Accountable Welfare Reform: What Consumers Think

Abstract

In the wave of organizational change that is now sweeping the public sector, there is considerable focus on the need to define performance standards, ensure quality of care, and guarantee efficient, effective service delivery (Dilulio, Garvey, and Kettl, 1993; Osborne and Plastrik, 1997). One area of public service currently undergoing significant change is the public welfare system. In the wake of the 1996 Personal Responsibility Act, public welfare programs are facing their greatest change since the program's inception. Although the majority of these changes have focused on limiting client benefits, imposing sanctions, and addressing linkages between welfare and work, there is general understanding that the mission of the public welfare system is different. This change in mission provides an opportunity for the public welfare system to revitalize its current service, redesign its procedures, and expand on its outcomes evaluation. Critical work will be needed to develop performance standards and quality service indicators to guide such efforts. This article argues and demonstrates that we can develop these service standards and measures for the new public welfare system by listening to recipients as consumers of service. Literature Review Demands for more efficient operations have resulted in the public sector's use of private market concepts (Osborne and Gaebler, 1992; Osborne and Plastrik, 1997). Instituting such processes as re-engineering, performance-based budgeting, and consumer-driven service is posited to improve public sector performance (Kettl and Dilulio, 1995; Kettl and Milward, 1996). The introduction of consumer satisfaction as a measure of service quality and the implementation of continuous improvement processes in the public sector have begun in earnest (Myers and Lacey, 1996), while evidence for links between satisfaction and service outcome is being explored (Halachmi and Bockaert, 1996). As public sector agencies are pushed toward management for performance and results, attention to consumer satisfaction may improve service quality and assist in maintaining citizen confidence in these organizations. There are many reasons why consumer satisfaction should be considered as a primary measure of quality. In particular, there is growing evidence from the health care field that treatment outcomes are positively correlated with patient satisfaction. Several studies have documented the negative impact of patient dissatisfaction on health care. Dissatisfied patients are less likely to keep scheduled appointments, to follow medical regimens and instructions, or to take medication as prescribed (Linn, Linn, and Stein, 1982; Ware and Davies, 1983; Weiss, 1988; Zimmerman, 1988). They are more likely to avoid routine visits and, when they do seek care, it may require more costly treatment (Mechanic, 1980). Patients who like their doctor and are satisfied with their health care organization are less likely to switch physicians or to disenroll from plans (Hsieh and Kagle, 1991; Ware and Davies, 1983). There is a strong economic incentive to minimize patient behavior that results in changing providers, delaying healthcare helpseeking, and decreasing medical noncompliance. Enhancing patient satisfaction can serve as a strategy for improving health behavior, marketing services, and controlling costs. Recent social marketing literature suggest that one critical way to improve social welfare services is attention to consumer satisfaction (Andreasen, 1995). Re-engineering in the public sector should target customer service and consumer-focused organizations in its efforts to improve performance (Halachmi and Bockaert, 1996). Consumers and public sector employees working in tandem, instead of cross-purposes, might minimize missed appointments, dissatisfaction with workers, and noncooperation with short- and long-term goals. Both groups could contribute to improved organizational performance. …