&Accessibility;&P:&Professionalism;&Ac:&Accountability& 302 Table&6A)6:&Perceived&autonomy,&dependence,&and&flexibility&in&relation&to&organizational&response&to&LHIN&MSAAs&and&CCAC&contracts& Response' Perceived'dependence' Perceived'flexibility' Impact'on'autonomy*' Org(s)' ' Admin.' Service'delivery' ' MSAA$$$$$$$$$$$$$$$$$$$$On&LHIN&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&MSAA& Compliance& Yes&75%&funded& Not&flexible.&& & & CSA&9& Yes,&64%&funded& Flexible,&how&the&organization&works& & No& CSA&6& No,&15%&funded& Flexible,&meeting&targets& & & CSA&13& Internal& Yes&100%&funded& Flexible,&meeting&targets**& & & CSA&10& modification& Yes,&50%&funded& Not&flexible& & & CSA&2& For&funded&services& N/A& Yes& No& CSA&4)1& Yes,&80%&funded& Flexible,&meeting&targets& & & CSA&3& Programs&dependent,&68%&funded& Flexible,&meting&targets& & & CSA&11& No,&20%&funded& Flexible,&meeting&targets& & & CSA&4)2& Compromise& Funded&programs&dependent& Flexible,&meeting&targets& & & CSA&11& Avoidance& No,&20)30%&funded& Not&flexible& Yes& & CSA&1& CCAC$$$$$$$$$$$$$$$$$$$$$On&CCAC&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&CCAC& Internal& Yes,&85%&funded& Some&CCACs&flexible& & Yes& CSA&8& modification& No,&but&loss&of&fund.&would&impact&prog& Use&to&be&more&flexible& & Yes& CSA&12& More&than&LHIN& Flexible,&meeting&targets& Yes& No& CSA&4)1& Yes,&80%&funded& Flexible,&meeting&targets& & & CSA&4)2& More&dependent&than&on&LHIN& Flexible,&meeting&targets+& & Depends& CSA&5& Branch&dependent,&95%&funded&& Flexible,&meeting&targets& & & CSA&4)3& Compromise& Branch&dependent,&95%&funded& Flexible,&meeting&targets& & & CSA&4)3& Branch&dependent&,65)70%&funded& Flexible,&meeting&targets& & No& CSA&7& Defiance& Programs&dependent,&95)98%&&funded& Some&CCACs&flexible& & Yes& CSA&5)1& + More&dependent&than&on&LHIN& Flexible,&meeting&targets & & Depends& CSA&5& Branch&dependent,&95%&funded&& Flexible,&meeting&targets& & & CSA&4)3& Yes,&80%&funded& Flexible,&meeting&targets& & & CSA&4)2& *&There&is&missing&data&with&regard&to&autonomy&as&this&question&was&cut&off&when&interviews&ran&too&long.&&& **&Also&identified&that&they&have&to&“fully&comply.”&&& +&But,&becoming&less&flexible&over&time.&& Green&–&propositions&supported;&Orange&–&not&supported& & 303 ! Table!6A)7:!Participant!reported!perceived!strictness!and!role!clarity!in!relation!to!organizational! response!to!LHIN!MSAAs!and!CCAC!contracts! Response' Strictness' Role'clarity' Organization(s)' MSAA$ $ $ $ Compliance! Strict! HCC!role!)!clear! CSA!6! Strict! HCC!role!–!clear.!! CSA!9! LHIN!role!–!not!clear! ! HCC!role!–!clear! CSA!13! LHIN!role!–!clear! Internal!modification! Strict! HCC!role!)!clear! CSA!10! Strict! HCC!role!)!clear! CSA!4)1! Unsure! HCC!role!)!clear! CSA!2! Unsure! HCC!role!–!not!clear! CSA!3! ! HCC!role!)!clear! CSA!11! ! HCC!role!–!clear! CSA!4)2! LHIN!role!–!clear! Compromise! ! HCC!role!)!clear! CSA!11! Avoidance! Financial!is!strict! HCC!roles!–!not!clear! CSA!1! CCAC$ $ $ $ Internal!modification! Strict! HCC!role!–!partially!clear! CSA!4)1! Strict! HCC!role!–!clear! CSA!4)2! CCAC!role!–!clear!! Strict! HCC!role!)!clear! CSA!4)3! Somewhat!strict! HCC!role!–!not!clear! CSA!12! Reasonable! HCC!role!–!not!clear! CSA!5! Reasonable! HCC!role!)!clear! CSA!8! Compromise! Strict! HCC!role!!)!clear! CSA!4)3! Fair! HCC!role!!)!clear! CSA!7! Defiance! Strict! HCC!role!–!clear! CSA!4)2! CCAC!role!–!clear!! Strict! HCC!role!)!clear! CSA!4)3! Fair! HCC!role!–!clear!! CSA!5)1! ! Reasonable! HCC!role!–!not!clear! CSA!5! ! Table!6A)8:!Organization’!access!to!resources!and!perceived!additional!resources!required!to!meet! accountability!requirements!in!relation!to!responses!to!MSAA!and!CCAC!contracts.! Response' Organizational'size' Additional'resources'required' Organization(s)' MSAA$ Compliance! Small! None! CSA!6! Medium! Time,!Tech,!HR! CSA!9! Medium! HR,!Time! CSA!13! Internal!modification! Small! None! CSA!11! Small! None! CSA!3! Small! HR,!Time*! CSA!10! Medium! Time,!HR! CSA!2! Large! Financial,!HR,!Time! CSA!4)1! 304 Compromise! Avoidance! CCAC$ Internal!modification! Compromise! Defiance! Branch! Small! Small! Financial,!HR,!Time! None! Time,!Financial,!HR! CSA!4)2! CSA!11! CSA!1! Medium! Large! Large! Large! Branch! Branch! Large!(FP)! Branch! Large! Branch! Branch! Branch! Time,!Financial,!HR! Time,!Tech! Financial,!HR,!Time! Time,!Tech! Tech,!HR! None! HR,!Time! None! Time,!Tech! Time! Tech,!HR! None! CSA!12! CSA!8! CSA!4)1! CSA!5! CSA!4)2! CSA!4)3! CSA!7! CSA!4)3! CSA!5! CSA!5)1! CSA!4)2! CSA!4)3! *Not!perceived!as!“additional”! ! Table!6A)9:!Participant!reported!quality!responsibility!in!relation!to!organizational!response!to!LHIN! MSAAs!and!CCAC!contracts! Response' Responsibility'for'quality' Organization(s)' MSAA&$Organization$ Compliance! Organization! CSA!6! Organization! CSA!9! Primary!frontline!staff! CSA!13! Internal!modification! Organization! CSA!4)1! Organization! CSA!3! Organization! CSA!10! Collective! CSA!11! Collective! CSA!2! Collective! CSA!4)2! Compromise! Collective! CSA!11! Avoidance! Collective! CSA!1! CCAC$–$Collective$ Internal!modification! Collective! CSA!4)2! Collective! CSA!5! Collective! CSA!8! Collective! CSA!4)3! Mostly!organization! CSA!12! Organization! CSA!4)1! Compromise! Collective! CSA!4)3! Collective! CSA!7! Defiance! Collective! CSA!4)2! Collective! CSA!5! Collective! CSA!4)3! Collective! CSA!5)1! 305 306 Appendix 6-B: Role/ involvement descriptions Managing contracts/agreements: General management of services covered under the contracts/agreements. This may include monitoring targets, overseeing service delivery under contracts/agreements, and ensuring that the organization meets requirements and the terms of the contracts/agreements. Managing accountee: Involved in generally managing contracts/agreements and monitoring service delivery from HCC organizations under agreements/contracts. Report monitoring: Reviewing reports from accountees. Monitoring: Monitoring HCC organizations under contracts/agreements in terms of their targets (beyond just reports). Reporting: Preparing and submitting accountability reports to LHINs and CCACs. Meetings: Attending meetings as part of the contract/agreement. Negotiating: Involved in negotiating the agreement/contract between the LHIN/CCAC and the HCC agency. Relationship management: Managing the business relationship between accountor and accountee with regard to contracts/agreements and broader quality improvement efforts. The Urban CCAC respondent described this as follows: “… we have a series of activities around quality improvement that are outside of the contracts. It’s work that we are doing together with the service providers to improve quality in client experience. It’s beyond just what our basic contract relationship is.” (Urban CCAC). Procurement: Managing the CCAC procurement process (at the CCAC). Preparing proposals: Involved in preparing proposals to LHINs and CCACs for funding (RFPs in the case of CCACs). Indicator development: Involved in developing indicators that are included in accountability requirements (only related to LHIN MSAA). Feedback: Providing feedback to LHINs or CCACs regarding service delivery. This includes sitting on committees that are put in place by LHINs or CCACs which were established to get service provider perspective on service delivery. 307 Appendix 6-C: Descriptions of organizational goals Status and volunteerism: Organizations identified clearly their not-for-profit status and/or strong volunteer support as part of their statements. Their status and/or use of volunteers are identified as being a key aspect of their organizational identity. Commitment to client: Organizations explicitly specify a dedication to support the needs of clients, including respect, dignity and inclusive care without discrimination for clients and their caregivers. Accessibility: Commitment to providing care to individuals when it is needed. Also includes non-discrimination clauses. Professionalism: Specific mention of the use of professional staff or staff commitment to professionalism. This also includes identification of a commitment to delivering high quality care, the use of evaluation for improvement and evidence-informed service delivery. Innovation: Organization identifies that they strive for new, innovative approaches to care and service delivery. Quality of life: Specific mention of seeking to improve the quality of life of clients Leadership: mention of goal of leading the sector in some way (in terms of delivering high quality care, specific services, etc.) Team/partnership: Organization identifies the important of working as a team within the organization or with other health care service providers, families, caregivers, clients, and communities. Accountability: Organization identifies a commitment to accountability and transparency. Influence social/health policy: Commitment to influence social and health policies