William Richard Scott

Transcription

>>>DR. KALUZNY: Why don't we begin. It really is a personal privilege for me to introduce Dick Scott. I've known, worked with him a number of years. On a very personal note, I think I first encountered the name Scott with Scott & Blau when I was a graduate student at another university, the University of Michigan. And, you know, your image when you're 25 years old and you're reading these legendary books is, these guys are just sort of old and crotchety and so forth and so on. Right. Ten years later to fast forward this, I happened to be sitting on a study section or some kind of advisory committee with Scott and there he was. Just a decent, nice, humane person. It was just a wonderful experience. And ever since then it's been a very close and rewarding relationship. Dick is presently Professor Emeritus in Sociology. I think since the beginning of time he was professor and it just recently became emeritus. But I think what is also interesting when you look at his work at Stanford, he's also a clinician with courtesy appointments in the School of Medicine, in the School of Business, in the School of Education. And for a number of years, I think more than ten, headed up and was the founding director of their Center of Organizational Studies. Which was a unique thing that brought all the people who were interested in organizations to interact together. If you'd begin thinking about multi-level interventions this clearly had to be one of these things. I mention all this because several points. Number one, the fact that he's been involved in four or five different schools reflects a really broad exposure and interest in the major social issues of our time, and the ability of sociology to contribute, to really dealing with the conceptual and analytical issues associated with understanding organizations, how they function, what are the factors effecting their change over a period of time. These are major, major things. Secondly I'd like to point out, as I look around the room I'm reminded that not only has Dick been very busy in publishing books and papers, and I can't remember how many, but it's a pretty impressive list. He also has been very productive in turning out some of the new scholars of which we have a significant number in this room. Who have been either his students or exposed to him in a particular way, for which we're most grateful because these people will continue to work in an area that I think is where the future is and where we're going. The third thing I want to mention is the fact that, I mentioned he's emeritus. And in one of the conversations I had with Dick, maybe two or three years after you achieved emeritus status, he said I'm flunking retirement. You know, that was a very profound statement because on the other hand, as we all deal with these kinds of things, I think of myself. But more importantly, in his case he continues to make a tremendous contribution while he's flunking retirement, in which he's currently added to his repertoire of activities, his portfolio, where he's involved with the engineering community. Civil and environmental engineers. And if I may be so bold as to advertise a forthcoming book, your Cambridge University Press, Global Projects Institutional and Political Challenges. I think it's going to be a real winner. Dick, thank you very much. >>>[APPLAUSE] >>>DR. DICK SCOTT: Well, this seems like an odd time for a keynote somehow, or it's more like a swansong I think. It's clearly the end. But I'm here because I was persuaded to come by Arnie and by the two Steve's. I appreciate the invitation. And as you heard from Arnie I'm an organization sociologist and I've primarily concentrated my attention on study professional organizations, schools, research institutes, hospitals, health care organizations, and now engineering firms. I'm not an expert as you will quickly find out, I'm not an expert on cancer care systems. Everyone in this room knows much more about that than I do. What little I know I learned when I was on the advisory board working with Arnie and Dick Warnecke intervention program, and I thought that was fascinating work. I've looked over a number of the papers before I came, and I listened to the discussion today. I'm very pleased to observe yet another locale in which there is thoughtful and productive interaction between the social scientists, medical scientists and researchers across the spectrum. And I wanted to comment a little on the papers, but I'll sort of refer to them in a glancing way. I thought the most useful thing I could do with my 30 minutes of allotted fame here is to offer a somewhat related but alternative framework for thinking about multi-level analysis. But first, a couple of background comments. I sort of grew up with the field of organization studies. As Arnie said I began in Chicago working with Peter Blau and he was one of the founding people that sort of created a new, more macro level approach. And so as a part of that process, one of the things I observed over time was an expanding sort of levels of analysis world in which we began by thinking about organizations primarily as environments within which individuals behave, and then we began to think about organizations themselves having structures, and certain kind of distinctive competence. And then we moved up to look at the organization sets and the exchange partners that they had, and then we moved up to looking at types of organizations. And finally we moved up to level organization fields. And I'll come back to organization fields because from my standpoint, and I think for this group, I think organization field provides a very nice possible focus for multi-level work because it encompasses the individual, the structural, the population level and provides a framework within which one could talk about those things. In addition to expanding levels of analysis, there have been over time expanding scope of variables. We began by looking fairly narrowly at organizations and instrumental systems, we used a sort of economic exchange models and so on. Then we began to think about power and politics, both intra and inter-organizational. A move to look at relational systems and the more symbolic and cultural elements. And then finally and more recently to look at these sort of knowledge systems that really needed to mobilize and create and increase the capacity in that way. Now, I think the expanding perspectives that we're talking about are very nicely reflected in all the papers we've heard and the papers I've looked over for the conference. They all take seriously the importance of social context and the central role that it plays in explaining behavior. They all recognize the complexity of this context, the fact that they're interacting and reciprocally interdependent variables. They recognize that there are multiple types of variables that are operating, political, social, economic, psychological and so on. And as we also have heard, because cancer care is a prolonged process, all this takes place very often over long periods of time and across multiple types of systems. And so there's a lot of complexity there to look at which I think we can get our heads around by looking at the perspective of fields. And so that perspective is one which takes as the focus of attention a set of organizations that in the aggregate are doing similar kinds of things. So think about cancer care organizations for example. But also, not just a population. You think about the key suppliers, the key exchange partners, the key regulators, the key funders, both vertical and horizontal connections, because they are important players in this thing called field. An alternative definition that I've offered is the notion of field connoted the existence of a community of organizations that partakes of a common meaning system and whose participants interact more frequently and faithfully with each other than with those outside the field. Now, what does it mean more concretely to take an organizational field perspective? Well, an approach that my colleagues and I developed at Stanford several years ago was to think about, well what are the critical components of fields? Well, they're actors. And the actors are both individual and collective. There are patients, there are physicians, there are nurses, there are health care systems, there are hospitals and so on. Those actors vary in terms of being more or less central, peripheral, some of them are very emergent as in social movements, some of them are highly established and highly vested in their environment. So there is the actor component, number one. Number two, and I think this is the most neglected part of the discussions I heard today. There is also a set of institutional logic. That is, what are the cognitive and the normative assumptions associated with each of those kinds of actors? Each brings a somewhat different set of perspectives. And in a world like cancer care where there is so many different kinds of professional groups, different kinds of physicians, different kinds of nurses, different kinds of legal people, different kinds of administrative people, in this world you find a wide range of really quite differing and very often conflicting sets of values, assumptions, perspectives, belief systems and so on. And so we need to take into account actors and their associated beliefs, norms, expectations, values and so on. And then third, all of this takes place within a set of frameworks. And many of those governance frameworks, and these are frameworks that attempt to provide for some means of coordination, control, order, stability, whatever. And those, of course, frameworks exist both at the organizational level, at the multi-organizational level, it may be alliances and that kind of thing among organizations, but also on up to the national, the state and the national levels and so on. So all of a sudden we've got a lot of different levels and types of phenomena going on here. In addition, fields, of course, are all organization fields, are always subcomponents of larger societal systems. And the societal systems increasingly are subcomponents of larger transnational systems. So we always recognize that even though there's a complex entity, we have to see it as a part of a larger system and framework. Now, just thinking about the larger environment of the health care system. One of the things I didn't hear nearly as much about that I wanted to was the fact that if you want to talk about context, seriously, in Las Vegas, California, in the United States of America, you have to recognize very, very forcefully what a distinctive context this is. What a distinctive context the American context is, particularly in health care. Tom Vogt alluded to this, but we really need to give a lot more attention to this as effecting virtually everything we were talking about today. To begin with, in the United States much more so I think that in most countries, the boundary between the health care system and any of the fields that go within the health care system is much more permeable and much more invaded by broader societal logic than it is in many countries. The health care system is really highly vulnerable and highly open to a wide range of political and social and external societal forces. And when we talk about multi-level interventions, you don't start a whole constant at the societal level. It's going to be there. In fact this conference almost didn't happen because of events at the societal level. So that has to be very much in mind. Think about the values of the society. Very much a market orientation. We think the market solves everything, and we think the government is the problem instead of the solution. There's a whole set of assumptions there about the conditions under which health care is provided that constitute a set of very important boundary assumptions on the kind of interventions that we try to examine and try to study. It's a very federalized system. The national government is very distinct from the state governments, and the state governments are very separate and different and very distinctly unique across the societies. And so when we talk about what's happening at the state level we say, well what state. You know, which state? Which state are you talking about? And so these are another set of variables. We live in a society in which there is enormous, enormous attention to and emphasis on the freedom and the autonomy of individual actors. And so there's a suspicion of any kind of authority or any kind of control. And particularly in the medical world there is an enormous amount of attention to the prerogatives and the autonomy of the providers and so on. These are all factors that have an enormous effect on what we're talking about. A little more locally, in terms of the funding environment for, looking at intervention in health care systems, there is the funding environment and the insurance companies, and those kind of agencies. There is the structure of research funding, the structure of NIH and the disease orientation, the disease focused orientation, the different branches of that. With respect to the foundations, what are their agendas for research. And so all of those things begin to have an enormous effect on what kind of interventions are possible, what kind of interventions can be sustained and so on. And so we live, the health care system generally is a part of a very distinctive societal context that is continually intervening in the kind of things we think we're trying to study and examine, and perhaps try to change. We use this field level model in our study to look at the structure of generally medical care delivery systems in one complex area, the San Francisco Bay area. And we looked there at a 50 year period, speaking of time. Looking, taking a longitudinal approach. What are the changes that have occurred in the health care system of the United States or at least in a significant specialized case within the United States. And in terms of actors for example, going back to the list, in terms of actors. We found over time the physicians and the nurses, the other kinds of individual providers, had become, of course, much more numerous, but also much more specialized than they were 50 years ago. The physicians are increasingly organized into groups, both actual and virtual. There are new types of roles of all kinds that didn't exist at all, of course, 50 years ago. The more generalized organizations like community hospitals are increasingly being replaced by the specialized agencies and the urgent care centers, and the renal dialysis centers and so on. Non-profit forms increasingly replace or challenge for profit forums. And so enormous changes over time in the kinds of actors. But the institutional logics, we begin with a period in which by and large most of the logics were dominated by physicians and by the profession of medicine, moving into a context later where the federal government begins to worry not only about quality of care as defined by physicians, but about access and equity and those kinds of concerns. And then you begin to move towards a concern now with increasing attention to the logics of efficiency, cost effectiveness and cost attainment in a more recent period. So the government structures began with largely professional associations, were of course added to by federal and state regulatory groups. And so there have been changes across the board there. And so at the present time, if you look at the larger medical care system, these really very highly differentiated, specialized actors, co-exist together with their conflicting logics creating a kind of a cacophony which really has an enormous effect on the provision of medical care in this country. Now let me say just a couple of words about the advantages of a field level conception for multi-level approaches. First of all, I think it stresses the centrality of organizations to the way in which things happen in modern society. I think organizations are the major actors in a complex modern society. We created organizations to be our agents and increasingly most of us, you and I, are now their agents. And they have an enormous effect, enormous effect on how we organize our world and our work. It shifts attention, most of the levels, tables and so on, talk about different variables and different measures. It shifts attention from generalized attributes and factors to talk about specific actors, specific types of actors, embedded in particular context. It customizes the notion of levels. It says, okay, there are levels, but the levels are occurring within what kind of setting, within what kind of larger field. It is very heuristic. You can use field boundaries to talk about the whole health care delivery system, the whole medical establishment if you want to. You can also use it to go down to talk about specific policy arenas. Or, you could use, for example, this to talk about what is the organizational field that develops around a particular type of intervention, a particular type of agency. If we want to intervene in this way, what are the kind of social individual and collective actors, what are the logics they bring, what are the government structures going to be activated. You could look at that as a way of bounding the field of interest to your research. They're dynamic. A lot of emphasis in the papers, in Jeff's paper and others, on the importance of time. These structures are best mapped and understood over time. They are developing and changing over time. It encourages, indeed almost forces us to think about more longitudinal approaches and models. One of the best books that talks about these kinds of issues is a recent book by Paul Pearson called Politics in Time. He said almost all of our social science analysis neglects the historical dimension. We don't realize the extent to which most of the effects we observe have long term, mostly outcomes we observe have long time effects. And most of the interventions we have have long time outcomes. And we just, they're just censored right and left censored. The field approach, because it's deeply embedded in institutional perspective, emphasizes the co-existence and the co-interdependence of both cultural and structural factors. Actors have particular locations in relational space, they also have distinctive identities, they have distinctive interests. It's very important to think about the cultural material that surrounds the kinds of actors that we're trying to understand. It's like, to think about looking at action is like trying to look at an actor in a play without knowing what the plot is. It's like trying to look at a player engaged in a game and not knowing what the game is about. You really need to ground the action, the context. The meaningful context is not only structural, it is also cultural, and that needs to be unpacked and understood. The field approach also accommodates this ongoing, ever present tension between structures and actors. It recognizes that actors are embedded in context, that they are constrained by those contexts, but they're also empowered by those contexts. And it recognizes the actors are themselves agents. And when I say actors I mean both organizations and individuals. This concept of a dynamic relationship between structures and actors was greatly advanced by two kinds of elements. One, Anthony Gidden's work on structuration theory, that recognizes that the duality of agency and context, that context both grows out of action and agency, but also then provides a setting in which further action takes place. And also the introduction now of strategic and economic arguments makes us recognize that actors very often react to their context in very strategic ways, and not simply in dumb, confirming ways. You don't have to assume that we are cultural dopes in order to take an organizational field perspective. And finally, this notion really celebrates the notion that contemporary modern societies are really composed of local, social orders. These are the building blocks of our contemporary society. So as my colleague Neil Fleekstein says, the theory of fields is a generic theory of social organization in modernity. I've got several more pages. Let me say just a couple of more things. First of all, it's very important to recognize that these institutions that surround the fields and that comprise the fields because they penetrate actors and the logics and the governance structures, these are not unitary but really very often conflict. And a lot of the interest in these fields is about the kind of conflicts that occur. So in one of the best studies that I know of, of a multi-level analysis of a medical care field, Carol Heimer and her colleagues, she's at Northwestern, have done a very nice analysis of the behavior and attempts to understand the behavior of people in a neonatal intensive unit. And, of course, she finds that there are three major complexes of institutions that are at work that converge here. The medical professionals as that's broadly defined, the state in its legal and regulatory requirements, and then the parents and the relatives. And she points out, because most of these encounters take place in a medical setting, the presence and the pressure of the professionals and their standards becomes dominant. The major logics that are involved in these kinds of settings are medical standards and medical criteria. Although as the time concept would point out, before the birth occurs or the neonatal child appears, of course their other contexts were dominant. The family context and so on. Later in the course of the development, other kinds of contexts. But if you choose which ones are dominant, depending on what you want to focus on. And Heimer suggests that one way to think about this is, in many ways you can think about it as a kind of garbage can model. And the question is, well, how are decisions made and what happens in this kind of setting. And the question is, well, who's present, who has standing to make decisions and so on. Who has the right to say what a problem is, who has the right to define what a solution is. And she talks about how do the logics get played out in this setting depending on who, the answer to those kinds of questions. And then very specifically she talks about looking carefully at the effect of legal institutions. For example, in neonatal units. And she finds out, for example, their effect is quite variable and it depends a lot on what kind of law you're talking about and how the law gets activated. And so, for example, there's civil law. And to the extent that that institutional form enters into the field depends upon, she says the behavior there is highly reactive. And it's because of the concern for medical malpractice. And so the managers and providers take all kinds of steps to avoid medical malpractice, in a highly reactive way. So it's dealt with because of the consequences of not dealing with it. Whereas, for example, criminal law is much less likely to intervene. And the only way it comes in is when physicians think they see absence of child neglect or child punishment of some kind. And so they use that law. They bring it in. They're the agents that say, we need to get a court order, and then they bring it in. And so the presence of these larger environmental elements gets activated by particular actors because of their interest and agenda and the setting. And you need to understand what the actor's interests are and what the setting's about. And so let me just conclude by saying, let me illustrate a few of the ways in which this multi-level approach might be embedded in an organization field perspective. Think about, for example, the effect of law and politics. Well, you would want to look at, what is the receiving organization that is subject to those laws. If it's a highly visible medical center then it's going to be more likely to be influenced, it's going to be more likely to have a role in shaping those policies and so on, than if it's a periphery of the field. You need to think about the effect of time. How long has this set of interventions or this set of approaches gone on? How mature is it? What's the level of degree of consensus among the providers and the players there. One needs to look at the effect of specific community context. What are the community demographics, what are the social economic status of the patients and the families in the area. What's the strength and activity of specific interest groups. And then finally there's the effect of the organization and its participants and the demography, and their relative power and influence within the organization itself. So it's some, I think one of the better ways to approach a multi-level analysis is to think about setting boundaries around a specific field to be examined from this context. It allows you to focus on social structural aspects, on symbolic cultural aspects, in a historical context. And it allows the interplay, allows us to examine the interplay of these multiple forces, how they work themselves out over time. And so my own priority would be to say think a little bit about the possibility of using that kind of analytic, that kind of, it's not a theory, but it's a conceptual framework to help us frame and to bound these conditions and these systems that we're trying to study and make interventions in. Thanks a lot. >>>[APPLAUSE] >>>DR. KALUZNY: Dick, thank you very much. I think your notion of fields, permeability of boundaries is a very central kind of idea that I think we need to spend more attention and pay attention to. I'm particularly intrigued with your comments on the legal aspects because here's another profession that plays many, many different roles at it interacts with the clinicians the managers. And it can have a very important influence depending upon what is the issue involved. I'm currently living with this now because my daughter's a lawyer for the insurance company. And when she goes into these conversations I ask her to use her married name rather than her professional name. But we get along pretty well. We have a couple of minutes for questions, and I'm sure Dick would like to respond to any points of clarification or comments or questions. >>>MS: I appreciated the comments because it actually took me back to my dissertation. I did my dissertation on (inaud.) Philadelphia. I didn't know it then, but I guess I was doing multi-level intervention analysis. It was a team at the institution that I was doing post doc in that was going out to Korean churches offering serological testing to Korean immigrant churches. And they observed that there was a differential response to their interventions, that sometime they would go out and they would have a very low response rate, 10%. And other times they would go out and they would have a 90% response rate where people were actually coming up to be tests. So they were very confused by this and the coincidence was that I was a post doc and I did some Peace Corps volunteering in Korea. I spoke Korean and I actually was interested in the sociology. And I did it for observation. I also collected the information (inaud.) churches. And I was thinking about all kinds of different things in this field that might influence serological testing rates. Well kind of long story short, I did a historical study on the culture of Christianity in Korea and some background information on the field, the team that was going into the field doing the tests, the institution, that institution's orientation to the community and all that. What it all boiled down to in the end, at least in my analysis, was that they were going to three different types of churches. Korean Presbyterian churches, Korean Methodist churches, and Korean Catholic churches. And Korean history and the history of Christianity, those contexts, was that the Korean Presbyterian churches were very hierarchal oriented and very conservative. And the Korean Methodist churches were a little bit less so. And then the Korean Catholic churches, nobody listens to the priests. So what was happening was, when the team would go out and go into the field, they would talk with the pastor or the minister, the Presbyterian pastor said sure, come in and do serological testing. They had 90% screening rates. The Methodists had about 2%, and the Catholics had about 10%. So without knowing it, in a way I was doing this kind of field analysis. I collected all of the demographic information, the survey questions, we had (inaud.) data, nothing turned out to be statistically significant in terms of explaining the result until I looked at the (inaud.) and what was going on there. So in a sense I think that was kind of bold, my own example, but it was an example of how... >>>DR. KALUZNY: It's very relevant to what Dick was mentioning. Ron, thank you. Ok. Yes? One more question and we'll have to end it for a long day. >>>FS: (inaud.) San Francisco State University. And I'm (inaud.) we're very interested in understanding how (inaud.). And one of the things that I really appreciated about your presentation that seems to be missing in the other papers that were presented today, is the importance of knowing the roles, as you stated knowing the plot. Which really is taking into account the culture, the behaviors, the practices, the beliefs, the values. And in fact we know the disparities are due to differences in the clinical appropriateness of particular treatments and prevention strategies and on and on. You really need to meet the needs of different populations, different population groups. And that sometimes there's also differences in the biases of the physicians, the stereotypes that they have of their patients. And so all of that has to play out if we're going to make a difference in our country that's becoming increasingly more diverse. And so I think it just adds another whole layer that other people had thought of. But I think you were the one that really talked about the importance of having that be a central part of thinking across on these levels. Thank you. >>>DR. KALUZNY: Very nice. Thank you very much. Okay, I'm going to turn this over to Steve. And Dick, thank you so much for an excellent presentation. >>>[APPLAUSE]