An examination of the organizational structure, communication process and clinic flow provides important information on site-specific organizational culture and climate. Theories and research provide support for the relationship between certain types of organization cultures and corresponding effectiveness or ineffectiveness in accomplishing goals. For example, one study using case studies and survey data to study this relationship finds that highly effective organizations tend to be based on four basic cultural traits: involvement, consistency, adaptability and mission.

Organizational structure, communication process and clinic flow are indicators of cultural traits and can be characterized accordingly in terms of effectiveness. Organizational culture is related to organizational climate. A study on the effects of organizational climate and inter-organizational coordination associated with the quality and outcomes of children’s service systems found that organizational climate indicators, including low conflict, cooperation, role clarity and personalization, were the main predictors of successful service outcome. As such, an action plan to address the problem of childhood obesity would be enhanced if these organizational dynamics were promoted.

The WIC environment provides important information on site-specific culture and climate. It includes, among other factors, the operational dynamics of the local clinic and the interactions between the local clinic and the Virginia Health Department's central office regarding the implementation of federally regulated WIC policies and procedures. An examination of the organizational structure, communication process and clinic client flow is important to determine the most effective strategies for maximizing success in implementing a new childhood obesity prevention program within the constraints of the organization. In other words, the development of an action plan to address the problem of childhood obesity could conceptually "work on paper" but fail as a result of structural characteristics of the WIC environment such as space problems or, perhaps, staff resistance to change. The organizational assessment provides detailed background information on the setting in which our study will be conducted. This will assist other states/programs in replicating the model that is developed and implemented.

The purpose of the local WIC organizational assessment is to obtain baseline information on the WIC environment, considering the factors outlined above, to provide information during the action plan development stage. It also provides an opportunity to encourage WIC professional and support staff to participate in the planning and to fully become involved in the project development in a meaningful way.

The environment was assessed at on-site visits by the UVA nutritionist/ researcher and social scientist, with follow-up information gathering by the social scientist in cooperation with the WIC nutrition supervisor and other staff in Northern Virginia.

Since the submission of the grant, at which time Falls Church had more nutritionists than did Springfield, the staffing patterns have changed. Staffing needs are calculated with a standard formula. Table 1 shows the FY 2000 staffing needs. As shown in the table, Falls Church, with its higher average number of participants (n=2,421), has a higher need of professional staff (CPA=4.0) compared to Springfield (CPA=3.5), with 2,053 participants. The present staffing—compared to the staffing needs to most efficiently provide WIC service—indicates that Falls Church has fewer professional staff (CPA=3.85) and slightly fewer office services assistants than needed compared to Springfield, who reports adequate professional staffing but fewer office services assistants than needed.

Note: CPA is calculated based on the number of Nutritionists and Nutritionist Assistants, (CPA = Competent Professional Authority; OSA = Office Services Assistant)

Illustrated below are the organizational charts of the Springfield and Falls Church WIC clinics.

Springfield WIC Staff: Basic Roles and Responsibilities

Lead Nutritionist: The lead nutritionist is responsible for assessing, counseling and referring WIC clients, as well as prescribing the food package and completing the assessment and documentation forms. She is also responsible for overseeing the other nutritionists and nutritionist assistants.

Nutritionist: The nutritionists are responsible for assessing, counseling and referring WIC clients, as well as prescribing the food package and completing the assessment and documentation forms. They also plan and lead the group classes.

Nutritionist Assistant: The nutritionist assistant is responsible for screening patients (measure height, weight and hemoglobin levels). She also educates patients during the screening process.

Front Desk Office Staff (OSA): The front desk office staff person is responsible for scheduling clients, checking clients in, updating client personnel and financial information in the database.

Office Staff (OSA): 5 FTE office staff are responsible for distributing WIC checks to clients, sending the certification and enrollment forms to the State Department of Health, putting forms in charts and filing charts. The office staff is the first line of communication to the WIC clients.

Lead Nutritionist: The lead nutritionist is responsible for assessing, counseling and referring WIC clients as well prescribing the food package and completing the assessment and documentation forms. She is also responsible for overseeing the other nutritionists and nutritionist assistants.

Nutritionist: The nutritionists are responsible for assessing, counseling and referring WIC clients as well as prescribing the food package and completing the assessment and documentation forms.

Nutritionist Assistant: The nutritionist assistant is responsible for screening patients (measure height, weight and hemoglobin levels). They educate patients during the screening process and plan and lead the group classes.

Office Staff: The front desk office staff person is responsible for scheduling clients, checking clients in, updating client personnel and financial information in the database.

They are responsible for distributing WIC checks to clients, sending the certification and enrollment forms to the State Department of Health, putting forms in charts and filing charts. The office staff is the first line of communication with the WIC clients.

The Nutrition Program Supervisor, who is participating on this grant, has supervisory authority over both sites. It is her responsibility to communicate WIC policy updates and revisions to staff.

Springfield. The Springfield WIC office is located in the same office as the local health department. Health department nurses refer appropriate patients into WIC from their clinics. Additionally, new patients are often referred from the Home Tomorrow program. The Home Tomorrow program is a home healthcare program that follows up with patients immediately postpartum. Nurses from the health department refer appropriate patients and make appointments into WIC within ten days of delivery. Additionally, patients are referred to WIC by other physician offices, child care centers and school nurses (for adolescent pregnancy).

Falls Church. The Falls Church WIC office is located on the 5^th floor in the same building as the local health department. The heath department clinics are located in the same area as the WIC clinics. This provides the opportunity for nurses to refer women to WIC as appropriate. In addition, community referrals are also made from many sources including friends of potential clients, school nurses and physicians. Many low- income women made self-referrals.

Summary. The communication flow for client referral is comparable at both WIC sites. More research is needed to further investigate the adequacy of foreign language interpreters for the multi cultural needs of diverse clients.

For recertification: Approximate time for total recertification process: 60-70 minutes.

1. Clients walk into the waiting room and go to the front desk personnel to sign in. They are given a clipboard of forms (health history, food frequency) to complete. Once the client completes the forms, financial eligibility is determined and the front office staff put the required forms into the client's chart and puts the chart in the nutritionist assistant's client box. [15 minutes]
2. The nutritionist assistant collects the chart and brings the client into the screening room, where the client’s weight and height are measured and hemoglobin is taken. The nutritionist assistant then charts all information on standardized forms and growth chart. The nutritionist assistant then puts the chart in the nutritionist’s box and brings the client back to waiting room. [15 minutes]
3. The nutritionist then picks up the chart, reviews the forms (food frequency, growth chart, hemoglobin level, health history form) and brings the client and the family to her office for individual nutrition counseling. After the nutrition education session, the nutritionist brings the client back to the waiting room, goes to her office and writes nutrition prescription for food package, writes note (uses statewide standardized form and writes some individualized comments), attaches forms to the front of the chart and brings the chart to office staff, who issue checks. [15 minutes]

4. The office staff then make up checks for the client. The checks are pre-printed in most cases, except for new clients or clients whose situation has changed (for example, a pregnant woman who delivered and came to her appointment with her new baby). Manual checks are written for new clients with special food packages and for clients with a food package change. The client is called and given their WIC checks, signs the register, schedules next appointment and leaves the office. The office staff put the forms in the chart, file the chart and enter pre-designated information into the computer. [10-15 minutes for pre-printed checks and 20-30 minutes for hand-written checks]

1. The process is the same as that for recertification except that the office staff has to hand write and explain the WIC checks, which takes approximately 10-15 minutes longer per client.

1. Client walks into clinic and signs in at front desk. Front office staff put client’s folder in nutritionist's box.
2. Nutritionist waits to have 5-6 WIC clients to give group educational series.

 

3. After class, clients go to back office staff and gets checks from one staff member, then goes to another to make next appointment.

• Recertification occurs every six months and check pick-up occurs every two months.

For recertification: Approximate time for total recertification process: 45-60 minutes

1. Clients walk into the waiting room and go to the front desk personnel to sign in. They are given a clipboard of forms to complete. Once the client has completed the forms, the front office staff put the required eligibility forms into the client's chart and puts the chart in the nutritionist assistant's client box. [10 minutes]
2. The nutritionist assistant collects the chart and brings the client into the screening room, where the client’s weight and height are measured and hemoglobin is taken. The nutritionist assistant then charts all information on standardized forms and growth chart. The nutritionist assistant then puts the chart in the nutritionist’s box and brings the client back to the waiting room. [15 minutes]
3. The nutritionist then picks up the chart, reviews the forms (food frequency, growth chart, hemoglobin level, health history forms) and brings the client and the family to her office for individual nutrition counseling. After the nutrition education session, the nutritionist brings the client back to the waiting room, goes to her office and writes the nutrition prescription for a food package, writes note (uses statewide standardized form and writes some individualized comments), attaches the forms to the front of the chart and brings the chart to office staff, who issue checks. [15 minutes]
4. The office staff then make up checks for the client. The checks are pre-printed in most cases, except for new clients or clients whose situation has changed (see description in Springfield section). The client is called to the front desk and given their WIC checks, signs the register, schedules next appointment and leaves for home. The office staff put the forms in the chart, file the chart and enter pre-designated information into the computer. [10 minutes for pre-printed checks and 15 minutes for hand-written checks]

1. The process is the same as that for recertification except that the office staff have to hand write and explain the WIC checks, which takes approximately 10-15 minutes longer per client.

Check Pick-Up Process: Approximate time for check pick-up process: 15-30 minutes

1. Client walks into clinic and sign in at front desk. Front office staff put client’s folder in nutritionist's box.
2. Clients wait in the waiting room until called for the group classes. Group classes are held every 30 minutes. The classes last approximately 5-10 minutes.
3. After class, clients go to front office staff, pick up WIC checks and make next appointment.

• Recertification occurs every six months and check pick-up occurs every two months.

Each WIC clinic was considered in terms of cultural traits and climate characteristics based on findings from organizational studies cited in the introduction. Cultural traits include:

• Involvement
• Consistency
• Adaptability
• Mission

There was little perceived difference between the two clinics regarding involvement of the staff in clinic functions surrounding nutritional counseling and assessments. Due to the nature of the organization, there is limited opportunity for significant involvement for staff to have input into deciding how services are provided to clients. This is typical for bureaucratic organizations that must provide services to many people. Staff involvement is best sought for special projects, such as the Childhood Obesity Prevention Project, to the extent possible.

Both WIC clinics had professional nutritional staff who provided information about clinic functions and who actively participated in the focus groups. At each clinic, there was less involvement of the support staff in client counseling, as was to be expected due to job positions and functions. However, at both sites, certain support staff reported interacting with clients about health and fitness issues at times when the clients were in the clinic. There was no pattern in regard to this interaction. The amount of non-professional contact time within the WIC clinic appears to be a function of the support staff person's personality. In other words, more extroverted staff might tend to share personal stories about obesity or child care than would the more introverted staff. It appears that information is transmitted to certain WIC clients but a further investigation of the impact of this informal information exchange is beyond the scope of this assessment.

Consistency in the application of rules and policies was noted at both clinics. The consistent application of rules and regulations comes in part because the Nutrition Program Supervisor is a well-organized, well liked person who supervises nutritional staff at both WIC clinics. In addition, the WIC policies and procedures are based on structured federal guidelines regarding eligibility and are not subject to random change.

Adaptability concerns the willingness of the organization to "bend" the organizational rules if necessary to meet the needs of new programs and special needs of the population. Self-reports from the staff and supervisor indicated there were certain limitations to the option to be adaptable at both WIC clinics. These limitations are primarily based on the time issues surrounding when WIC clients were in the clinic. In other words, there is only so much time to implement an intervention or prevention program and still provide the required services to clients.

The nutritionists at both sites expressed the importance of nutrition counseling, fitness and related activities as being key to their jobs. The mission element, in this regard, seems related to their career choice more than to a shared mission of the WIC clinic per se. For the support staff, their work involvement appears, for most, to be more income generating rather than feeling part of a group to accomplish goals they report as meaningful.

Summary. Overall, as part of building the Action Plan in Year 01, it is recommended that staff at all levels be included in the process to increase their feelings of involvement and mission. In addition, finalizing the logistics on the best way to implement the new Prevention Program need a "buy-in" from all staff who will be in the clinic during the project period.

Organizational climate indicators that have been predictors of successful service outcomes include:

• Low conflict
• Cooperation
• Role clarity
• Personalization

At the two WIC sites, we were only able to note role clarity, perceived cooperation among the staff and personalization. Not enough time was available to explore issues of conflict and conflict resolution among staff.

Overall, the Springfield District Office and the Falls Church District Office appear to have role clarity for personnel, as demonstrated by written position descriptions with specific tasks outlined. These job tasks are followed by staff and are typically part of the staff evaluation.

Staff cooperation and personalization appeared adequate at both sites. During the observation visits, it appeared that the Springfield site had a more cohesive staff, which was probably due to staff who had been working together in the same capacity for a longer time. At the Falls Church site, there had been recent staff changes. However, this does not suggest that the staff at one site was less cooperative or lacked a desired degree of personalization that would motivate staff to accomplish goals.

Summary. It is suggested that role clarity and cooperation be addressed in terms of the changes in job tasks that might be related to the Year 02 Prevention Project. Involving the staff in the development of the Action Plan should facilitate this effort.

Supervision. Office support staff are supervised by a different supervisor than the Nutrition Supervisor and are often funded through programs other than WIC (e.g., local funding, co-op funding).

Time and Frequency of Nutrition Education. Currently, the system is designed to provide nutrition education to participants every other month. However, participants may decline nutrition education and still receive program benefits. In addition, education is short in duration. Messages will need to be short and consistent to ensure multiple exposures. Staff should increase nutrition education provided by capitalizing on the participants’ time in the clinic, including time spent in the waiting room and with all staff. A variety of educational mediums can ensure exposure to messages.

Loss to Follow-up. It is currently unknown how long participants in VA remain on the Program, as dropout rate information is only collected as monthly aggregate data. A system to increase participation and track program dropouts will need to be established.

Staff Turnover. Staff turnover rates vary; however, it will be important to adequately train new employees and ensure that they are following protocol.

Adaptability. Staff duties may be expanded as a result of the intervention design. It is important to get staff "buy-in" on intervention procedures and ensure adequate training.