ORGANIZATIONAL COMPLEXITY, EMERGENCY MANAGEMENT PLAN ADEQUACY, AND ...

187 Pages·2015·3.73 MB·English

by  Cherie Boyce

ORGANIZATIONAL COMPLEXITY, EMERGENCY MANAGEMENT PLAN ADEQUACY,
AND NURSING HOME RESILIENCY: A CONTINGENCY PERSPECTIVE

By

CHERIE BOYCE
B.A. University of West Florida, 1995
M.P.A. University of West Florida, 1998

A dissertation submitted in partial fulfillment of the requirements
for the degree of Doctor of Philosophy
in the College of Health and Public Affairs
at the University of Central Florida
Orlando, Florida

Fall Term
2015

Major Professor: Thomas T. H. Wan
© 2015 Cherie A. Boyce
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ABSTRACT
Some social and organizational behavior scientists measure resiliency through anecdotal
qualitative research, i.e. personality analyses and stories of life experience. Empirical evidence
remains limited for identifying measurable indicators of resiliency. Therefore, a testable
contingency model was needed to clarify resiliency factors pertinent to organizational
performance. Two essential resiliency factors were: 1) a written plan and 2) affiliation with a
disaster network.
This contingency study demonstrated a quantifiable, correlational effect between
organizational complexity, disaster plan adequacy and organizational resiliency. The unit of
analysis, the skilled nursing facility proved vulnerable, therefore justifying the need for a written
emergency management plan and affiliation with a disaster network.
The main purpose of this research was to verify the significance of emergency
management plans within a contingency framework of complexity theory, resource dependency,
systems theory, and network theory. Distinct sample moments quantified causal relationships
between organizational complexity (A), plan adequacy (B) and resiliency (C). Primary and
secondary research data were collected from within the context of public health and emergency
management sectors within the State of Florida.
The research unit of analysis was the licensed skilled nursing facility specified as a
nursing home (NH). Most units were affiliated with healthcare systems, while 19% of the sample
were not affiliates. The randomly selected sample population of 200 Florida NH administrators
provided primary data through a self-administered survey of randomized questions related to the
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staff’s comprehension of the facility’s disaster plan and disaster resource management
procedures.
Internal validity from social desirability bias was minimized in two ways: 1) by using
secondary data retrieved from trusted sources: CMS, MDS 3.0, and CASPER 2012 and 2) by
using survey questions with a 5-point Likert scale to capture staff knowledge, skills and attitudes
(KSAs). Distribution of the survey was during the end of hurricane season and the beginning of
the annual plan approval cycle (November 4, 2014 until January 19, 2015).
Definitions, calculations, and interpretations of the performance data varied among
sources. This lack of clarity created two research challenges: 1) no clear definition of resiliency
between healthcare providers and emergency management agencies and 2) no clear definition of
organizational complexity. This lack of definition created a problem with utilizing customary
performance indicators of organizational behavior within a Donabedian model of medical care:
structure (A), process (B), and outcomes (C).
The term resiliency was borrowed from the biological sciences as absorbing, coping and
recovering from disruption of routine. In this study, the term resiliency represented disaster
response and recovery capabilities for nursing homes that are derived from the complex internal
system of patient care. According to Ashby, the state of complexity can be too complicated to
quantify and organizational research projects determine component definitions (Ashby, 2007).
In other words, complexity factors are identified by the research methodology. This study
analyzed the adequacy of emergency plans designed for nursing home staff, some of the factors
were strongly correlated, for example patient comorbidities and level of staffing. For this study,
organizational complexity included: acuity indexes, ADL scores, staff hours, staff ratings and
occupancy rates. Due to the large quantity of available data, organizational complexity data for
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this research was reduced into three NH organizational components: patient acuity, workload and
administrative strengths.
These factors required three standardized measurement models to improve the accuracy
of predicting organizational complexity influence upon plan adequacy and NH resiliency
outcomes within the context of a disability centric environment.
The primary finding from this research was the confirmation that disaster plans improve
NH resiliency by 16%. The endogenous construct, Plan Adequacy (B) demonstrated a
significant resiliency effect of .8 within a scale of absolute 1.
In summary, this empirical study offers strong proof for the contingency theory that NH
resiliency is directly influenced by a well-written and exercised emergency plan. Even though
the NH population remains vulnerable to emergencies from an organizational perspective, the
results confirmed a strong contingency perspective for NH resiliency exists within four disaster
plan areas: plan approval status; memorandums of agreement; disaster exercises; and network
affiliations.

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ACKNOWLEDGMENTS
This dissertation would never have been completed without the extensive knowledge and
support of Dr. Thomas T.H.Wan and committee members: Dr. Reid Oetjen, Dr. Fernando
Rivera, Dr. Naim Kapucu and Dr. Ning “Jackie” Zhang. These professionals are among the best
examples of academic and research excellence in Central Florida. Dr. Wan displayed the most
patience as guide and advisor that one could hope for when pursuing an advanced degree.
This research project could never have taken place without guidance, staff support, and
financial assistance from the University of Central Florida, College of Health and Public Affairs
(COHPA) office and the Graduate Dean’s Fellowship Award. Other important resources
provided through COHPA were a quiet study area with the latest software and access to
CASPER data.
Additional acknowledgment is made to the Centers for Medicare and Medicaid, the
Administration of Health Care Agencies, the Florida Division of Emergency Management, the
Orange County Office of Emergency Management, the Orange County Health Department, and
the Florida Council on Aging, the University of South Florida Elder Studies, and the Florida
Health Care Association.
Appreciation is also given to fellow researchers and advocates for public health that
contributed in specific ways to this dissertation process: Ray Runo, Preston Cook, David
Freeman, Carmen Weatherford, Gil Ihrig, Mimi Reggentin, Mike Principato, Suyrea Reynolds,
Kathryn Hyer, April Henkel, Samme Ripley, David Heath, Latarsha Chisholm, Tom Bellomo,
Karen Lane, Keith Kotch, Ron Plummer, Ajit Lalchandani, Bryan Koon, Holly Overstreet,
Robyn Epley, and Myron Fottler.

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TABLE OF CONTENTS
ABSTRACT ................................................................................................................................... iii
ACKNOWLEDGMENTS ............................................................................................................. vi
TABLE OF CONTENTS .............................................................................................................. vii
LIST OF FIGURES ....................................................................................................................... ix
LIST OF TABLES .......................................................................................................................... x
CHAPTER ONE PROBLEM STATEMENT ................................................................................ 1
1.1. Research Goal ...................................................................................................................... 1
1.2. Theoretical Framework ........................................................................................................ 2
1.3. Propositions.......................................................................................................................... 4
1.4. Delimitations and Limitations.............................................................................................. 7
1.5. Definition of Terms.............................................................................................................. 8
1.6. Problem Summary ............................................................................................................. 12
CHAPTER TWO REVIEW OF THE LITERATURE ................................................................. 13
2.1. Historical Overview of Contingency Theory and Research Literature ............................. 22
2.1.1. Complexity Component of Contingency Theory ........................................................ 29
2.1.2. Resource Dependency Component of Contingency Theory ....................................... 33
2.1.3. Systems Learning Component of Contingency Theory .............................................. 34
2.1.4. Network Collaboration Component of Contingency Theory...................................... 37
2.1.5. Routine Networks and Disaster Response Networks ................................................. 38
2.2. Research Literature Specific to Resiliency ........................................................................ 43
2.3. Disaster Network Collaboration ........................................................................................ 48
2.4. Critique of the Validity of Contingency Theory Research ................................................ 51
2.5. Summary of What Is Known About Contingency Models ................................................ 51
CHAPTER THREE RESEARCH DESIGN ................................................................................. 54
3.1. Research Methodology ...................................................................................................... 54
3.2. Sample................................................................................................................................ 56
3.3. Research Procedures .......................................................................................................... 60
3.4. KSA Survey Instrument ..................................................................................................... 60
3.5. Treatment of Data .............................................................................................................. 62
3.6. Descriptive Analysis .......................................................................................................... 63
3.7. Correlation and Regression Analyses ................................................................................ 64
3.8. Confirmatory Factor Analysis............................................................................................ 64
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3.9. Analysis for Reliability ...................................................................................................... 69
3.10. Delimitation of Social Desirability Bias .......................................................................... 71
CHAPTER FOUR FINDINGS ..................................................................................................... 72
4.1. CFA and Measurement Modeling ...................................................................................... 73
4.2. Organizational Complexity Measurement Model .............................................................. 74
4.3. Plan Adequacy Measurement Model ................................................................................. 84
4.4. NH Resiliency Measurement Model .................................................................................. 89
4.5. Structural Equation Model ................................................................................................. 94
CHAPTER FIVE HYPOTHESIS TESTING ............................................................................... 99
CHAPTER SIX CONCLUSIONS & IMPLICATIONS ............................................................ 110
6.1. Contingency Framework Conclusions ............................................................................. 110
6.2. Implications for Disaster Decisions ................................................................................. 120
6.2.1. Evacuee Transportation ............................................................................................ 121
6.2.2. Disaster Plan Templates ............................................................................................ 122
6.2.3. Disaster Plan Implementation ................................................................................... 125
6.3. Alternative Explanations of Findings .............................................................................. 127
6.4. Recommendations for Plan Adequacy Improvements ..................................................... 128
6.5. Recommendations for Future Research ........................................................................... 131
6.6. Summary of Conclusions and Recommendations ........................................................... 132
APPENDIX A: KSA SURVEY INSTRUMENT ....................................................................... 135
APPENDIX B: DISABILITY STATUS OVERVIEW .............................................................. 141
APPENDIX C: UCF IRB APPROVAL LETTER ..................................................................... 143
APPENDIX D: AHCA CHECKLIST ........................................................................................ 145
APPENDIX E: DESCRIPTIVE STATISTICS .......................................................................... 151
APPENDIX F: CORRELATION TABLES ............................................................................... 164
APPENDIX G: ADL CALCULATIONS WORKSHEET ......................................................... 167
REFERENCES ........................................................................................................................... 169

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LIST OF FIGURES
Figure 1: Theoretical Framework ................................................................................................... 3
Figure 2: Emergency Management Phases ................................................................................... 11
Figure 3: National Criteria for Decision to Evacuate or Shelter in Place ..................................... 28
Figure 4: Florida Cultural Diversity ............................................................................................. 31
Figure 5: Survey Sample Represents FL NH Population ............................................................. 59
Figure 6: Percentage of Rural Florida Nursing Homes ................................................................ 63
Figure 7: Proposed Measurement Model for Organizational Complexity.................................... 65
Figure 8: Proposed Measurement Model for Plan Adequacy ....................................................... 66
Figure 9: Proposed Measurement Model for NH Resiliency........................................................ 67
Figure 10: Covariance Structure Model for NH Resiliency ......................................................... 69
Figure 11: Measurement of Indicators for Organizational Complexity (Revised) ....................... 83
Figure 12: Measurement Model for Plan Adequacy (Revised) .................................................... 88
Figure 13: Measurement Model for NH Resiliency (Revised) ..................................................... 91
Figure 14: Structural Equation Model for NH Resiliency ............................................................ 96
Figure 15: Evidence of Effects on NH Resiliency (Revised) ....................................................... 98
Figure 16: Hypothesis 1 Test ...................................................................................................... 101
Figure 17: Hypothesis 2 Test ...................................................................................................... 103
Figure 18: Hypothesis 3 Test ...................................................................................................... 104
Figure 19: Hypothesis 4 Test ...................................................................................................... 106

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LIST OF TABLES
Table 1: ADL Score Definitions ..................................................................................................... 9
Table 2: Demographics and Geography of Florida and USA ....................................................... 32
Table 3: Routine Networks and Disaster Response Networks ..................................................... 40
Table 4: Descriptive Statistics for NH Population and NH Sample ............................................. 59
Table 5: Confirmed NH Factors ................................................................................................... 68
Table 6: Descriptive Statistics for Organizational Complexity (n=102) ...................................... 78
Table 7: Correlation Matrix for Organizational Complexity Construct (n=102) ........................ 80
Table 8: Second Order Factor Loadings of Organizational Complexity ...................................... 81
Table 9: Parameter Estimates and Regressions for Organizational Complexity (Revised).......... 82
Table 10: Descriptive Statistics for Plan Adequacy (n=102)........................................................ 85
Table 11: Parameter Estimates and Regression Weights for Plan Adequacy (Revised) .............. 87
Table 12: Model Fitness Indices for Plan Adequacy .................................................................... 89
Table 13: Descriptive Statistics for NH Resiliency (n=102) ........................................................ 90
Table 14: Parameter Estimates and Regression Weights for NH Resiliency (n=102) ................. 91
Table 15: Model Fitness Indices for NH Resiliency ..................................................................... 92
Table 16: Correlation Matrix for Plan Adequacy Construct (n=102) ........................................... 93
Table 17: Correlation Matrix for NH Resiliency .......................................................................... 94
Table 18: SEM Causal Path Labels .............................................................................................. 95
Table 19: Parameter Estimates and Regression Weights for SEM for NH Contingency ............. 97
Table 20: Cumulative Effects on NH Resiliency ........................................................................ 105
Table 21: Hypothesis Testing Summary ..................................................................................... 109
Table 22: NH Plan Design Templates (n=102) .......................................................................... 126
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