Primary care and the congruence model.

What framework can be applied to any organization to analyze its strengths and weaknesses - and pinpoint specific areas for improving effectiveness? Created by organizational development experts Nadler and Tushman (and further expounded upon by Tushman and O'Reilly), the congruence model, traditionally used in other industries, can also be used to evaluate primary care organizations (PCOs), including private practice groups, as well as clinic settings.[1,2]

This model considers organizations to be open systems comprised of three major interactive components: inputs, throughputs, and outputs puts (Figure 1). Inputs include such factors as organizational history and external conditions; managed care regulations provide the clearest example of environmental changes that directly impact health care organizations today. Strategy is an essential input that serves as the driver for organizational functioning (through-puts) and specification of its outputs. Strategy includes mission and vision; an example in primary care is the mission of providing comprehensive, continuous patient care.

The second component is throughputs, those organizational elements and mechanisms that convert strategy and resources into products and services. Examples of task-related PCO throughputs shaped by the new health care climate include gatekeeping, clinical pathways, and benchmarking.

Outputs - third component of the open system - include measurable services, such as quality of patient care. While clinical care has always been the major output of medical practice, new outputs include both cost efficiency and patient satisfaction, as measured in surveys.

Open systems are dynamic and, as such, incorporate feedback mechanisms. For example, physician executives can gather data on the quality and quantity of outputs, such as clinical and economic profiling. They can then perform gap analysis, which is a comparison of how closely outputs match strategic goals. With the results of this analysis an objective, quantitative basis, leaders can make changes in inputs and throughputs to better align the organization to its environmental and create products and services that more closely accomplish the desired outputs.[3]

In addition to ongoing gap analysis, physician executives should keep abreast of environmental changes in order to update strategy, change outputs where necessary, and adjust throughputs to accomplish the new output objectives.

Several other general characteristics of organizational systems have important implications to primary care leaders. Because the various elements of the system are interdependent a change in one component will modify others. In addition, open systems naturally strive toward equilibrium. This tendency can result in one of two outcomes: a move toward a new balance, or resistance to change. As a result, when attempting to make changes, leaders must anticipate potential sources of resistance and plan ways to overcome them.

Effective leaders are critical to organizational functioning in several ways. Leaders use information from the external environment to develop and revise strategy proactively. They continually communicate the strategy (including mission, vision, and goals) to clarify priorities, roles, and tasks. And they monitor all aspects of internal organizational functioning, as well as the outputs to keep the organization on its course. Since there is no single right way to operate or change an organization to maximize its effectiveness, the role of leadership is paramount.

Applying the

congruence model to PCOs

What are the overall methods to increase organizational effectiveness? Figure 2 illustrates the congruence model in the context of the managed care environment. There are four throughput put elements; they are all linked and they reciprocally impact each other. They are:

1. Work Elements

These comprise the essential individual and group tasks that the organization must perform in order to accomplish its strategic objectives. There are three types of task flows. Each carries different implications for organizational dynamics and effectiveness; in addition, one or more types of task flows may exist for any given individual or groups of people. The first type of flow is parallel, where individuals independently accomplish their work; for example, primary care providers (PCPs) examine and treat parallel panels of patients. The second type of work flow is sequential, where an employee is dependent on receiving another's product or information. For example, primary care providers need feedback from diagnostic services, ancillary staff, and plan authorization personnel. For third type is interactive, where complex, reciprocal flows occur. PCPs interact act in this manner with specialists and mid-level providers on their clinical team.

2. Human Elements

Human resources considerations involve three aspects: 1) individual competencies, including skills, knowledge, and abilities needed to perform the work elements; 2) personal motivational structure, including needs for growth, achievement, affiliation, and power; and 3) team structure, i.e., the mix of competencies and motivations in each group. PCPs have skills, knowledge, and abilities based on completion of their graduate medical training. Their motivations include meeting their patients, needs, fulfilling professional standards, and obtaining financial security. Although the private solo practitioner was not traditionally team-oriented, today's group practice and clinic settings emphasize working cohesively within the group or clinic, as well as with ancillary staff and mid-level providers.

3. Organizational Elements

These are the formal structures and systems, including reporting relationships, formal work groups, information technology, and systems for performance measurement, reward, and control. In information technology, the growing use of comprehensive computer systems is improving decision-making abilities by alerting the physician to drug interactions, actions, providing comprehensive clinical and guideline databases. Increasingly, managed care companies are requiring or assisting in such computer linkages. Moreover, MCOs have been the driving force for economic as well as clinical profiling of physician performance.

4. Cultural Elements

These include informal, socially-oriented aspects of organizations such as power structures, communication patterns, group behavioral norms, values, and attitudes. This group of elements is the most difficult to observe and measure. Yet, in some ways, it is the most important because it is the source of resistance to change. This can be observed in PCPs' reluctance to give up clinical autonomy to practice guidelines or managed care utilization review. Given their education and orientation towards empirical evidence, physicians need strong efficacy data if they are to accept the guidelines and review procedures. In addition, because practicing physicians do not fully respect guidelines developed solely by academics, they need to see that physician leaders, who they hold in esteem, have actively participated in their development.

The congruence model assumes that the chosen strategy is correct, and that problems that limit organizational effectiveness - defined as inadequate or inappropriate outputs - due to either a lack of congruence between strategy and the functional elements or to a poor fit between two or more of the functional elements.

The first step in applying the model is to understand the environment and strategy in which the PCO is operating, analyze current outputs, and search for performance gaps between strategy and outputs. With knowledge of the performance gaps as a base, the next step is gather data on the four throughput elements, beginning with work elements. The final step is to use the data analyze incongruencies between all combinations of the four throughput elements to discover underlying causes problems and serve as the basis for generating potential solutions.

The impact of managed care

Managed care organizations have caused several major changes in the health care environment that directly impact PCOs. Managed care contracts emphasize the importance of primary care providers (PCPs) in their new role as gatekeepers. MCOs have new types of recordkeeping requirements, such as authorizations for procedures and utilization review reports. They often provide monetary incentives for less testing, fewer referrals, and less costly, but marginally beneficial, treatments. They also enforce sanctions, such as dropping physicians from the company's provider panel for lack of compliance with these requirements.

In analyzing the PCO in this new climate, one must consider the strategy and outputs. As a result of MCO requirements, strategies have changed to maximize four critical, measurable outputs: 1) clinical outcomes; 2) patient satisfaction; 3) cost efficiency; and 4) market share. While clinical outcomes were always paramount and patient satisfaction was implied, now cost efficiency and market share have gained equal or nearly equal importance with clinical outcomes and patient satisfaction. These changes have had profound impacts on the four organizational elements of PCOs. A summary of potential incongruencies among the elements which can arise are shown in Table 1.

[TABULAR DATA OMITTED]

Work elements have changed for the primarily care provider. The PCP must now do more actual patient care with less referral to specialists. The provider is being pressed to restrict resource consumption of services, a reversal of the practice model under the fee-for-service arrangement. The PCP must also comply with a host of MCO regulations. These regulations vary among MCOs; each has its own required forms, as well as different policies regarding, for example, authorizations for tests and procedures. Providers need to know these requirements in order to maximize their efficiency in seeing patients.

Due to these changes in work elements, potential incongruencies must be addressed by primary care management. First is the possible lack of fit between the work and human elements. PCPs will most likely need to upgrade their knowledge and skills in two areas: (1) some medical topics that had previously been in the purview of specialists; (2) computer literacy, particularly in online systems, such as clinical practice guidelines, databases, and MCO forms and requirements. Second is the possible incongruency between work and organizational elements. With the change in task flow that requires the PCP to be a gatekeeper, changes may be needed in formal organizational systems to make the job of gatekeeper more efficient, especially given the different requirements among MCOs.

Changes to the organizational element resulting from MCO requirements are causing potential incongruencies that limit PCO effectiveness. One of the most important ones is the lack of fit between the organizational and cultural elements as a consequence of a major, formal power shift in the organization away from physician autonomy. This runs counter to the values physicians hold closely as professionals able to exercise their own judgment regarding patient care. Resistance, both implicit and explicit, may occur.

A related incongruency may be found between organizational and human elements@ practice guidelines, set forth as a formal system, serve as a vehicle for limiting physician autonomy; this may affect PCPs' motivation levels. Another possible lack of fit between organizational and cultural elements relates to performance evaluation systems. In many cases these have changed to meet MCO requirements for patient satisfaction, cost containment, and market share measurements. New performance evaluation standards need to be communicated explicitly to PCPs to avoid role and task ambiguity. Another example can be found between managed care plan requirements and the physicians' perceptions of patients' best interests; this also can produce resistance to certain formal changes.

Up to this point, the congruency model has been used to analyze potential sources of decreased organizational effectiveness in PCOs' based on the impact of changes brought about by MCO requirements on physicians. In addition, incongruencies which may affect nurses should be considered by management in order to improve PCO functioning in the new managed care environment. There may be a lack of fit between work and human elements where nurses are now being called upon to provide more proactive case management or demand management functions. They may need skill upgrading to perform these new tasks effectively. If they do not receive additional rewards - monetary or non@ monetary - they may resist such changes.

Conclusion

The congruence model of organizational effectiveness is an excellent tool that physician executives can use to assess how well PCOs are accomplishing their strategic goals, as measured by specific outputs. In addition, they can use the model to analyze the four organizational throughput elements and pinpoint root causes of problems that hamper achieving desired objectives. This article has demonstrated some specific areas where changes caused by MCO requirements have affected PCO strategy and outputs, and where possible incongruencies between the work, human, organizational, and cultural elements may be limiting PCOs' organizational effectiveness. Using this approach can enhance PCO functioning by identifying potential and existing incongruencies.

Managed care initiatives have created new roles, processes, power structures, and objectives. Periodic analysis of congruency of the through-put elements with strategy and with each other is necessary to enhance organizational functioning. It is vital that physician executives exercise strong participatory leadership to guide changes in organizational values and culture, as well as to recognize and plan to deal with potential sources of resistance from PCPs, nurses, and support staff.

Primary care executives must monitor and internal organizational conditions, and use this information to revise strategy when necessary. Maintaining a perspective on the PCOs' history and communicating a vision of its future is also needed. Current concerns may be paramount, but they cannot obliterate the historical perspective on the continuum of primary health care delivery. This is essential to the PCOs' flourishing in the dynamic health care environment.

Key Concepts: Congruence Model/Primary

Care Organizations/Change/Managed Care/

Organizational Effectiveness

The congruence model is a framework used to analyze organizational strengths and weaknesses and pinpoint specific areas for improving effectiveness. This article provides an overview of organizations as open systems, with examples in the primary care arena. it explains and applies the congruence model in the context of primary care issues and functions, including methods by which the model can be used to diagnose organizational problems and generate solutions. Changes needed in primary care due to the managed care environment, and areas of potential problems and sensitivities requiring organizational changes to meet market and regulatory demands now placed on PCOs are examined.