Applying the RAAKERS™ framework in an analysis of the command and control arrangements of the ADF Garrison Health Support

Australian Defence Force Garrison Health Support operate in a complex relationship between a geography-based National Support Area (NSA) health care model, in which most of the medical resources and staff are owned by the single services; deployable capabilities, also owned by the Single services; and a National health care system that provides primary, secondary and tertiary health care both to the NSA and to deployed forces.  The Alexander Review, amongst other things, was required to inform the development of a command and technical control structure for health units that optimizes operational efficiency and effectiveness, and clarifies accountability to the Service headquarters and other Groups in the ADF. The RAAAKERS™ (Responsibility, Authority, Accountability, Awareness, Knowledge, Experience, Resources and Systems) framework was used as an analysis tool to assist in understanding the main command and control stress points in the Defence Health Services Division (DHSD). Structured interviews with many of the key staff of DHSD allowed the RAAAKERS™ construct to probe into the alignment of elements related to command capability, such as the Responsibility, Authority and Accountability attributes, and those associated with elements of control, such as the KERS attributes. In particular the paper shows how data from the interviews enabled construction of RAAAKERS™ metrics to highlight problematic areas related to technical control and to a lack of alignment in Responsibility, Authority and Accountability in some areas of DHSD.  The Viable Systems Model (VSM), developed by operations research theorist Stafford Beer, is a model of the organisational structure of any viable or autonomous system. As an additional analysis tool for the Alexander Review, VSM techniques were used to study Garrison Health Support and to determine the structure of the five internal systems needed for viability. This preliminary study also indicated stress points in the technical control aspects of Garrison Health Support and provided some support to the findings of the RAAAKERS™ investigation. Overall, we found that implementation of the RAAAKERS framework made explicit many command and control stress points in the DHS and provided some useful insights into the management of a large and very complex organisation.

Introduction

In March 2008 a Review into health support to the Australian Defence Force (ADF) was announced with MAJGEN Paul Alexander as head.

One of the purposes of the Review, colloquially known as the Alexander Review, was to:

“Inform the development of a command and technical control structure for health units that optimizes operational efficiency and effectiveness, and clarifies accountability to the Service headquarters and other Groups. This structure must comply with baseline clinical governance standards for patient safety, provider competency and reporting;”

The Defence Science and Technology Organization (DSTO) was engaged to provide lines of evidence in the report with respect to this requirement. In this paper a novel technique for measuring command and control capability is outlined and the related results from a study of Defence Health Services Division (DHSD) are presented. The RAAAKERS™ framework was used as an analysis tool to assist in understanding the main command and control stress points in the DHSD. RAAAKERS™ stands for Responsibility, Authority, Accountability, Awareness, Knowledge, Experience, Resources and Systems and was created by one of the authors (Durant-Law) as a way of representing the main attributes associated with management of a large or complex enterprise. This case study is the first time it has been applied to a real situation.

As described here RAAAKERS™ was used in the Alexander Review to shed light on command and control issues. It may also be thought of more generally as a diagnostic approach for effective management of organisations. RAAAKERS™ may be contrasted with the Balanced Scorecard (BSC)¹. The BSC is based on the perception of the firm as a largely stand alone profitability machine, which needs to be optimized to reach maximum efficiency^2. It can provide a systematic tool for combining financial and non-financial performance indicators in one measurement system, but it does not offer anywhere near the same degree of insight into command and control as does RAAAKERS™. More interesting is Drucker’s Five Most Important Questions self-assessment book and tool³. As part of a high level environmental scan of an organisation this asks the questions:

• What is our mission?
• Who is our customer?
• What does the customer value?
• What are our results?
• What is our plan?

It can be viewed as a guide for Boards of Management to enable them to stay focussed at the strategic level. However it lacks the level of detail necessary for the Alexander Review requirement to look into efficiency and effectiveness of Health command and control. Neither the BSC nor Drucker’s approach capture the complexities of the Garrison Health Support environment where the single Services and DHSD have overlapping areas of responsibility.

 

Background

 

The Alexander Review also considered recommendations from previous reviews into the ADF Health Services, including the Stevens review conducted in 2004⁴. Clifford⁵, in re-considering the Stevens review and its terms of reference, identifies command and control as central issues for the ADF Health Services. In particular Clifford argues that the decision to maintain the ADF Health Services long-standing command and control arrangements – in which the single services often have command of health capabilities and materiel whilst the DHSD was given technical control – leads to inherent difficulties for DHSD to meet its mission.

 

In this context the analysis reported here may be seen as providing detailed information and diagnostics on the current (mid 2008) model of command and control within DHSD.

 

The next section describes how data from the DHSD was gathered for the RAAAKERS™ framework and key results are presented. Based on the findings, Command and Control measures of effectiveness are also computed and discussed in terms of the insight these provide to the Alexander Review.

 

Data Gathering

Structured interviews were held with the senior managers and managers of the key directorates within DHSD. Each interview focussed on a questionnaire based on the eight attributes in the RAAAKERS™ framework. For each attribute a series of relatively straightforward questions probed the respondent for their judgement on how well their work area rated against that element. A summary question for each section was used as a data assurance technique to safeguard the overall score assigned to a RAAAKERS™ element. This method allowed the data to be gathered in approximately ½ hour for each interviewee.

 

Table 1 shows the guidance provided to the interviewees on the elements in the framework. Note the definitions of, and distinctions between, knowledge and experience in the table. In RAAAKERS™ knowledge refers to understanding of a field of endeavour gained through study or past training, while experience refers to the application of this knowledge in the context of the work currently undertaken (in this case by DHSD).

 

RAAAKERS™ Attribute	Questionnaire Guidance
Responsibility	This section looks at attributes related to   the sphere or extent of your activities and roles as head of a unit. It seeks   to find out how you view your responsibilities, how well defined they are, to   whom you are responsible, and how others see your responsibilities.
Authority	This section asks about the authority you   have to carry out your roles and responsibilities. This relates to the amount   of control you have, both within the work unit and outside, over tasks and   activities that you rely on to carry out your role.
Accountability	This section asks about how accountable you   are for the outcomes of your work unit. In this section we are particularly   interested in misalignment in accountability and responsibility – for example   when you may be accountable for an outcome over which you have little   control.
Awareness	This section relates to the awareness you   and your staff have of the state, activity, status or situation of your own   work unit and those with which you deal with on a regular basis or those who   you rely upon. For example, knowledge of the state of readiness of medical   staff in an Area Health Service or in the Reserves is a type of awareness at   the operational level, as is changes in the situation with respect to   recruitment or retention of medical staff at the strategic.
Knowledge	This section relates to the knowledge   available to you to assist in performance of your duties. This knowledge is   closely related to the “Familiarity, awareness, or understanding gained   through experience or study” and pertains to medical, academic, or military   training and experience that can be brought to bear on the tasks and   activities of the unit.
Experience	This section relates to the experience of   staff available to you to assist in performance of your duties. In this   context experience refers to familiarity and practice in working in the DHSD to   achieve its outcomes. In contrast with the knowledge referred to in the   previous section this is about how medical, academic or military know-how can   be applied in the ethos, work   structures and business processes of the DHSD.
Resources	This section relates to the resources   available to you in your work unit and to the resources of other units that   you rely upon. These resources can include access to personnel, and budget $   to run programs, perform training and attract and retain staff.
Systems	This section relates to the systems   available to you in your work unit. These could include information systems,   communication systems and systems for induction or on-the-job training.

Results and Intepretations

The RAAAKERS™ data obtained for DHSD is summarised in this section. Table 2 shows a summary across the work areas surveyed.

1	Responsibility	5	2.8
2	Authority	5	3.0
3	Accountability	5	3.9
4	Awareness	5	3.0
5	Knowledge	5	3.3
6	Experience	5	3.1
7	Resources	5	2.7
8	Systems	5	1.4
	Total Score	40	23.6