EMERGENCY MEDICAL SERVICES (EMS)
WITHIN THE STATE OF NORTH CAROLINA
AS A SUCCESSFUL PUBLIC SECTOR EXAMPLE
OF INNOVATION DIFFUSION
William Kellet Atkinson II
B.S., University of North Carolina at Greensboro, 1975
M.P.H., University of South Carolina, 1978
M.P.A., University of Colorado at Denver, 1990
A thesis submitted to the
Faculty of the Graduate School of the
University of Colorado at Denver
in partial fulfillment
of the requirements for the degree of
Doctor of Philosophy
1995 by William Kellet Atkinson II
All rights reserved.
This Thesis for the Doctor of Philosophy
William K. Atkinson II
has been approved for the
Graduate School of Public Affairs
When I began this thesis one of my professors, Dr. Franklin James,
warned "the thesis process can be lonely." He was right. However, the process
has also proven to be a source of contact with many persons willing to give of
their time, energy, expertise, and guidance. One of the most important
contributors has been my thesis chair, Dr. Peter deLeon. My decision to examine
innovation and diffusion came while I was a student in one of Peter's classes.
From that class forward, Peter has continued to provide information, academic
guidance and thesis direction. For all of Peter deLeon's help, I am grateful.
Likewise, Dr. James has been a constant source of information and
encouragement. Other members of my thesis committee, who include Drs. Tom
Clark, Dail Neugarten, and Sam Overman have also been available to review
numerous chapter drafts, provide useful feedback, and keep my work on track. I
owe a great deal of gratitude to each of these committee members for their
professional guidance and personal friendship.
I also owe another member of the Graduate School of Public Affairs staff,
Susan Perez, my appreciation for all her help since the first day I entered the
doctoral program to present. Susan is a remarkable lady who has always taken
time to help me work through the graduate school maze and doctoral process.
During the research phase of my thesis, numerous individuals and groups
provided assistance. Persons to whom I owe a debt of gratitude include the
following: Steve Acai, Bob Bailey, James Finison, David Flaherty, Chris Gentile,
Tom Harmelink, Ollie Harris, O'Neil Jones, Bill Osbourne, James O. Page, Tony
Seamon, Buddy Shaw, J.C. Sossman, Charles A. Speed, Carl Van Cott, David
Warren, Max Wesson, Ned Weyant, I.O. Wilkerson and John Witherspoon.
Additionally, staff members at the North Carolina Office of EMS and Guilford
County, N.C., Division of EMS provided invaluable information and
In my own work setting, my thanks are shared with Katherine
Montgomery and Adele Bassett for their editorial review assistance. And most
importantly, my work would not have been possible without the never-ending
assistance provided by Eddie Carrera. She has always been available to provide
support and technical assistance. Eddie, more than any other individual, gave
the greatest amount of her time and energy to see me through the thesis process.
On the home front, I want to thank my family, Allison, Kellet and
Brantley, for their understanding and support. For the hundreds of thesis
related hours spent away from family commitments, I apologize. Your
encouragement has meant a great deal, as has your sacrifice.
Likewise, my thanks are due to Ed and Betty Woodard, in Greensboro,
for providing a home away from home while conducting field research in North
Carolina. Also, I appreciate Ed's assistance with data collection through his role
with Guilford County EMS and Betty's constant support and encouragement as
only a fellow doctoral student can provide.
My thanks are also due to my uncle, William W. McLendon, M.D., of the
University of North Carolina School of Medicine, for leading me to a career in
healthcare. To William McRay, M.D., Jim Page, and the late Jim Finison, my
appreciation for supporting my interest in, and in fact love for, emergency
medical services. Finally, to my late grandfather, L.P. McLendon, esquire, and
my late father, Edward K. Atkinson, my thanks for teaching me to treasure the
value of education.
I. INTRODUCTION................................................... 1
Key Considerations .............................................. 2
Innovation Diffusion Research.................................... 6
Government Involvement........................................... 8
Demonstration Projects.......................................... 10
Emergency Medical Services ..................................... 12
Purpose of this Thesis......................................... 18
Thesis Organization............................................. 21
II. LITERATURE REVIEW............................................... 23
Introduction ................................................... 23
Innovation Diffusion.......................................... 26
Re-invention and the Incremental Nature of Innovations.......... 28
Innovation Diffusion Theory .................................... 34
Range of Research and Studies .................................. 43
Importance of Individuals....................................... 44
Leadership Issues .............................................. 49
Organizations .................................................. 54
A Matter of Timing ........................................... 55
Private and Public Sector Activities.......................... 59
Consumer Behavior ............................................ 64
Public Policy................................................. 71
Policy Staging................................................ 74
Policy Implementation ........................................ 76
Policy Implementation and Innovation ......................... 78
Research Hypotheses .......................................... 79
m. METHODOLOGY ..................................................... 81
Overview ..................................................... 81
The Case Study Approach ...................................... 82
Case Studies Within a Case Study ............................. 83
Urban-Rural Definitions ...................................... 86
Research Interviews........................................... 87
Written Records............................................... 90
Additional Considerations..................................... 92
IV. A HISTORICAL AND TECHNICAL OVERVIEW OF EMERGENCY
MEDICAL SERVICES.............................................. 93
Introduction ................................................. 93
The History of EMS ........................................... 93
Volunteer Rescue Squads ...................................... 96
Systems Approach .................................................101
Setting the Stage.................................................103
Legislative Activity: PL 93-154 ................................. 122
Technical Aspects of EMS Systems: Introduction....................128
System Profiles ..................................................128
Government Links to EMS ......................................... 130
Clinical Levels of Pre-Hospital Care .............................130
Personnel and Training............................................134
Response Time .................................................. 138
V. THE NORTH CAROLINA STORY.........................................147
North Carolina: The 1860s ........................................148
North Carolina: The 1960s ........................................152
A Statewide Study.................................................156
Isolated Legislative Action.........................................158
The Ambulance Act of 1967 ......................................... 163
An Early Urban Response.............................................165
A Different Response from Some Rural Areas..........................175
Policy Implementation: The Ambulance Act of 1967 ................. 182
The Board of Health's Role..........................................184
A Statewide Cause is Born ..........................................186
The North Carolina EMS Act of 1973 ............................... 193
Building a Team: The North Carolina Office of EMS.................196
Mass Communication: EMERGENCY!......................................198
North Carolina Recruits a Chief.....................................204
Building an Implementation Team.................................... 207
Implementation: The Good, The Bad and The Ugly......................215
Resistance from The Start...........................................221
A Battle in the West................................................228
Problems in the East................................................232
North Carolina's Shame: Illiteracy..................................237
Colonel Charles A. Speed............................................245
A New Chief for OEMS ...............................................247
EMS "Added a Cubit to My Stature" ..................................250
A Program with Value .............................................252
Closing Observations .............................................253
VI. CONCLUSIONS .................................................. 257
A Matter of Funding...............................................262
A Matter of Location..............................................271
Leadership Counts: Policy Entrepreneurs ..........................277
Unforeseen Variables .............................................284
Standards and Regulation......................................... 287
Interactive Nature ...............................................289
1.1 Top-Down/Side-to-Side Communication Model.................... 20
3.1 North Carolina: 100 Counties.............................. . 84
3.2 North Carolina: Three Regions................................ 85
5.1 North Carolina: Guilford County ..............................167
5.2 North Carolina: Five Bands ...................................179
5.3 1974 OEMS Organizational Chart................................210
5.4 North Carolina: Wayne and Gaston Counties.....................222
5.5 North Carolina Ambulance Provider Types, 1973-1984 .......... 254
This thesis will focus on innovation and diffusion within the public sector
and, specifically, the development and dissemination of out-of-hospital
emergency medical services (EMS) in the State of North Carolina. The method
will be historical and qualitative, using a case study approach, with the major
focal point on a time period between 1960 and 1980. This period of time, as well
as North Carolina in particular, has been selected for study because this state
was amongst the first in the nation to address EMS development, through state
government, on a statewide basis. Also, while many states approached EMS
development on an element by element basis, North Carolina approached EMS
from a comprehensive development perspective. Considerable federal and state
resources (i.e., funding) were applied to system development and talent (i.e.,
personpower) was drawn from both in state and out of state to support the
overall program and its implementation. At the time, no operating state model
was available to serve as a template for North Carolina EMS officials, although
the core elements of North Carolina's EMS standards (i.e., "essential elements")
were drawn from a federal EMS model.
Two fields of academic study, innovation diffusion and public policy,
represent the theoretical base upon which this thesis is built. Of these fields,
innovation diffusion will be the primary consideration, with public policy, and
implementation in particular, in a secondary role. Also, the phenomena of
chance (e.g., the right person at the right time) and policy formulation (e.g., the
right issue at the right time) will be narrowly explored in relationship to events
within the overall case study.
"Invention implies bringing something new into being; innovation implies
bringing something new into use" (Mohr, 1969:112). The new "something" can
be an idea, method, process, device, product, or service. Innovation diffusion is
the spread or dissemination of innovation, either product or service. Since the
early 1960s, the federal government "has been increasingly active" in innovation
diffusion of civilian technologies (Baer et al., 1976: iii), as well as services, in both
the public and private sectors. Also, although somewhat later, the federal
government has worked diligently to shift the focus of programs and services
from the federal to the state level. The results of these interventions have been
mixed. Mohr (1969:111) charges that many bureaucratic agencies "...fail to take
the initiative and supply the leadership that is required of them" in relation to
innovation diffusion. Even if public sector action has been taken and leadership
provided for, many innovations fail. Failure, of course, is subject to
interpretation. For our purposes, it should be stated that failure is present when
rejection, "...a decision not to adopt an innovation," occurs (Rogers, 1983:21).
Some researchers, including Rogers (1983:21), consider discontinuance, "...a
decision to reject an innovation after it has previously been adopted," also to fit
the definition of diffusion failure. Speed of diffusion, known as the rate of
adoption, is sometimes also factored in the definition of innovation failure. In
fact, rate of adoption issues are a common problem in innovation and will be an
important issue in the following chapters. However, in this thesis, only
innovation rejection will be equated to diffusion failure. Specifically, and as
relates to the North Carolina case study that follows, the EMS essential elements
that will be considered in the success/failure analysis will include only the
following key pre-hospital EMS components: staffing, training (and related
certification), transportation, and communications.
Innovation failures are often expensive, not only from the perspective of
financial resources, but also in terms of opportunity costs as they drain time,
energy, and personpower. Political fallout, too, can be "expensive" for
individuals, groups, agencies, and communities. Although the definition of
"good and questions of "good for whom" remain open to interpretation, public
sector innovation diffusion failures can also be expensive from the perspective of
"the public good" when new potentially valuable programs or services are
rejected and, therefore, remain restricted in their distribution. Thus, "What
precisely differentiates a successful policy [innovation] from an unsuccessful one
is a subject of intense interest for policy analysts, legislators, program
administrators, and tax-paying citizens" (Comfort, 1980: 35). This is especially
true today as the Clinton Administration enters the era of the information
superhighway, a roadway necessarily requiring new ideas, technologies, services,
and their diffusions.
To explore public sector innovation diffusion, one must consider academic
works from two fields of research, which overlap in some areas. The first is
known simply, and appropriately, as innovation diffusion. This field
concentrates on innovations and their dissemination (failed or successful)
through specific settings, such as agriculture, government, medicine, industry,
science, or general society. Innovation research has fixed its sights on
technology, services, and programs as diverse as smallpox inoculation patterns in
England and France in the eighteenth century (Miller, 1957), adoption of hybrid
corn (Griliches, 1957), driver education (Ross, 1958), mechanized refuse collection
(Baer et al., 1976), semiconductors (Tilton, 1971; Jelinek and Schoonhoven, 1990),
nuclear magnetic resonance spectrometry (von Hippel, 1988), nuclear power
reactors (deLeon, 1978), technology transfer (NASA, 1988 and 1989), public
policy (Atkinson, 1991), and commercial technology (Dakin and Lindsey, 1991).
Also, innovation research has drawn from the field of economics (e.g.,
Schumpeter, 1950). As these examples suggest, we will examine materials
drawn from both the private and public sectors, as all are intertwined.
The second area of consideration is public policy and, in particular policy
implementation, which is drawn from the fields of political science and public
administration. Today, "...the popularity of implementation studies has
succeeded in drawing public policy scholars from what was once almost an
exclusive attention to the politics of making laws to consider[ing] what happens
once laws are passed" (Ingram, 1990:462). This, however, has not always been
the case. Policy implementation once was characterized as a, "...frequently
overlooked step in the general policy process model" (Brewer and deLeon,
For innovation to diffuse, especially in the public sector, it must be
implemented. "Lacking proper implementation, policy innovation and selection
may end up being little more than intellectual exercise" (Brewer and deLeon,
1983:249). This observation is important in light of real-world experience with
policy implementation. For example, "Programmatic failures have been observed
in a large number and range of social programs..." (Brewer and deLeon,
1983:250). Perhaps as a result, starting in the 1970s, a growing number of
academic works related to policy implementation have appeared (Pressman and
Wildavsky, 1973; Lineberry, 1977; May and Wildavsky, 1978; Jones, 1977; Brewer
and deLeon, 1983).
Policy implementation will be explored in more detail in a later chapter,
but again it should be noted that materials related to policy implementation will
be of secondary consideration to materials drawn from innovation diffusion.
Innovation Diffusion Research
As a field of study, innovation diffusion has drawn upon a number of
academic disciplines, such as political science, economics, public administration,
urban planning, medicine, sociology, anthropology, history, and agriculture.
Regardless of the discipline, however, the principal emphasis has been on the
process of innovation. Also, the "one implicit or explicit purpose of many
diffusion studies has been to determine methods by which diffusion can be
hastened [rate of adoption]" (Rogers, 1962: 2). Innovation researchers, such as
Eric von Hippel (1988:9) note, of equal importance, "...attempts to direct or
enhance innovation [diffusion] must be based on an accurate understanding of
the sources of innovation."
There exist a number of innovation sub-areas and related research. For
example, technology innovation is the process by which society generates and
uses new products and production processes. It includes activities ranging from
the generation of a basic idea to its widespread use, including the research,
development, commercialization, and diffusion of new and improved products,
processes, and services for public and private use (Mogee, 1980). During the
1980s, technology innovation and diffusion, sometimes driven by government
involvement, were frequently on center stage within both the scientific and
popular press (NASA, 1988 and 1989). Although less frequently reported outside
specific professional literature, innovation and diffusion research has also focused
on non-technical programs, organizations, services, and public goods policies.
An example would be, "public programs geared toward achieving certain social
or economic policy goals... [including] new ideas, techniques, and products
sponsored by national or local public agencies" (Agnew, 1980: 1).
Public safety programs and services, such as EMS (the major focus of this
thesis), provide an example from the services innovation arena. Guidelines for
transferring government-sponsored service innovations among levels and units of
government have appeared in academic literature (Brown and Berry and Goel,
1991) and the popular literature as well. The federal government, for instance,
has published guidelines regarding the public safety areas of emergency medical
services (NAS/NRC, 1972) and law enforcement (DOJ, 1993). Private sector
special interest groups, such as the Advanced Coronary Treatment Foundation,
have also developed guides designed to encourage innovation diffusion in
emergency care (ACT, 1971-A and 1971-B).
Despite the many categories of professionals and disciplines involved in
the study of innovation and its diffusion, over time certain patterns or groupings
have been recognized as elements of the research process. Rogers (1962: 12) has
identified these elements, basically, as: "(1) the tracing of an innovation, (2) over
time, (3) through specific channels of communication, and (4) within a social
structure." Likewise, certain models of the innovation process have emerged,
"many of which show a linear progression of innovation activity through stages
from idea generation through diffusion" (Mogee, 1980: 176). Rogers' model over
time has been supported by other academic works (Ray, 1989). However, most
linear models of innovation have been shown to be too simplistic in light of the
fact that, "...the progress of innovation is rarely straightforward... sometimes
stages are shortened, skipped, or overlapped" (Mogee, 1980: 175). Also, many
outside considerations are involved with the diffusion process. For example,
many issues such as individual and group values and ethics, economics and
resource availability, timing and pacing, environmental and political factors, and
similar considerations have been shown to contribute to the success or failure of
innovations, as well as the speed with which either occurs. In fact, in today's
era of innovations related to issues as politically and socially sensitive as
reproduction and genetic manipulation, one must expect many factors to
influence the diffusion process (Elmer-Dewitt, 1994). Thus, the decision to
support an innovation is not a guarantee of successful implementation. This
said, however, one must add that when discussing innovation diffusion,
"...success and failure are slippery concepts..." (Ingram and Mann, 1980:12).
During the past few decades, governments at all levels and throughout
the United States, as well as internationally, have increasingly become active in
stimulating change and innovation (Baer et al., 1976; NASA, 1988; NASA, 1989;
Roessner, 1989-A; and Muller, 1989). Such involvement has not only included
direct research and funding of independent research and development activities
(e.g., public services, communications, transportation, and nuclear power
reactors), but also monitoring and evaluation activities (Roessner, 1989-B). For
example, in 1972, the United States Office of Technology Assessment (OTA) was
created "to help Congress anticipate and plan for the consequences of uses of
technology" (Shafritz, 1985: 378). More specifically, OTA has the mission of
assisting Congress with analyses of emerging and highly technical issues, as well
as identifying alternative policy options and providing early alert to new
innovations that could have important implications for future public policy.
Thus, the federal government is involved in both helping innovation to come
about, evaluating its effectiveness, guiding its diffusion, and being affected by it.
This involvement is reflected not only in government action, but also in basic and
applied research (Brown et al., 1991). This activity is similar to Toffler's
"anticipatory democracy," in his 1970 book Future Shock, which calls for
government to sift through complex issues ("noise") and "find the common
interest" (Toffler, 1970; also Osborne and Gaebler, 1992:230).
On a growing number of occasions, once an innovation has been
identified (either in or out of government), "demonstration projects" are utilized
to test or promote the innovation(s) in "a normal real world environment" (Baer
et al., 1976: iii). Such demonstrations are by no means a new government
undertaking (e.g., Congress, in 1843, approved federal funds for a demonstration
project of Samuel Morse's telegraph system). However, the number, range and
funding for such projects, including both technology and service demonstrations,
has greatly increased as the government's overall role in society has expanded.
When and if such demonstration projects are successful, they supposedly
assist in innovation dissemination by way of concept exposure. Alone, such
demonstration projects are thought by some researchers to be weak tools in
addressing some types of organizational barriers to diffusion, which must,
therefore, be approached via alternative government programs (e.g., regulation
and rewards). However, by providing seed funding, the federal government
attempts to remove certain known early barriers to diffusion, such as initial
economic risk (Teubal and Steinmuller, 1982). In this thesis, we will see that
such seed funding can represent a significant contribution to innovation diffusion
success, most particularly in the area of technology. Such activity is especially
important in an era when man has "learned to manufacture power," and through
these uses, bring about "social, economic, political, and intellectual" change
(Morison, 1966). Also, we will examine some of the factors that lead government
to "target," as identified by Roessner (1988), particular concepts and innovations
for planned exposure.
In 1976, RAND published a study, Analysis of Federally Funded
Demonstrations Projects: Final Report, for the United States Department of
Commerce, which examined a number of government-supported field
demonstration projects. Included in the RAND sample were two dozen
examples, ranging from computer-assisted electrocardiogram analysis to fish
protein concentration plants, a synthetic fuels program to saline water
conversion, the nuclear ship "Savannah" to Dial-a-Ride transportation systems.
The policy areas represented included energy, housing, transportation,
environmental protection, and public health. Likewise, a wide range of federal,
state and local agencies and services, as well as technologies, project
characteristics and settings, was reviewed. The central linking question was,
"What lessons can be learned [from these demonstration projects] that will help
federal agencies plan, design, and implement future projects more effectively?"
(Baer et al., 1976: 2). Specifically, the purpose of the RAND study was: "(a) to
identify major factors associated with successful and with unsuccessful project
outcomes, and (b) to formulate guidelines for federal agencies in improving the
planning, implementation, monitoring, evaluation, and dissemination of results
of future projects" (Baer et al., 1976: iii).
Beyond demonstration projects, researchers have also been interested in
"innovation policy" (Roessner, 1988), which can be defined as government policy
and programs designed to enhance innovation and its diffusion within science,
technology, or society as a whole. The actual policy formulation process,
although a consideration that will be viewed from an historical standpoint in this
thesis, is a separate field of study. However, once a decision is reached to
establish policy, the opportunity to encourage innovation diffusion presents
One might ask why government becomes involved in policy related to
innovation and diffusion. There are a multitude of possible answers ranging
from political to practical points of view. For example, government, through
policy, may become involved when a concept, viewed by government agencies
from a public goods perspective, is thought to be beyond the means or
inclination of private sector investment. In fact, employing this thesis, we will
see that a combination of factors can and do influence government decisions and
actions related to innovation and diffusion issues.
Emergency Medical Services
The problem to be addressed in this thesis is innovation diffusion in the
public sector. Employing a case study approach, we will examine statewide
emergency medical services (EMS) system development in North Carolina.
Specifically, this analysis will take place in relation to existing academic literature
from innovation diffusion and public policy. Accordingly, we will focus on issue
evolution, policy development and implementation, technical issues, as well as
political factors, related to early (1960-1980) EMS activities and developments in
North Carolina. Of particular interest will be top down (i.e., state-to-community)
and side-to-side (i.e., community-to-community; neighbor-to-neighbor)
communication in relation to the diffusion process. Also, differences between
some large population areas (i.e., urban) and low population areas (i.e., rural)
will be explored, especially as relates to financial resource availability to support
innovation. By identifying salient factors that led to a successful (i.e., widely
diffused) innovation diffusion (albeit by turbulent pathway), this information will
prove helpful in future public sector innovation diffusion attempts.
As background information, during the current century, the scope of
government involvement in the day-to-day affairs of average citizens has greatly
expanded. Government involvement in personal health care is an example
(Meyer et al., 1990). Although the U.S. Constitution makes no specific or direct
reference to individual health care, either as a personal right or as a government
responsibility, many questions related to health are now widely recognized as
being acute public policy issues. Perhaps because government is thought by
many to be in the best position to meet the public needs, a growing percentage
of public resources, both financial and human, have been directed to health
related concerns. In fact, many Americans now consider healthcare in the
United States to be in crisis. As a result, there is a growing public demand for
active government intervention and participation in the overall administration of
healthcare services, although for a long period of time government officials have
been "preoccupied with service delivery" and have failed to address the overall
issues of access and cost (Osborne and Gaebler, 1992:32).
The earliest dimensions of public health and, hence, the first areas of
direct governmental involvement, addressed only sanitation and infectious
disease (Hanlon, 1974). Today, the scope of public health and its related public
policy has a much larger focus. This includes sanitation, infectious disease,
individual health care for the geriatric and indigent, mental health services,
specific disease identification and response (e.g., AIDS), hazardous materials
control, occupational health, dental services, educational, and technical
components. One major area of government involvement which has occurred
within the past 25 years is safety and emergency response.
Until the late 1960s, very few communities in the United States provided
adequate EMS programs. In the 1950s and 1960s, the mounting toll of deaths
and disabilities associated with accidents, plus increases in cardiac-related
mortality and morbidity, were tacitly accepted by the public, medical
practitioners, and government officials, with little thought to possible
interventions that might reduce such deaths and injuries. Emergency care was
largely a neglected problem. Although groups such as the American Red Cross
were concerned with accident prevention and, this failing, "first aid," no
organized special interest or advocacy groups had come forward to exert pressure
on government or, for that matter, to even call general attention to the issue.
Likewise, federal, state and local governments had not yet recognized there was
a problem or, in response, initiated action to address it. As Brewer and deLeon
(1983:31) point out, "...one cannot have a policy unless a problem is recognized,
the policy making mechanisms are alerted, and policy alternatives are
generated." Lineberry (1977:9) adds that once the policy process has begun,
"Public policy is conditioned by the past and made by the present for the
future," an observation supported by this thesis.
During this period, governments at all levels (local, state, and federal) had
little or no direct involvement in emergency health services, other than in the
military setting. Some local government units provided for ambulance service
through municipal hospitals, police or fire departments, or their public health
department. Yet this early domestic interest was still limited to clearing the
streets of injured persons or, as some have phrased it, "sanitation" (Page, 1978:
23). As late as the early 1960s, it was estimated by the federal government that
nearly 50 percent of ambulance services in the U.S. were operated and staffed by
morticians (GAO, 1986). In most locations, "ambulance services" provided little
more than a "scoop and run" service; untrained personnel in hearse-type vehicles
sped to an accident scene, "scooped" up the victim with no regard to injury or
care, and raced (sometimes with both the driver and attendant riding in the cab)
to an ill-equipped and poorly staffed emergency room. The lack of trained
personnel and equipment was largely reflected in the number of lives lost.
During the past few decades, a number of studies focusing on death secondary
to trauma have consistently shown that a substantial proportion of patients died
because of a lack of timely emergency care on-scene and during transport to a
hospital (West et al., 1979). Specifically:
In 1965, heart attack and injury, two leading causes of death,
accounted for over 700,000 and 100,000 deaths, respectively.
About half these victims died before reaching a hospital. Studies
conservatively estimate that 15 to 20 percent of those injury and
prehospital coronary deaths could have been prevented with
improved emergency medical services; in some areas even greater
rates could be achieved (GAO, 1986: 11-12).
The situation related to the nation's emergency medical posture was
dismal. As an example, in an article that appeared in a 1967 issue of The Tournal
of Trauma, written by a surgeon who had recently seen Vietnam combat service,
the following condition was offered (Eiseman, 1967: 55):
Wounded in the remote jungle or rice paddy in Vietnam, an
American citizen has a better chance for quick definitive care...
than were he hit on a highway near his hometown in the
continental United States. Even if he were struck immediately
outside the emergency room of most U.S. hospitals, rarely would
he be given such prompt, expert care as routinely is furnished
from the site of combat wounding in Vietnam.
Several years later, however, the national picture of emergency health
care began to change radically. The need for formal systems to provide
emergency medical services (EMS) on a nation-wide basis became clear. Many
key elements of EMS systems were identified by the federal government and
included in the EMS Systems Act of 1973 (Public Law 93-154), including
manpower, training, communications, transportation, facilities, critical care units,
mutual aid, consumer participation, accessibility to care, transfer of patients,
standard recordkeeping, consumer information and education, review and
evaluation, disaster linkage, and use of public safety agencies. Because PL 93-154
called for the development of a comprehensive system, with a minimum of
fifteen complex components, an EMS system built around the federal model (and
standards) actually became many different innovations rolled into one umbrella
innovation known as EMS. North Carolina state government adopted the federal
EMS model and actively pursued implementation of same across the state. Some
of the federally identified elements (e.g., training, vehicles, communications)
required primarily local compliance, while other elements (e.g., air-ambulance,
hospital categorization) called for regional or statewide provision of service
through a limited number of multi-county, or regional providers (Gentile, 1991).
As this thesis will demonstrate, some elements of the federal EMS model would
prove far easier to implement than other elements.
Like an onion, once one begins to peel back the layers of the innovation
we call EMS, we immediately encounter layer upon layer of core innovations.
Some of these system building blocks are technological innovations (i.e., new
vehicle types, biomedical telemetry, cardiac monitors, etc.). Other blocks are
clinical innovations (trauma care), while still others are educational innovations
(training standards). To complicate matters even further, many of the base
elements of an EMS system are co-dependent of other elements. For example,
the addition of innovative vehicles and equipment is of little value without
adoption and completion of innovative training. Too, it quickly becomes clear
that the economic resources requirements for implementation of such a system
are significant. Comprehensive resource availability (or lack thereof) is thus a
major issue in innovation diffusion, and in this case, an integrated EMS policy.
Such concerns will be examined in this thesis.
In recognition of the complexities and resource requirements associated
with new federal standards, PL 93-154 provided for federal grants for EMS
planning, initial establishment or expansion of existing emergency services
programs for given locations, and authorized research related to emergency care.
Additional details regarding the Act will be covered in another chapter, but it
should be emphasized that "...the central theme and intent of the EMS Act was
to develop systems of emergency medical care that would significantly decrease
death and disability rates" (Boyd, 1977).
Today, individuals experiencing acute illness or injury are likely to receive
initial out-of-hospital medical attention from a formal emergency medical service
system. EMS systems providing advanced emergency care now exist in most
urban communities, as well as a growing number of rural communities across the
nation (Cady and Scott, 1994). Medical literature, the media, special interest
groups, medical academic centers, vendors, and service providers have reported
that EMS systems, when well staffed, equipped, located, and coordinated, save
lives that were almost always lost before the advent of such systems (Crampton
et al., 1975; Geddes, 1986; Dean et al., 1988; Bachman et al., 1986; Atkins, 1986;
Asensio et al., 1988; Scott, 1970; Crampton, 1984; Eitel et al., 1988; CDC, 1992).
Purpose of the Thesis
Considerable time and money from both the public and private sectors are
involved in innovation diffusion. Many innovations, although seemingly "good"
concepts, fail to spread, though the converse ("bad" innovations spreading) is
also an issue. Still, identifying the variables that lead to success or result in
failure of innovations, specifically when government is involved in the
dissemination process, is important to advancing the field. If such variables can
be identified, reduction of the cost, time, and overall resources required to bring
about successful dissemination may become apparent, thus improving the
chances for widespread dissemination.
Given this background, the main focus of this thesis will be government
and its role at the federal, state and local levels in EMS development and
diffusion. Through a case study approach, communities in which various factors
differ (i.e, access to technology, community values, financial resources,
educational levels, etc.) will be considered in relation to statewide EMS system
development in North Carolina. This is important given that innovation
diffusion has been considered from many perspectives, but few studies or guides
have explored innovation diffusion led by state-government. Of particular interest
are lines of communication occurring during the innovation diffusion process. In
this case, we will focus on top-down (vertical) and side-to-side (horizontal)
information exchange (Figure 1.1). Accordingly, this thesis adds to a thin base of
knowledge related specifically to state level government involvement in
innovation diffusion efforts.
In the mid-1970s, the literature reported that some providers believed
there was no role for state government in EMS; that EMS is a local, or at the
very most, a regional concern. In 1995, there are still individuals and
organizations that question the role of state government in EMS. This study, in
part, addresses the role and value of state government in EMS matters. More
importantly, this study will demonstrate the importance of leadership from loithin
state government, in the innovation diffusion process associated with public policy.
The next chapter, II, examines a broad range of literature drawn from the
fields of innovation diffusion and public policy. Although the focus of this
thesis, as previously stated, is on public sector innovation, private sector
research and considerations will also be examined in Chapter II. This is
important because these materials are interconnected in research and application.
Chapter in addresses the methodology used in the research for this
thesis, which is a case study approach. Included are details concerning
individuals interviewed for this study.
Chapter IV explores the history of emergency medical care globally, but
with an emphasis on events that influenced development in the United States.
Governmental involvement in technological, medical and policy innovations,
especially via the military in times of war and through such agencies as the
National Aeronautics and Space Administration (NASA) are considered. This
information provides a background canvas upon which the North Carolina case
story can be presented in context to the nation-wide effort to develop and
implement EMS systems at or about the same time. Chapter IV also covers key
technical considerations in modern EMS systems. This information is provided
so readers unfamiliar with the subject of EMS can enhance their understanding
of the complexities and terminology associated with EMS. Likewise, for those
readers already familiar with EMS, this section will allow for a comparison of
observations and conceptual views.
Chapter V, "The North Carolina Story/' presents an overall case study of
the development of emergency medical services in one state. The critical time
frame is 1960 through 1980, although pertinent information from before and after
this central time period will be added for background and evaluation purposes.
Of particular interest will be leadership by state officials in the innovation
process, various lines of communication, and activities at the county and regional
levels related to EMS development.
Chapter VI ties together all of the proceeding chapters. Findings related
to the research hypotheses and literature covered in Chapter II, as well as
observations drawn from Chapter V will be summarized. The goal is to address
the key research questions and, along the way, also provide useful information
for future public policy and innovations diffusion considerations.
The purpose of this chapter is twofold: (1) to examine broadly the
literature associated with innovation and its diffusion, and (2) to examine
narrowly the pertinent literature associated with public policy, with special
emphasis on implementation. The intent by so doing is to provide a framework
around which subsequent chapters can be considered, especially with reference
to the research proposed in Chapter I. In addition, the hypotheses proposed as
part of this thesis are first identified in this chapter.
As noted in the previous chapter, materials and concepts drawn from the
field of innovation diffusion will serve as the principal backdrop for the research
presented in this thesis. As we shall see, many academic areas are represented
in the literature associated with today's field of innovation diffusion. As a result,
no single work will capture all there is to say on the subject. Thus, it is
important to review (at times in detail) numerous areas of previous research on
the subject. One available tool to assist in so doing is a basic model of the
innovation diffusion process. This model is best articulated through the
communications literature, with the best example being the work by Everett
Rogers. As we shall see, this model acts to tie together works on innovation
diffusion regardless of their academic base.
Before reviewing the innovation diffusion literature, a point should be
added. Although the focus of this thesis is innovation diffusion in the public
sector, there is no escaping the very close relationship between public and
private sector innovation diffusion. DeLeon (1984:484) notes, "Political science
has difficulty limning the interaction between the public and private sectors
regarding innovation: where does one begin and the other end, especially as the
two increasingly become inseparable partners." Much of the research on
innovation in general has centered on private sector diffusion, even in cases
where the original innovation came by way of public sector research,
development and overall activities. A large portion of this research has centered
on technology, products, and consumer services. This has been true not only of
the publicly reported academic research on the diffusion process, but also of
commercial research designed to identify ways to encourage diffusion (i.e.,
marketing). Public sector concerns, however, are not without research. From
the beginning of the innovation literature, public sector examples can be found.
Many will be noted in this chapter and it is fair to suggest that even more
examples will be generated in the future as the lines between private and public
sector diffusion become even more closely aligned (e.g., healthcare and
communications). Also, interest in the public policy implementation process
should receive growing attention, as well as research efforts, as a greater
percentage of the nation's economy is turned to public sector activities.
Of secondary consideration in this chapter are works and concepts
associated with public policy. Of specific focus will be policy implementation.
Two areas of academic concentration, public policy and political science, combine
to build the foundation for much of the work in policy. The first materials on
policy implementation can be traced to the early 1970s, with a visible explosion of
works occurring in the late 1970s or early 1980s.
It is quite impossible to ignore materials drawn from policy
implementation when exploring innovation diffusion in the public sector. As
noted in Chapter I, this thesis considers the innovation of emergency medical
services and its diffusion, particularly through state government involvement,
within the State of North Carolina. Thus, we are dealing with public policy,
public agencies (federal, state and local) and their actions, as well as public safety
programs. Likewise, politics, economics and public funding, public sector
management, system operations, environmental impacts, agency-to-agency
communications, technology transfer and application, and a host of similar
considerations come into play. Public as well as private sector responses to
proposed and actual change via innovation diffusion, especially as related to
individuals and groups, are also key considerations. Accordingly, it is central to
the purpose of this thesis to examine materials drawn from both the innovation
diffusion and policy implementation literature.
Given this background, we will now move forward with our examination
of the pertinent literature through two sections: (1) innovation diffusion, and (2)
The scope of this thesis does not call for an exhaustive understanding of
the origin of base ideas (although we will retrospectively trace the origins of EMS
in a later chapter). However, all new ideas start in one location or, at most, in a
very limited number of locations; e.g., the AIDS virus is reported as having
simultaneously been discovered in two separate laboratories, on two separate
continents (Said, 1992:15). With this said, everything has a beginning and so it
is with base innovations.
The question is often asked, "Where did that idea come from?" In
response, the answer to the origin of "that idea," or any idea is complex.
Edmund Burke, the 18th century British statesman, suggest that, "We are in a
manner compelled to acknowledge the hand of God in those immense
revolutions [innovations and related change], by which, at certain periods, He so
signally asserts His supreme dominion, and brings about that great system of
change" (Clemens and Mayer, 1987: 144). Burke, in his public sector role,
viewed innovation as "...derived from the confined view that newness was good
for its own sake" and, therefore, he chose only to use the term reform" when
speaking of innovations (Clemens and Mayer, 1987: 144). Burke's opinion
notwithstanding, others chose to address innovation more directly. According to
Rogers (1983:135), "One of the ways in which the innovation-development
process begins is by recognition of a problem or need." This is often true, but
one, of course, does not always set out to bring about an innovation (or for that
matter, to solve a problem or meet a specific need). Knowledge for the sake of
knowledge is often enough to drive interest. "Humans crave information,
wanting to know more about themselves and their world," according to Berry
(1993:3). Such knowledge, "...expands and accumulates" in a progressive
manner over time (Van Doren, 1991: xvi). Today's communication technology,
which we will examine separately in another section of this chapter, greatly
enhances man's ability to share base knowledge and, at times, innovations
stemming from such knowledge. However, with or without a means for high-
tech communications, man has always taken advantage of the opportunity to
accumulate knowledge and spread ideas. Rogers (1986:68), in Communication
Technology, examines the history of communication and states, "In order to
understand the full nature of the new communication technologies, one must
look to the past as well as the future."
Basalla (1988:6-7) agrees with the previously noted concept of "necessity"
as one driver of man's ideas, but he goes on, with example in mind, to warn:
A search for the origins of the gasoline-engine-powered motorcar
reveals that it was not necessity that inspired its inventors to
complete their task. The automobile was not developed in
response to some grave international horse crisis or shortage.
National leaders, influential thinkers, and editorial writers were
not calling for the replacement of the horse, nor were ordinary
citizens anxiously hoping that some inventors would soon fill a
serious societal and personal need for motor transportation. In
fact, during the first decade of existence, 1895-1905, the automobile
was only a toy, a plaything for those who could afford to buy one.
Regardless, however, of the intent or driving force, humans do generate
ideas that occasionally represent innovations. Not all such ideas are
revolutionary, although a simple idea in one location may represent a
revolutionary innovation in another. However, a majority of innovations are
incremental in nature. Accordingly, we next explore this subject.
Re-invention and the Incremental Nature of Innovations
One phenomenon associated with innovation diffusion is re-invention.
Rogers (1983: 16-17) describes re-invention as "...the degree to which an
innovation is changed or modified by a user in the process of its adoption and
implementation." Clemens and Mayer (1987: 80) reference man and his
"...unpredictable psychic twists and turns that make one person's nature
remarkably different from another's." This noted, there should be little wonder
in the fact that people view the same or similar information in different ways.
From a public policy standpoint, for example, Nelson Polsby (1984) reports that
there are often many differences in the intent of lawmakers versus
implementation by administration. Interpretations vary, as do priorities. Murray
Dalziel and Stephen Schoonover (1988: 133) state, "All successful change plans
are revised many times over the course of implementation." These are key
points not only in innovation diffusion, but also policy implementation.
Resource availability, conflicting assignments, the absence of
implementation skills, and poor productivity, to name but some examples, may
block or alter the course of innovation diffusion. Timing, too, must be considered
in the context of enabling legislation, policy directives, and "...how a public-
private interface should be structured given a particular technology and particular
market considerations" (Brown et al., 1991).
The so-called "creative mystique," too, may influence innovation through
re-invention (Levitt, 1983). Although slippery, one can define being creative as
having the ability to generate new ideas and, once generated, act on them. The
possibility always exists that a creative individual or group will modify an
innovation because he/she has a "better idea" (i.e., incremental innovations).
Experience in different system settings may also result in new ways to look at the
same situation, thus leading to innovation modification.
Regardless of the reason, re-invention is relatively common and
demonstrates that customization is to be expected as ideas pass from setting to
setting. This is not a new concept, but rather one that stretches throughout
history, as is evidenced through artifacts tracing long series of changes in basic
innovations as they move about geographically and in time. George Basalla
(1988: 78) notes, "...exploration, travel, trade, war or migration" contribute to
"...[The] exchange [of] information about novel techniques and artifacts." He also
notes the work of H.G. Barnett (1953), in which Barnett states "All imitation
must entail some discrepancy." Thus, re-invention, be it unintentional or
deliberate, should be expected to represent an element of innovation diffusion.
The degree to which an innovation is modified through re-invention may be
slight. However, one change often leads to another and the end product may be
considerably different than the original model.
As this discussion points out, generally innovations are incremental in
nature (i.e., improvement and changes to previous ideas, methods, devices or
services). Joseph Schumpeter (1950) has noted, "The essential point to grasp is
that in dealing with capitalism [and, therefore, technological advances] we are
dealing with an evolutionary process." Nelson (1990-A:194) adds, "Technological
advance inevitably proceeds through the generation of a variety of new
departures in competition with each other and prevailing practice." Incremental
change is most likely to be reported in the private sector. Driven by profit goals,
many companies constantly work to improve their product line to gain a market
advantage. Warner (1974:447) notes, "Many of the most significant innovations
find their way into the mainstream of economic life while undergoing a continual
or sporadic technological evolutionary process...," known as a product cycle. For
example, the Sony Walkman, an individual consumer entertainment product, has
undergone change after change after change in Sony's effort to establish and
expand market share in a highly profitable consumer product area. Many of the
electronic innovations introduced to the consumer via the Walkman series have
later appeared in similar entertainment products, as well as other electronic
devices. Such incremental innovations are driven by competition in the private
marketplace and the desire for market growth and dominance, and, of course,
profit. As a side note, this type of ongoing product improvement, through
innovations built upon innovations, is a cornerstone in the current private sector
quality improvement movement in the United States (Kinlaw, 1992, and Swor,
New product diffusion (which equals, in this example, innovation
diffusion) is required if product growth, through increased consumer demand, is
to occur. Economic gains can, and do, create a powerful incentive in the private
sector to encourage wide product dissemination (i.e., diffusion). We will
examine the role of entrepreneurs and their organizations, as drivers of
innovation diffusion, in a later section of this chapter. We will also explore
marketing, in both the private and public sectors, as a means for driving such
diffusion through increased consumer demand.
It is relevant to mention that the possibility of economic loss, or even the
perceived absence of potential for economic gain, will often lead the private
sector away from a given technological, product or service innovation and its
diffusion. In such cases, the public sector often has an opportunity to move
forward with a specific innovation in the real or perceived interest of public need
and benefit. The absence of private sector interest, of course, is not a guarantee
that the public sector will recognize, value, need or act upon a given innovation.
But, it is clear that the public sector is the domain of many innovative broad
spectrum programs and services that are without clear economic advantage to
private sector concerns. Also, there are examples, including EMS, where there is
found a mixture of public and private resources, providers and programs built
around the same innovation and its diffusion. Clearly, when both public and
private sector participants are involved, the need for a balance between
competition and cooperation is present (deLeon, 1978). This balance,
unfortunately, is not always present in real-world situations.
The incentives and other reasons for mixed public-private involvement are
many and frequently change, often very quickly, along the way. Occasionally
the private sector leaves the marketplace, thus leaving the public sector to
provide services or programs (e.g., non-public hospitals in inner city
neighborhoods). On the other hand, occasionally it is government that moves
aside to allow private enterprise to assume responsibility. One example program
moving from the public sector to the private sector involves military weapons
and, specifically, small arms development and production. From the 1790s to the
1960s, the US Government manufactured many of its own rifles through
government plants such as Springfield Armory (Raber, 1988:1). A number of
innovations, such as interchangeable weapons parts, came from Springfield and
other government plants. Regarding Springfield, Raber (1988:1) states, "Despite
the extraordinary output of semi-automatic rifles in World War n, Springfield
Armory could not survive the post-1945 commitment to private procurement of
army ordnance." Also, McNaugher (1984:10) reports Springfield Armory fell
victim to "the politics of procurement." McNaugher (1984:10) continues,
"Springfield Armory seemed attached to developing and producing a
marksman's rifle," but military tactics had changed. McNaugher adds, "Aimed
fire played virtually no role at all in the ebb and flow of combat on the modern
battlefield. Newer forms of firepower suppressive and assault fire which relied
on volume rather than precision -- had taken on new importance." In short,
Osborne and Gaebler (1992:xv) note, "...[at one point] government armories
manufactured weapons, and no one would have considered letting private
businesses do something so important. Today, no one would think of letting
government do it."
Savas (1987:3) notes, "The word 'privatize' first appeared in a dictionary
in 1983 and was defined narrowly as 'to make private, especially to change (as a
business or industry) from public to private control of ownership'." Savas goes
on to note, ".. .but the word has already acquired a broader meaning; it has come
to symbolize a new way of looking at society's needs, and a rethinking of the
role of government in fulfilling them." Accordingly, Naisbitt and Aburdene
(1990) predict the privatization movement will continue to grow, as does the
recently elected Republican majority in the U.S. Congress. Peter Drucker (1994),
likewise, has suggested that traditional public programs have and are moving to
a third sector, known as "the social sector" (i.e., nonprofit, non-government
sector). Osborne and Gaebler (1992:30) refer to this newly identified sector as
Regardless of the example type, the response of each sector at times of
such "breakpoints" (a concept that will be discussed later in this chapter) is often
critical to the diffusion process. The transfer of responsibility within a sector
(McKearney, 1994) or outside a sector (Savas, 1987) is always a possibility,
assuming that the conditions that foster and support change are present.
Regardless of the location by sector, however, ongoing change along the roller
coaster ride associated with the innovation diffusion process is to be expected.
This is especially true in view of the incremental nature of innovation and the
likelihood of one innovation building upon another.
Innovation Diffusion Theory
Garry Brewer (1980:341), in "On the Theory and Practice of Innovation,"
A number of theoretical perspectives and approaches can be
discerned in the literature and scholarship on innovation. No
single theory has been devised that satisfies scientific criteria of
generalizability, parsimony and replicability; rather the current
state of theoretical art is quite disparate, piecemeal, and in some
areas even in turmoil. Nonetheless, something can be learned by
exploring the field.
In this section we will note a number of research areas now associated
with innovation and its diffusion. Currently, diffusion research is conducted by
researchers from many disciplines, with the list still growing. Such fields include
political science, economics, public administration, urban planning,
anthropology, education, medicine, sociology, marketing, geography,
psychology, agriculture, engineering and communications. Of these,
communications is thought by many to play the most important role.
According to Rogers (admittedly a communications theorist) (1983:5),
"Communications is a process in which participants create and share information
with one another in order to reach a mutual understanding." Rogers (1983:5)
goes on to state, "communication is a process of convergence..."
Communications research, as it relates to innovation diffusion, centers on
innovation development, communication pathways and technology, individual
and group behavior, persuasion and attitude, change resistance, externalities and
a host of complex variables. In fact, diffusion research studies in almost all fields
are guided by a general model drawn from communications research. McAnany
(1984) states that this "common theory" explains why so many diffusion studies
continue to be conducted.
As noted in Chapter I, the innovation communications diffusion model
basically deals with: (1) an innovation, (2) communicated through certain
channels, (3) over time, (4) among individuals in a social system. The opinions
held by members of a social system, along with numerous other factors, directly
affect the likelihood and rate of adoption. Rogers (1986:117) states five real or
perceived features of innovation are key to adoption and diffusion: "(1) relative
advantage, (2) compatibility, (3) complexity, (4) reliability, and (5) observability."
These are defined (Rogers, 1983: 15-16) as follows:
1. Relative advantage: The degree to which an
innovation is perceived as better than the idea it
supersedes. The degree of relative advantage may
be measured in economic terms, but social-prestige
factors, convenience, and satisfaction are also often
2. Compatibility: The degree to which an innovation is
perceived as being consistent with existing values,
past experiences, and needs of potential adapters.
An idea that is not compatible with the prevalent
values and norms of a social system will not be
adapted as rapidly as an innovation that is
compatible. The adoption of an incompatible
innovation often requires the prior adoption of a
new values system.
3. Complexity: The degree to which an innovation is
perceived as difficult to understand and use. Some
innovations are readily understood by most
members of a social system; others are more
complicated and will be adopted more slowly.
4. Trialability: The degree to which an innovation may
be experimented with on a limited basis. New ideas
that can be tried on the installment plan will
generally be adopted more quickly than innovations
that are not divisible.
5. Observability: The degree to which the results of an
innovation are visible to others. The easier it is for
individuals to see the results of an innovation, the
more likely they are to adopt it. Such visibility
stimulates peer discussion of a new idea...
The beginning of innovation diffusion research can be traced to isolated
exploration of specific changes (innovation adoptions) in society. Examples
include education, psychology, sociology, agriculture, medicine, economics,
communications, business administration, journalism, military sciences, urban
planning, anthropology, public health and academic management. One of the
most frequently referenced early examples is drawn from the field of rural
sociology. Bryce Ryan and Neal Gross, through their 1940's-era research into
hybrid seed adoption, laid the groundwork for many future innovation diffusion
studies. Specifically, Ryan and Gross (1943) examined the patterns, and factors
associated with same, of hybrid corn seed adoption by Iowa farmers after the
innovative seed became available in 1928. The seed was developed by
agricultural specialist at the Iowa State University and other land-grant colleges.
The main findings of the Ryan and Gross studies were related to adoption
rate factors and S-curve patterns, lines of communication between opinion
leaders and early adapters, the role of salesmen in encouraging product
diffusion, and the importance of information in the adoption process. The
importance of interpersonal, side-to-side communications (i.e., farmer-to-farmer)
and positive experience (i.e., economic gains) too were central findings in this
ground breaking work.
One theoretical relationship shown in many diffusion studies, including
those by Ryan and Gross, is the logistic functional form. In fact, from the
perspective of a mathematical model, "There are numerous models of innovation
activity through stages from idea generation through commercialization and
diffusion" (Mogee, 1980: 176). One mathematical approach is the analogy drawn
to disease theory (Davies, 1979: 9-10):
Epidemiologically, the model is that of an epidemic. The basic model is
mt is the number of individuals, in a fixed population of n, having
contracted an infectious disease at time t. Thus, the number of
individuals contracting the disease between times t and t+1 is
proportionate to product of the number of uninfected individuals
and the proportion of the population already infected, both at time
t. The magnitude of /3 will depend on a number of factors, such as
the infectiousness of the disease and the frequency of contact.
This model, of course, is the equation of the above noted logistic
time curve with its symmetrical "S" shaped curve.
[Alpha is a constant of
Innovation diffusion is generally thought to follow this same curve in
keeping with the 1903 work of Gabriel Tarde, The Laws of Imitation, as reported
by Rogers (1983:41). Tarde suggested that the adoption of innovations follow a
normal, S-shaped distribution over time. At first, only a few individuals adopt
the new idea, then great numbers of individuals accept the innovation, (so-called
market penetration), and finally the adoption slackens as market saturation is
approached. Tarde (1903) thus noted generalizations associated with innovation
diffusion that he called "the laws of imitation." For all practical purposes, Tarde's
laws parallel what later diffusion literature would refer to as "adoption of
innovation." For this reason, Tarde is considered one of the early fathers of
The S-curve approach provides an excellent macro-model of innovation
diffusion, but, on the micro-level, numerous flaws are present. For example,
many factors are subject to inclusion in the innovation diffusion process. This
point was made by Rothwell and Zeqveld (1988:19-20), when they stated:
a. Innovation is a highly complex and high-risk process
involving many inputs financial, economic,
technical and social and many factors.
b. Technology innovations often also require
c. The process of innovation can be different (from
place to place).
d. Innovation can be a markedly regional or 'local'
e. Innovation can progress very differently in different
countries [tradition, values, etc.].
f. From a large number of empirical studies... we know
that innovations rarely fail for technical reasons, but
rather for other reasons.
Because of the above noted factors, individual innovations have their own
individual rate of adoption (i.e., the relative speed with which an innovation is
adopted within a given environment). To be sure, the pattern most often
associated with innovation is the S-curve. However, the slope and inflection
points of each S-curve are subject to great variation. Some innovations diffuse
quickly, but "...the duration of the diffusion stage is often fairly lengthy"
Davies notes that research specifically related to rate of adoption questions
has identified some factors that speed the process of diffusion along the S-curve,
including a demonstration of early profitability in the private sector. Public
sector studies, too, have identified factors associated with rapid innovation
diffusion, including the presence of "innovation champions" in programs such as
the US Nuclear Submarine Program, the National Endowment for the Arts, and
NASA (Roberts, 1992:55).
One important component regarding innovation diffusion S-curves
concerns measurement. One might ask, "What are we measuring?" The answer
varies, but the most common consideration based on the communications model
is the movement, with adoption, of an innovation through a given society.
Thus, it is the number of individuals or organizations (within the relevant
population) adopting an innovation at any given point that is generally plotted
over time. Based on a wealth of previous innovation diffusion research, certain
observations can be made about individual-level adoption. Specifically, there are
five adopter categories used to rank members of society as to innovativeness.
These categories include: (1) Innovators, (2) Early Adopters, (3) Early Majority,
(4) Late Majority, and (5) Laggards. Rogers (1983: 247-251) provides the
following insight into each adopter category:
1. Innovators: Venturesome... They are very eager to try new ideas.
This interest leads them out of a local circle of peer networks and
into more cosmopolite social relationships. Communications
patterns and friendships among a clique of innovators are
common, even though the geographical distance between the
innovators may be considerable... While the innovator may not be
respected by the other members of a social system [for operating
outside the norm]... the innovator plays a gate keeping role in the
flow of new ideas into a social system.
2. Early Adopters: Respectable... Early adopters are a more integrated
part of the local social system. Whereas innovators are
cosmopolites, early adopters are localities. This adopter category,
more than any other, has the greatest degree of opinion leadership
in most social systems... The early adopter is considered by many
to be 'the individual to check with' before using an idea.
3. Early Majority: Deliberate... The early majority adopt new ideas
just before the average member of a social system. The early
majority interact frequently with their peers, but seldom hold
leadership positions... The early majority may deliberate for some
time before completely adopting a new idea.
4. Late Majority: Skeptical... The late majority adopt new ideas just
after the average members of a social system. Adoption may be
both an economic necessity and the answer to increasing network
pressure. Innovations are approached with a skeptical and
cautious air, and the late majority do not adopt until most others
in their social system have done so.
5. Laggards: Traditional... Laggards are the last in a social system to
adopt an innovation. They possess almost no opinion leadership
and are the most localized in their outlook; many are near isolates
in social networks. The point of reference for the laggard is the
Sometimes the same innovation is tracked along more than one S-curve.
An innovation may be moving through one community at a different rate than
another community. For that matter, an innovation may have been completely
adopted in one location before it ever appears in another. Thus, you may have
one macro tracking for the overall innovation and its diffusion, while at the same
time tracking several micro diffusions in limited settings. Diffusion rates are
known to vary in different settings. Because of limited resources (i.e., funding),
for example, rural communities are many times less likely to rapidly adopt new
programs and services that require significant expenditures (Flora et al., 1992).
Smaller organizations, empirically, are less likely to adopt new ideas than are
larger concerns (Katz and Kahn, 1978). Again, this is often linked to economic
and other resource issues. Setting level public support, as well as political
support, is likewise an important issue in adoption and rate of diffusion (Roman,
Despite all we know about innovation diffusion on a macro level, it
nevertheless remains an imperfectly understood process on the practical level.
This suggests that groups, including government, with an interest in innovation
and its diffusion should not only be implementing policies toward innovation,
but should at the same time be initiating studies to improve our understanding
of the process of innovation and its economic, social, and other impacts.
Range of Research and Studies
As mentioned earlier, the range and depth of innovation diffusion
research has been great. Numerous fields are represented in the academic
literature, with many of the fields appearing to have worked in isolation
originally. Examples include education, psychology, sociology, agriculture,
medicine, economics, communications, business administration, journalism,
military sciences, urban planning, anthropology, public health and academic
management. However, even within tightly confined boundaries, most of the
researchers "...uncovered remarkably similar findings," i.e., logistic functional
form (Rogers: 1983:38). By the mid-1960s, changes occurred as boundaries fell
and a trend toward cross-disciplinary viewpoints began in innovation diffusion
research and related published studies. Rogers (1983:39) notes, "All of the
diffusion research traditions have now merged, intellectually, toward one
invisible college, although diffusion studies are still conducted by scholars in
several different disciplines."
In retrospect, there seems to be no shortage of subjects considered from
the perspective of innovation. Several examples include state lottery adoption
(Berry and Berry, 1990), innovation among the states (Walker, 1969), and
innovation in the states (Gray, 1973) from political science and public
administration; development and diffusion of nuclear power reactors (deLeon,
1978) from public policy; innovations among health professionals (Becker, 1970)
from public health; marketing of social causes (Fox and Kotler, 1980) from
marketing; media coverage (Deutschmann and Danielson, 1960) from journalism;
technological innovation in industry (Mogee, 1980) from government;
international diffusion of semiconductor technology (Tilton, 1971) from
economics, and weapons systems (Hartmann and Truver, 1991) from military
science. These, of course, are only several of several thousand possible study
examples. The point is this the river of diffusion literature is deep and the
stock plentiful, although certain subject areas (specifically state-led innovation
diffusion) remain lacking in depth.
Importance of Individuals
Until the 1970s, much of the research related to innovation and its
diffusion concentrated on the individual and his or her role in all phases of the
innovation process. According to Addison Bennett and Samuel Tibbits (1986: 3),
this focus is appropriate as "Innovation is a human experience that begins and
ends with people." At the core of the matter is human knowledge and the
spread of innovations, often in the form of material objects, from one person to
another. One possible focus is acceptance and adoption of an innovation within a
confined locale. However, the broad focus of innovation diffusion research also
lends itself to an indepth look at the spread of ideas over time, space, and large
Some innovations never reach the point of local use. Other innovations
spread locally, but are limited in spread thereafter. Yet others gain much wider
distribution, including entire nations, continents and even global adoption.
Research concerning broad-scale dissemination has been plentiful, with recent
examples being pharmaceuticals (Henderson, 1994), manufacturing equipment
(Tyre, 1991), broad-spectrum technology (Reddy and Zhao, 1990), electronics
(Jelinek and Schoonhoven, 1990), military arts (Keegan, 1993), and financial and
business services (Barras, 1990). Other examples, from the 1970s and 1980s,
include agriculture (Feller et al., 1987), communications (Rogers, 1986), industrial
advances (Abernathy and Utterback, 1978), and satellite telecommunications
Concerning the role of the individual, though, much of the early
innovation diffusion research focused on word-of-mouth (side-to-side
communication) and material spread dissemination. Rural sociology, as
previously noted, has examined agriculture and innovations in agricultural
techniques and materials in considerable detail. Such agricultural studies have
demonstrated the importance of one-on-one communications. This type of
exchange is referred to earlier in this chapter as side-to-side communication.
Such individuals, specifically those who influence change, became known in
innovation diffusion literature as "opinion leaders" and "change agents." Rogers
(1983:27-29) defines these terms as:
1. Opinion Leaders: ...An individual [who] is able to influence other
individuals' attitudes or overt behaviors informally in a desired
way with relative frequency. It is a type of informal leadership,
rather than a function of the individual's formal position or status
in the system. Opinion leadership is earned and maintained by
the individual's technical competence, social accessibility, and
conformity to the system's norms.
2. Change Agents: ...An individual who influences clients'
innovation decisions in a direction deemed desirable by a change
agency. He or she usually seeks to obtain the adoption of new
ideas, but may also attempt to slow down diffusion and prevent
the adoption of what he or she believes are undesirable
innovations. Change agents use opinion leaders within a given
social system as lieutenants in diffusion campaigns.
The role of the individual in the innovation and diffusion process can also
be traced to economic history and anthropology. George Basalla (1988) suggests
a "theory of technological evolution" that relies heavily on individual needs (i.e.,
individuals are driven to create things that meet basic biological needs) and
diversity (i.e., individual needs, or at least perceived needs, vary). The controlled
use of fire, the wheel, stone and early metal tools, as well as a series of
evolutionary weapons for individual use, are noted by Basalla as examples of
ancient innovations that spread through person-to-person contact. Also, one
important point is the early emphasis on adoption for practical purposes, as
opposed to acceptance based on scientific reason. As an example, stone-tool
manufacturing, "...flourished for over two million years before the advent of
mineralogy or geology" (Basalla, 1988: 27).
Presumably, and based on anthropological studies, the historical diffusion
of various ideas, often reflected through artifacts, was accomplished by way of
individual and group travel from point-to-point, most typically, traders. This
concept, in later times, is carried forward to organized population movements,
such as the first English and European settlers to arrive in North America.
Clearly, individual settlers and groups brought with them ideas, items, theories,
and laws that were, and still are, widely disseminated in various forms. This
represents an example of an occasion when a common idea in one location may
represent a revolutionary innovation in another. The converse, of course, can
Individuals, too, must be considered in relation to failed innovations.
People, individually or in groups or within organizations, often cause
innovations to fail by either inaction (i.e., lack of support) or active opposition.
Researchers such as William Bridges (1991) point to the difficulties associated
with change and transition brought about as a result of innovation. Specifically,
"...the blank stares, muttering, foot-dragging, and subtle sabotage that turns a
good plan into an unworkable mess" (Bridges, 1991:ix). However, Bridges also
notes that there is a difference between change and transition. Specifically,
"Change is situational: the new site, the new boss, the new team roles, the new
policy. Transition is the psychological process people go through to come to
terms with the new situation" and "Change is external, transition is internal."
More importantly, if not most importantly, Bridges states "Unless transition
occurs, change will not work." In his 1981 work, The Change Resisters. George
Odiorne tells about ".. .the troubles we have fallen into because we can't manage
change in modern society." Odiorne notes, "Managers, administrators,
politicians, parents, and institutions as well as professionals all are troubled by
resistance to change."
Alvin Toffler (1970) has referred to this malady as "future shock" and
notes that people are overcome with inaction when the rate of change is too fast
for their minds and metabolism to bear. With specific reference to government
budgeting, but certainly applicable to policy issues in general, Aaron Wildavsky
(1984) writes of "... the extraordinary complexity of programs and processes"
with which people and organizations must deal. While acknowledging that
certain "environmental conditions are given," Wildavsky (1984:8) adds:
The mind of man is an elusive substance. It cannot be directly
observed for most purposes and inferences about it are notoriously
tricky. No wonder our attention is more readily caught by the
clash of wills in the exercise of influence and the confrontation of
An important aspect of Wildavsky's work is the overall complexity he
notes. He writes of experience, roles and perception, fairness and equality,
strategies, reform and outcomes. Each involves change, or resistance to change,
and the related transitions. Wildavsky, of course, is not the only researcher to
give such attention to the notion of complexity.
Odiorne (1981:15) developed concepts such as "activity traps" where
organizations, and the individuals associated with them, "...start out for what
once was an important and clear, perhaps even noble, objective, but in an
amazingly short time become so enmeshed in the activity of getting there that
they forget where they are going." The reason for this trap, most often, is
complexity along the pathway to change. Personal interest, tradition, fear,
existing technical systems and the limits associated with same, as well as poor
planning, to mention but a few possibilities, combine to bring the movement
toward change to a halt. As a result, Odiorne notes, "nothing really changes."
Bennett and Tibbits (1986) note, "Since the human mind and human behavior are
the dominant factors in the innovating process, the process itself and its
achievements are continually susceptible to injury caused by criticism,
persuasion, or emotional attachment ...[change] is essentially a human
experience insufficiently defended from the perils of human resistance and
People's responses to innovation (as individuals or as part of a group or
organization) vary. As previously noted, there are at least five categories of
respondents (i.e., innovators, early adopters, early majority, late majority, and
laggards). Depending upon various environmental factors, innovation diffusion
can, at any point, grind to a halt. Also, the innovation can change course
Innovation and its diffusion are social processes. Accordingly, the roles of
leadership, argument, persuasion and example must come into consideration
when examining the diffusion process. Bass (1981:7) notes, "...definitions of
leaders tend to view the leader as a focus of group change, activity, and
process." However, leadership, with reference to diffusion, does not necessarily
require the involvement of a formal group, community, organization or business
leader (although such involvement is often present and most always helpful).
Leadership can come informally and, at times, indirectly. Side-to-side (or
horizonal) communication is the key concept. Gardner (1990:6) states:
It was once believed that if leadership traits were truly present in
an individual, they would manifest themselves almost without
regard to the situation in which the person was functioning. No
one believes that any more. Acts of leadership take place in an
unimaginable variety of settings, and the setting does much to
determine the kinds of leaders that emerge and how they play
Cribbin (1981:160), with regard to informal leadership, states:
The source of informal [leadership] is the social system. It is
geared to the satisfaction of people's needs and involves tension-
reduction activities, friendships, gossip, and conversations about
politics, fashion, sports, women's rights, and so on.
Decisions regarding the acceptance and adoption of innovation are not
often instantaneous for individuals or groups. The process occurs over time and
is directly linked to awareness, perception and attitude. Culture, tradition, rites
and rituals, as well as values and ethics, play important roles in organizations.
In fact, Deal and Kennedy (1982:21) have suggested that "Values are the bedrock
of any [organizational] culture," and, "values provide a sense of common
direction for all guidelines for their day-to-day behavior." Leadership, be it
formal or informal in nature, is likely to be tied to values, ethics, and similar
considerations. Gardner (1990:71) refers to leadership in this context as "morally
acceptable leadership," and notes, "We want leaders to serve the common good
and at the same time serve our special interest, whatever those may be."
Leaders, be they opinion leaders or change agents, often play a major role
in the process of innovation diffusion through one-on-one or group
communication. Such communication does not need to be fancy, but rather
synchronous with one's peers. The key is the ability to persuade, which can be
defined as the ability "...[of] one person [one source] to change the mental or
emotional state of another person [receiver]" (Perloff, 1993). Katz and Kahn
(1978:528) note that leadership is measured in "influential increments," which
means persuasion power "...over and above mechanical compliance with the
routine directives of the organization."
Change agents are individuals who influence other individuals "...in a
direction deemed desirable by the change agent" (Rogers, 1983:28). Current-day
marketing firms and, specifically, their representatives, represent a clear example.
Likewise, salespersons often act as change agents. However, simply wanting to
persuade someone of something is not a guarantee that persuasion will occur. As
is the case with an opinion leader, the change agent must be in a position of
respect or trust to be effective. French and Raven (1960) have stated that there
are five types of power: expert power, legitimate power, reward power,
punishment power, and referent power. Of these, referent power (i.e., influence
based on ties and identification with another individual) is perhaps the most
likely source of informal leadership. Many times such ties, and the respect
necessary to assume a leadership role, are linked to technical ability and
organization lore, which "...provides increased acceptance of his or her
suggestions and directives" (Katz and Kahn, 1978:528). With either the opinion
leader or change agent, changes may come about intentionally or as a result of
example. For instance, the leader or agent may reach an individual decision to
adopt a new idea, product, process or policy. As a leader, others will likely
observe such decisions. This, alone, may be enough to trigger diffusion of the
leader's or agent's action. Example and working relationship have long been
recognized as a key leadership influences within organizations (Gabarro, 1987).
One important note regarding opinion leaders and change agents is that
there may be more than one such leader or agent working in the same
environment. Bass (1981:192) observes, "...in some groups most of the power
resides in the [formal] leader; in others, it may be widely shared, equalized
among members [informal leaders] and [the formal] leader." If this is true, each
leader or agent may have different opinions and, therefore, advice for his or her
peers, followers, or formal leaders. Majone (1989) notes, "Each of the stages ...of
deliberation is independent, but only within limits, and as part, of the entire
process." As a result, various endemic barriers to diffusion may be built within
the given environment. Conversely, all efforts to enact change may be voluntarily
withdrawn in an effort to maintain group balance and peace. This is especially
true in cultures that consider group or community cohesiveness to be a strongly
held value. With regard to this thesis, of particular interest is the impact of and
resistance to innovation diffusion in the rural setting. Speaking of "power" (i.e.,
the ability to make something happen that otherwise would not happen or to
prevent something from happening that others wish to make happen) in the
rural environment, Flora et al., (1992:72-73) state:
The whole process by which solidarity is maintained often makes it
easier for communities to unite against outside threats...Rural
communities often unite against government regulations or
programs, whether they be nuclear-waste dumps, fluoridation of
water, medical-waste incinerators, mandatory kindergarten, or
inappropriately conceived farm programs.
Regarding local leadership in the rural environment, Flora et al., (1992:68)
One of the features common to many rural cultures is the notion
that their members are all 'just plain folks'. Everyone is socially
equal. If differences exist, they are a matter of
circumstance...[The] Density of acquaintanceship (the extent to
which community members interact with one another)... [makes
identification of the formal leaders difficult].
Peter Drucker (1994:62) warns that in the newly emerging "rise of the
knowledge worker," some parts of society may lack the skills (i.e., education)
necessary to survive economically. If such skills are absent, a "change in
attitudes, values, and beliefs" is necessary to obtain the required skills.
Specifically, a basic education and "a habit of continuous learning" are required.
Rural environments, as well as the overall "blue-collar" environment in urban
settings, face uncertain times due to the shift toward knowledge based
employment. Leadership, especially if directed to change resistance, will likely
have very negative effects on follower in such situations.
Before leaving the subject of leadership, it should be noted that leaders
themselves also have to pass through stages of adoption. Generally, strong
leaders take on innovation personally. Baron (1986: 151) notes, "Today's and
tomorrow's leaders must embrace change as a value to be nurtured in themselves
and their organizations." Baron (1986:152) goes on to say "...it is ultimate
hypocrisy to demand of your organization things you won't do yourself, and
adds, ".. .but changing yourself is absolutely one of the hardest things on earth to
do." With reference to "the best leaders," Cribbin (1981:15) reports "[They] not
only accept new ideas, [they] go out of [their] way to encourage them."
Beginning in the 1970s, much of the work related to innovation diffusion
began to shift from the level of the individual to that of organizations (Rogers,
1986). Using this approach, not only are individuals viewed as important, but
also the setting itself. For example, researchers are interested in the concept of
"innovative organizations," which deals with organizational environments in
which innovations appear to develop and spread most quickly (Amendola and
Expanding the scope of research to organizations quickly brings into focus
new concerns, such as variables (many of which act as barriers) that innovations
confront as they move in and around groups of people. Such considerations have
been referenced by many works (Kanter et al., 1992; Wohl, 1984; Osborne and
Gaebler, 1992; and Lewin, 1991). On the other hand, adoptions that affect
organizations positively (i.e., economic gain) with regard to innovation diffusion
have also been referenced (Nelson, 1990-A; Foray, 1991, and Henderson, 1994).
An important emerging area of study should be noted. Specifically,
organizations and individuals now encounter the problem of how to recover from
catastrophic failures of complex systems. Such problems call for new solutions,
via innovations, at a rate previously unknown. New problems often represent
the beginning of the search for new innovations. Thus, a cycle of development or
evolution of initial innovations is established. Entire paradigm shifts, driven by
"change drivers," may result (Kissler, 1991). This, of course, nicely fits into the
social transformation to a "knowledge based society" reported by Drucker (1994).
Specifically, the organizations are changing in that they are self-contained. Many
knowledge specialists come together, as a team (with teams constantly changing),
to work on an end product. As a result, the definition of education (and skills) is
A Matter of Timing
Time is an important variable in innovation diffusion. As previously
noted, time is a specific element of the communications model of innovation
diffusion (i.e., "over time"). Many social science research projects provide a
snapshot of behavior rather than an ongoing story. DeLeon (1978 and 1984:485)
has suggested that innovation diffusion, too, is subject to "...analytic
disaggregation." However, time-order is an important consideration. DeLeon
(1984:485) supports this observation, stating "However one may choose to 'state'
the innovation process, it should be clear that different actors with different
objectives and criteria play different roles during the innovation/diffusion
Regarding time, Rogers (1983:20) notes:
The time dimension is involved in diffusion (1) in the innovation-
decision process by which an individual passes from first
knowledge of an innovation through its adoption or rejection, (2)
in the innovativeness of an individual or other unit of adoption -
that is, the relative earliness/lateness with which an innovation is
adopted, and (3) in an innovation's rate of adoption in a system...
Time clearly is important in understanding the innovation diffusion process. For
example, when does the process begin and, more importantly, what factors
contribute to its start and rate? Also, why does an innovation fail to diffuse at
one point in time only to arise again in a future time period and succeed? The
concept of "breakpoints" helps provide possible answers. Specifically,
breakpoints are "...sudden changes in business conditions that take the form of
business discontinuities" (Strebel, 1992:vii). Changing markets, technology and
political frontiers are all thought to contribute to the environment in which
breakpoints occur. Breakpoints, of course, are not limited to business. They can
and do occur in all settings within the public and private sectors. In government,
for example, Osborne and Gaebler (1992:1-2) feel:
...in 1990, the bottom fell out. It was as if all our governments had
hit the wall, at the same time.... Yet there is hope. Slowly, quietly,
far from the public spotlight, new kinds of public institutions are
emerging. They are lean, decentralized, and innovative.
Although the events surrounding breakpoints may appear to occur
suddenly, the factors associated with breakpoints may build slowly. Paul
Kennedy (1987:xv-xvi), makes the following point:
The relative strengths of the leading nations in world affairs never
remain constant, principally because of the uneven rate of growth
among different societies and of the technological and
organizational breakthroughs [innovations] which bring a greater
advantage to one society than to another.
In fact, Kennedy (1987:536) makes the observation that, "... all societies
are subject to the inexorable tendency to change." The new reality, Kennedy
goes on, "... can [not] be controlled by any one state, or individual... But, there
is an awful lot depending upon the skill and experience with which they manage
to sail on the stream of time" (1987:540).
Strebel (1992:7 ) states, "Anticipating breakpoints is foremost a question of
being able to read signs." Trend and trajectory become important, as well as the
ability to see beyond the existing situation. Innovation leaders must have the
insight to distinguish between "turning points" (Fombrum, 1992), which call for
strategic fine tuning, and breakpoints, which call for adoption of innovation.
Although not always a formal process, ongoing analysis of a variety of factors is
essential. For example, natural cycles, technology, economic conditions, political
currents, resource availability and competition all have the potential to carry
weight in the innovation process. Individuals, as well as organizations, can and
often do follow such information in search of opportunities to introduce
innovations. Private sector "trade shows," for example, provide an opportunity
to learn something about where various industry are going. Such events also
provide an opportunity for change agents (i.e., vendors) to diffuse innovations.
Almost all industries and professions now sponsor such innovation exposure
opportunities. Government at all levels also sponsor trade shows, as well as
demonstration projects, both of which are designed to foster innovation
diffusion; air shows are just such a demonstration. Outside such projects,
government workers are also encouraged to deal with the subject of "anticipatory
government" in which they (the workers) can avoid being "future blind"
(Osborne and Gaebler, 1992:219-249).
Individuals can also act in an anticipatory manner. James Belasco (1990:6)
argues, "The active leader at any level in the organization [can identify the]
need and move quickly to develop a new strategic approach." Not only the
ability to see, but also the ability to share an inspired vision, according to Belasco
(1990:11), are important keys in gaining support for innovation adoption. Works
such as Shapers of American Health Care Policy (Weeks and Berman, 1985),
direct our attention to the importance of individuals in bringing about innovation
adoption not only in public policy, but also programs and services. A common
characteristic among such change leaders is the ability to identify innovations and
introduce them at specific breakpoints. Recognition of the opportunities
associated with innovations and breakpoints, too, is a skill closely associated with
the private sector.
With regard to timing, missing in the literature are materials dealing with
innovation diffusion (especially as relates to change leadership) and chance
events. Specifically, and as will be noted in the main case study associated with
this thesis (Chapter V), sometimes innovation diffusion is linked to the
availability of the "right person" (with "the right leadership") at the "right time."
Also, the "right organization," or the "right political events," or the "right
resources" are considerations. Such things are surely subject to interpretation,
but nevertheless are believed by this author to be considerations in
understanding innovation diffusion, especially in complex settings.
Private and Public Sector Activities
Economics plays a major role in innovation and its diffusion. According
to Nelson (1990-A:193), "Economists...[for a long period of time] have touted
capitalism as an engine of technical progress." Today, Nelson adds, "Virtually all
contemporary general accounts of the capitalist engine are based on Joseph
Schumpeter (1950) in his Capitalism, Socialism, and Democracy." Specifically,
"...for-profit firms, in rivalrous competition, are the featured actors" (Nelson,
1990-A: 193). Business, of course, is tightly tied to the economic landscape. The
entrepreneur, who is defined as the individual who imagines opportunities to be
realized, is a central player in business and, therefore, economic matters.
Accordingly, when discussing innovation diffusion, it is important to consider
such matters as the role of entrepreneurs, economic incentives, business
opportunities, consumer behavior, and private sector efforts to drive demand
and, therefore, diffusion (i.e., marketing).
As previously noted, economic gain, be it actual or simply perceived as a
strong possibility, can and does often drive the innovation and diffusion process.
This said, of course, the private sector often sells its innovative ideas, goods, and
services to the public sector. For example, when a major program or service
innovation is introduced through the public sector, frequently the technology,
training, and related components must be acquired through private sector
sources. Weapons systems development and acquisition provides perhaps the
best example of this public-private sector relationship. Van Creveld (1989:1)
notes, "...war is completely permeated by technology and governed by it." The
private and public (e.g., NASA) sectors contribute to technology development
and production, but most often it is government that purchases military
hardware and support technology from the private sector.
Public sector programs and services sometimes leave open, by design or
default, new or expanded private sector service opportunities. Osborne and
Gaebler (1992) provide several examples, such as private fire service in Scotsdale,
Arizona; environmental protection through private groups such as the Council
for Solid Waste Solutions (Dupont, Procter & Gamble, and other large chemical
companies); and, higher education through private universities. Regardless of
product or service example, economic opportunity is the very core of private
enterprise. Savas (1987:4) notes that one key goal of privatization is cost-
effectiveness, which is believed by many (including Drucker, 1994) to be a by-
product of competition.
Public sector organizations, of course, are not the only entities that
purchase technology, services, products and other byproducts of innovation from
the private sector. Individuals (private citizens), non-profit organizations (i.e.,
"the third sector"), and most remaining elements of society have some level of
consumer relationship with the private sector. Because of the importance of
these relationships, we will examine entrepreneurs, consumer behavior and
marketing in the following sections.
Peter Drucker (1973:3), talking about paradigm divides, states:
History knows divides. They tend to be unspectacular and are
rarely much noticed at the time. But once these divides have been
crossed, the social and political landscape changes.
Drucker (1973 and 1994) refers to the other side of the divide as being "the new
reality." In business, "paradigm shifts" (often brought about through
innovations) often result in significant economic opportunities. For example,
John Love (1986), discussing the beginnings of McDonald's Corporation, tells an
interesting story about innovation and diffusion. Founder Ray Kroc, an
entrepreneur, shifted America's view of restaurants not through development of
the innovation known as "fast food," but rather through diffusion of the
innovation. Brothers Richard and Maurice McDonald developed the first
McDonald's. But, "They were inventors [innovators] who had the vision but
lacked the drive and organizational skills needed to capitalize on their invention"
(Love, 1986: 10). Restaurants were traditionally family businesses, but Kroc saw
an opportunity to change the focus. By taking advantage of this opportunity,
McDonald's started up the S-curve (a curve, one might add, they are still
ascending). However, the success of McDonald's sparked a firestorm of
competition through other entrepreneurs whose fast food enterprises began their
own journey along individual S-curves. This was not to be unexpected, as
Drucker (1973: 256) points out, because innovations of this nature often trigger,
"...an explosion of entrepreneurship."
The entry of multiple providers to the service arena is not without risk.
Sharon Oster (1990: 20) reports, "...as more people try to exploit a good
opportunity, the quality of the opportunity diminishes." Many individuals or
companies in the face of such competition sellout. Others, like McDonald's,
begin a seemingly unending effort to succeed through innovation. This is the
pattern of continuous improvement, based bn innovations built on innovations,
mentioned in an earlier section of this chapter. It is also a pattern associated
with so-called "innovative organizations," which often set service, program or
According to Willard Zangwill (1993:1), "...for most firms, innovation
drives their success." More importantly, Zangwill continues, "The innovation a
firm achieves today defines its tomorrow."
Entrepreneurs can also be found in the public sector. Kingdon (1984:188)
reports, "The [public sector] entrepreneurs are found in many locations. No
single formal position or even informal place in the political system has a
monopoly on them." With regard to public policy, Kingdon refers to such
individuals as "policy entrepreneurs," and reports they are:
...advocates who are willing to invest their resources time,
energy, reputation, money -- to promote a position in return for
anticipated future gain in the form of material, purpose, or
As another example, this time drawn from law enforcement, a movement is well
advanced around the concepts of "agency accreditation" and "community
policing" and "citizen oversight" (Williams, 1988; Osborne and Gaebler, 1992:49-
51, and US DOJ, 1993).
In his 1973 book, Management: Tasks. Responsibilities, and Practices.
Peter Drucker examines in some detail the contributions of government (and
specifically public sector "innovative organizations"). Using Great Britain as an
example, Drucker (1973:784) notes, "Local government reform ...in the middle of
the nineteenth century created new institutions, new relationships, and, above
all, established new tasks for government." Drucker (1973:593) also uses the US
Space Program as an example of a public sector entrepreneurial "model." In fact,
with regard to technology, few who know the field would question the
contributions flowing from the space program, especially with regard to the
National Aeronautics and Space Administration (NASA). One only need review
a copy of NASA Technical Spin-Offs to gain an appreciation for the
entrepreneurs at work within government. Also, and as the above noted
document title suggests, one will quickly see the importance of public/private
sector cooperation in the development and diffusion of space-related technical
A final public sector example is drawn from health service. Specifically,
the National Institutes of Health have continually demonstrated entrepreneurial
behavior in such areas as rural health, injury control, child immunization,
venereal disease treatment and tracking, environmental health, and mental
health services. Many health service advances have resulted (Hanlon, 1974).
Entrepreneurs, as well as their private sector companies, are interested in
consumer behavior. Researchers, too, focus on individual, group and
organizational behavior in relation to innovations and their adoption. As a
result, at least six models of consumer behavior have been identified (Sternthal
and Craig, 1992: 39-55):
.. .based on the assumption that consumers attempt
to maximize the utility of their decisions subject to
Psychoanalytic Model -
...views two opposing forces as guiding behavior.
One, the id, that drives one to ways that are
antagonistic to society's aims. The other force, the
superego, drives the desire to act in socially
acceptable ways that are learned through
Perceived Risk Model -
...suggests that consumption is dependent upon the
individual's perception of risk inherent in a
Engel-Kollat-Blackwell Model -
...A five step process of decision making which
include information input, information processing,
product evaluation, general motivating influences
and internalized environment influences.
Webster-Wind Model -
Explores variables in industrial buyer behavior and
the behavior of individuals within the confines of an
organization. Four classes of factors are considered:
environmental, organizational, social and individual.
Howard-Ostlund Model -
...considers exogenous variables (i.e., institutional
and societal environment as well as personal
characteristics); information processing (i.e., neutral
sources, interpersonal, feedback), and cognitive and
purchase process (i.e., motives and ends).
Although these models stem from research concerning consumer behavior
in relation to the private sector, the information is likewise useful to public sector
concerns. Communication is the central issue, be it top-down or side-to-side in
nature. Acceptance and adoption of innovations in the public sector require the
same individual, group and organizational "buy in" as do private sector
decisions. Winston Mahatoo (1985:23) notes, "To understand the external and
internal influences on consumer decisions, it is necessary to understand the
nature and complexities of the decision process." Basically, the process is driven
by ".. .involvement with the product, topic, or issue, and the degree of the
individual's perceived differentiation among options" (Mahatoo, 1985: 24). There
are high-involvement decisions, which mean more to the individual (i.e., risk or
gain), and low-involvement decisions (i.e., little or no risk to the individual).
Risks, be they financial, psychological or physical, may be perceived or
real. Risk analysis has become a standard practice in many industries and fields,
with an example being healthcare (Levey and Loomba, 1973:336). Also,
knowledge of risk has become pertinent when considering the diffusion process.
Oftentimes, in fact, knowledge of this nature allows for development of a formal
approach to encouragement of diffusion through marketing. One problem,
regardless of analysis or marketing effort, remains the element of chance.
Roncolato (1995:36), with reference to war but applicable to other settings, states,
"Chance touches every facet in every act...."
John Keil (1985: 126) states, "...too often ...the idea [innovation] has
possibilities but dies because we haven't been able to convince others of its
merits." Thus, the field of marketing has arisen in response. As a field of study,
and a profession, marketing has many focuses in both the private and public
sectors. Some will be explored in this section.
Houston Elam and Norton Paley (1992: 7) define marketing as:
... is a total system of business interacting activities designed to
plan, price, promote, and distribute want-satisfying products and
services to organizations and household users at a profit in a
This definition assumes that marketing only applies to for-profit ventures. This,
of course, is not the case. Some argue that "marketing" is not a word clearly
associated with the public sector. However, few who have stopped to consider
the US Postal Service and its private sector marketing style in relation to UPS
and Airborne Express could deny the existence of marketing programs in direct
use by government.
Seymour Fine (1992) explores marketing designed around public and non-
profit agencies and causes. "Like all businesses, public and non-profit
organizations buy, sell, provide, and deliver ideas, services, and goods. They
transact with suppliers, middlemen, and customers....1' (Fine, 1992:15). Fine's
1992 work, which is a follow-on to his earlier work (Fine, 1981), represents some
of the specialized materials now available concerning marketing directed toward
innovation diffusion in the public sector. As a side note, however, it should be
stated that the importance of "selling" in government, as in business, is not a
new concept. Returning to the postal service example, in the late 1700s, the U.S.
Government had a statue that required mail routes to be advertised. From a
political-practical standpoint, today it has become clear that "selling" an idea (i.e.,
new concept) is an essential element of the policy process. Nowhere is this point
more clearly demonstrated than in planning and economic development in the
public and private sectors. Again, witness the deregulated U.S. Postal Service of
Returning to the broad subject of marketing, regardless of sector, an
entire new field known as "relationship marketing" has developed around the
availability of a growing consumer data base coupled with high-tech methods to
communicate with consumers (Berkowitz et al., 1992: 260). Word-of-mouth
marketing, too, is of interest (Wilson, 1991). Specifically, the focus of this
marketing area is customer-driven information. In business, there is little
question that customer experience, both positive and negative, will be shared
with other customers or potential customers. Talk comes in all forms, such as
grapevine talk, opinion leader talk, employee talk, financial talk and advertising.
Sometimes talk is unplanned (such as may occur between one consumer and
another). Other talk is clearly planned (such as through conferences and
advertising). The point is that talk can be key, from both positive and negative
standpoints, to the success or failure of any given innovation and its diffusion.
Accordingly, both private and public sector entities often turn to information
exchange (and concept exposure) in an effort to encourage diffusion.
Communications technology contribute greatly to the ability to direct marketing
activities to a wide audience. Communications technology (which we will
explore next) also contributes greatly to the overall scope, speed and potential
success rate associated with innovation diffusion in general.
Individual-to-individual communication continues to be the basic element
of innovation diffusion, although the age of mass communication has removed
the requirement for direct person-to-person contact. In fact, mass
communication pathways often set the stage for diffusion. Works such as Future
Shock (Toffler, 1970), "... demonstrate to a wide audience the importance of
trying to anticipate the future, to understand potential long-term implications of
change, both positive and negative, before they occur" (Barker, 1992:20).
Similarly, as the world moves further and faster along the communication
technology highway, we can expect technology innovations and resulting societal
changes to occur at a heretofore unknown pace. Information technology and the
communications networks that result (e.g., information highway) will surely be a
major focus in future diffusion research. In fact, works have already appeared
that deal directly with information technology and the competitive advantages of
remaining near the head of the innovation curve (Jelinek and Schoonhoven,
1990, and Gerstein, 1987). Mirabito and Morgenstern (1990:ix), in The New
Communications Technology, state "... we now have, at our disposal, an ever
growing assortment of tools that have forever altered the way we communicate
with each other and the world around us." The advent of the personal computer
has been accelerated by the advent of high-tech, low-cost equipment for
individual use. Likewise, refinement of older technology, coupled with emerging
new technology, is reducing the communications distance between people and
Mirabito and Morgenstern (1990:2) point out, "We employ a number of
communications systems to exchange information and are developing ones that
will enable us to exchange a greater volume of information, in a shorter time
period, than at any other point in history." Rogers, in Communication
Technology: The New Media in Society (1986:3), asserts, "Communication
technology has had a very strong impact on the nature of scholarly research on
human communications." Rogers goes on to point out:
In the past, the basic division of the scholarly field of
communications has been a dichotomy on the basis of channel:
interpersonal channels, which involve a face-to-face exchange
between two or more individuals, versus mass media channels, all
those means of transmitting messages such as radio, television,
newspaper, and so on.... Now, scholars recognize a third category,
machine-assisted interpersonal communication, that has certain
qualities of both mass media and interpersonal channels yet is
different in several important ways from either one.
Communications technology clearly has the ability to enhance the
innovation diffusion process, and vice-versa. Management and communications,
as a result, are different in those high-tech organizations that survive a changing
environment. Jelinek and Bird Schoonhover (1990:429) note, The high-
technology firm's management practices are distinctly different from standard
management and seem inextricably intertwined with their need for, and practice
of, innovation." Competition, above all other points, is most frequently
mentioned by Jelinek and Bird Schoonhover as driving the need for technological
changes. Technological change, according to Buchanan (1992:21), is a process "...
which has characterized Western Civilization for the past three hundred years."
Buchanan (1992:xiii) goes on to say:
... we live, in the twentieth century, in a process of profound and
continuing change, which is different from the cyclical change of
the seasons or the natural process of ageing. It is, rather, a change
in the conditions of life, life has become a process of permanent
transmutation. ... This process of change has been driven by
innovations in sources of power, in manufacturing techniques and
in the means of transport and communications in other word,
Communication, and the means to block or foster same, is recognized as
key to innovation diffusion. James Burke (1978:81) states, "... the ability to make
instant contact with almost any place on Earth has enabled us to tune our
economic and political activities to a fine pitch." Business also has been directly
affected by communications technology. Specifically, "At an international level
the ability to exchange vast amounts of information almost instantaneously has
made possible the operation of giant multinational corporations whose existence
blurs the distinction between national boundaries, draws countries in which they
function closer together, and calls into question the old concept of national
sovereignty" (Burke, 1978:81). George Basalla (1988:78), notes:
No society is so isolated or self-sufficient that it has never
borrowed at least some aspects of its technologies from an outside
source. Because humans engaged in normal communications are
bound to exchange information about novel techniques or artifacts,
general cultural contacts are the oldest means of transferring
knowledge from one culture to another... What is traditional
practice for one culture may be an important innovation in a
Thus, communications, technology, and innovation are linked hand-in-hand.
Dye (1975:1) defines public policy as, "...whatever governments choose to
do or not to do." Jones (1977:3) points out, "The term 'policy' gets used in many
different ways to refer to highly diverse sets of activities or decisions [in the
public sector]." Policy decisions occur at all levels of governments and with
growing frequency, depth and breadth, to include policy decisions related to
innovation. Roessner (1988:22) explains, "The aims of, and governmental
expectations from, policies toward innovation are many and varied as are the
policies themselves and the tools designed to meet policy aims."
Because of the importance of public policy as well as the complexities
associated with public issues, over the past forty years, a growing number of
researchers have entered the public policy arena. Several facets of policy
research have developed, the result among researchers being, "...ever-increasing
specialization" (Schneier, 1969:ix). Today, "Policy is a word with many
interpretations and interpreters" (Brewer and deLeon, 1983:6). Many of the
interpretations and interpreters come from the "policy sciences," which represent
researchers interested in "...knowledge of the decision or policy process and
knowledge in that process" (Brewer and deLeon, 1983:9).
Public policy decisions are often viewed in the broadest terms as being
designed to solve or prevent problems in society. However, one does not have
to look deeply into the subject of public policy to discover that this view is very
simplistic. The events and factors leading to and associated with public policy
and its process are complex. For example, Lasswell (1971:15) states:
The fact is that one person's problem may be another person's
profit. Problems result from events affecting people differently.
Not all problems become public; not all public problems become
issues; and not all issues are acted on in government.
Lasswell's observations point out that perception, definition, and motivation are
important factors when considering public policy. Such matters are, in fact,
important in relationship to mapping the public policy process and marking key
points of interest along the way.
Historically, public policy has not been the main focus of political science,
but rather institutions, politics, and processes have been in the spotlight.
Increasingly in recent years, however, academic researchers have turned their
attention and resources to the subject of public policy. In fact, a number of
research fields have shown an interest in public policy issues. Political science is
perhaps the clearest example, but other fields include public administration,
environmental science, hospital and public health administration, economics and
Several models of the overall public policy process have been developed.
Examples include, but are certainly not limited to: Group Theory (i.e., interaction
among groups is the central fact of politics with public policy as the equilibrium
between struggling groups); Systems Theory (i.e., public policy as a response to
outside forces); Elite Theory (i.e., public policy as the preferences and values of
the governing elite); Incrementalism (i.e., public policy as a continuation of past
policy activities with only incremental modification); Game Theory (i.e., choice
decisions dependent on the effects of choices by others), and Rationalism (i.e.,
correctly designed policy to maximize value to society). The purpose of such
models, according to Dye (1975:1) is:
(1) to simplify and clarify our thinking about government and politics, (2)
to identify important political forces in society, (3) to communicate relevant
knowledge about political life, (4) to direct inquiry into politics, and (5) to suggest
explanations for political events and outcomes.
Although there are contradictions between the various models, there are
also complementary overlaps. It appears reasonable to state that no single model
provides for all of the content and application possibilities associated with public
policy. Accordingly, the important fact is that such models provide an approach
to systematic identification of causes and consequences through formal methods
of review. Overlap will likely continue to exist among with various approaches
to public policy analysis.
Of major interest within the policy sciences is the concept of policy
staging. Specifically, policy is viewed as a process (occurring over time) that has
identifiable stages. Anderson et al. (1978:6-11) report these stages as: "Problem
formation; policy agenda; policy formulation and adoption; policy
implementation, and policy evaluation." Brewer and deLeon (1983:18) drawing
upon Lasswell (1971), classify the stages as: "Initiation, Estimation, Selection,
Implementation, Evaluation, and Termination." Variations of this stage model
are widely accepted throughout the discipline.
Although a major focus in this thesis will be the policy implementation
stage, other stages of the policy process are also important. Brewer and deLeon
(1983:18-21) define the stages as:
 Initiation: Begins when a potential problem (which
could just as well be an opportunity) is first sensed,
i.e., problem recognition or identification...
 Estimation: Concerns predetermining risks, costs,
and benefits associated with each possible option
that emerges from initiation and with new ones that
analysts discover as they continue their work...
 Selection: Refers to the fact that someone may
eventually make a decision; the prior analytic work
to imagine and define the problem and assess the
alternatives usually play a role in this...
 Implementation: Is the execution of the selected
option an option that may bear only faint
resemblance to estimation's orderly
recommendations often to the analysts's
wonderment, frustration, or chagrin...
 Evaluation:.. .retrospective in practice...asks
questions of the following sort: What individuals
and what policies and programs were successful or
unsuccessful? How can that performance be
measured and evaluated? Were any criteria
established to make those measurements? By
 Termination: Concerns the adjustment of policies,
programs, and organizations that have become
dysfunctional, redundant, outmoded, or
With regard to this thesis, the policy stages of initiation, estimation,
selection, and implementation are all important. However, policy
implementation is the central concern and will next be explored.
Policies are brought into being through the policy making process. Once
developed, however, a policy must be directed to an operating unit, agency or
organization if it is to be carried out. Policy implementation, which means bring
policy into effect or carrying it out, is a line-level government function. In fact,
".. .implementation is the largest part of government if measured by the people
engaged in it or by the funds spent on it" (Lindblom, 1980:64). However,
Ingram (1990:463) warns, "Where implementation starts and ends is not settled.
While implementation is commonly referred to as a stage, boundaries are not
clear." Lindblom (1980) also notes, "The complexities of the play of power in
policy making -- its indirection, unpredictability, frustration, reversals, and
inevitable partial failures multiply in policy implementation."
Pressman and Wildavsky (1973) are said to have, "...christened [the]
infant area of study, implementation" (Ingram, 1990:462). Since that time,
significant growth has occurred in activities related to the specific study of policy
implementation. But, according to Ingram (1990:476), researchers have:
...disagreed among themselves on a wide variety of fundamentals
[i.e., "When the implementation state begins and ends; whether
the appropriate perspective for research is statutory authorization
or deliverer's actions; how to measure good implementations; and
what are the critical factors affecting implementation"].
Regardless of possible conflicts, however, the value in such questions and
research is clear. Pressman and Wildavsky (1984:6) state, "By concentrating on
the implementation of programs, as well as their initiation, we should be able to
increase the probability that policy promises will be realize." This goal is not
without need. While policy making itself is an "untidy process" (Lindblom,
1980:4), policy implementation too is subject to unlimited turns, twists, and
modifications. For example, Lindblom (1980:65) continues, "Implementation
always makes or changes policy to some degree...at the hands of administrators."
Some reasons and factors are said to include: incomplete specification of policy
(e.g., no law can or does cover all contingencies); incentive failure (e.g., no real
reason to follow direction and no punishment for failing to do so); limited
competence (e.g., administrative personnel do not have the knowledge or
background to carry out the assignment); inadequate resources (e.g., lack of
staffing, funding, equipment, buildings, etc.); conflicting criteria for application
(e.g., conflicting guidelines); bureaucratic politics (e.g., control issues); and,
agency resistance (e.g., we simply don't want to do it), (Lindblom, 1980:65-68).
As might be expected, many of these issues are linked. More importantly, such
factors may be hard to identify and, in some cases, hidden intentionally by those
involved with the process.
Policy Implementation and Innovation
As we shall see in the chapters that follow, the positive or negative effects
of public policy implementation on innovations are many. Conversely, this is
also true of the effects of outside factors on implementation itself. For example,
it is known that, "...[there are a] number of factors that may adversely affect
implementation" (Ingram, 1990:465).
As early as 1973, Pressman and Wildavsky warned, "...implementation
under the best of circumstances is exceedingly difficult" (Pressman and
Wildavsky, 1973:xiii). Many factors within government, including agency
leadership, limited human and economic resources, political and special interest
group pressures, work ethic, individual and group values and attitudes, and a
host of similar factors combine to influence the possible outcome of any given
public policy implementation effort (or lack thereof). Too, even if agency internal
issues are not present (a very rare, if not impossible, event), outside positive and
negative considerations are generally encountered. As a result, public policy
successes and failures are closely tied to the implementation process and its
relationship to internal and external factors. Thus, public sector innovation
diffusion is clearly linked to public policy implementation.
Innovation diffusion and public policy provide the theoretical base for this
thesis. Drawing from this base, and as outlined in this chapter, three hypotheses
will be tested in relation to the North Carolina case study. The research
hypotheses are as follows:
(1) Rate of innovation EMS adoption will be faster in urban
(metropolitan) versus rural (non-metropolitan) locations.
The following assumptions, to be examined, are noted:
Urban areas are more likely to face major service problems, such as
EMS provision, before rural areas.
The urban tax base can more readily support rapid innovation diffusion
than that of the rural area.
Rural areas have greater demands on lesser resources.
Citizen and leadership attitudes in urban areas are more likely to be
change orientated than attitudes of similar individuals in rural areas.
(2) The availability of intergovernmental transfer of funding, from the
federal government to state and local governments, acts to
encourage significantly policy development or adoption, as well as
The following assumptions, to be examined, are noted:
Federal funding is often used for seed money for newly proposed
State and local governments are in need of, or at least desire, federal
financial support for local programs.
Federal, state and local policies are coordinated in support of intended
(3) Leadership, on the part of individual leaders within government
("policy entrepreneurs"), is essential to the success of government-led
innovation diffusion efforts.
The following assumptions, to be examined, are noted:
Not all leaders are equally equipped (have the required skills) to bring
about organizational change.
Policy entrepreneurs must be willing to assume political, and therefore
Timing and style of leadership can be the difference between
success and failure.
Communication skills are central to policy entrepreneurship.
Following a review of EMS historical and technical information in Chapter
IV and the North Carolina case study in Chapter V, we will examine the above
noted hypotheses, in Chapter VI (Conclusions), in relationship to proceeding
information and materials in this thesis.
This thesis uses a case-study approach to examine the development and
diffusion of emergency medical services (EMS) in the state of North Carolina. As
noted in Chapter I, North Carolina was selected because it was one of the first
states in the nation to address EMS from a comprehensive, statewide,
government driven perspective.
As noted in the previous chapter, and based upon the innovation
diffusion and public policy literature, the following hypotheses are proposed in
relation to the research presented in this thesis:
(1) rate of EMS innovation adoption will be faster in urban (metropolitan)
versus rural (non-metropolitan) locations,
(2) the availability of intergovernmental transfer of funding, from the
federal government to state and local governments, acts to encourage
significantly policy development or adoption, as well as innovation
(3) leadership, on the part of individual leaders within government
("policy entrepreneurs"), is essential to the success of government-led
innovation diffusion efforts.
Research interviews for the study were conducted by the author in 1991
during two site visits to North Carolina, one visit to California, and by
telephone. With permission of the subjects, all interviews were recorded and
Written documents, files, personal correspondence, journal and news
reports, as well as policy guides, were collected, copied and reviewed. These
documents or copies are in possession of the author. The purpose of collecting
and considering multiple source materials was to develop convergent lines of
evidence, thus allowing for increased construct validity within the overall study.
Also, such materials allow for establishment of a chain of period specific evidence
for comparison against oral interviews covering the same time period in
The Case Study Approach
Be it innovations in procurement (Amorim, 1994), privatization (McIntosh,
1994), business services (Barras, 1990), public policy (Muller, 1989; Polsby, 1984)
and technology (von Hippel, 1988; deLeon, 1978), the number of variables
involved in any given innovation and its diffusion process is virtually unlimited.
To identify and map these variables and model successful programs, case studies
have been utilized repeatedly in innovation research (DOJ, 1993; Rogers, 1983;
Roessner, 1988; Rogers and Shoemaker, 1971; deLeon, 1978, and Tilton, 1971).
In fact, the most common approach to innovation diffusion studies is that of the
case study. No other methodology can encompass the contextual variety
indigenous to the innovation diffusion process.
According to Yin (1989:13), "...case studies are the preferred strategy
when 'how' and 'why' questions are being posed, when the investigator has
little control over events, and when the focus is on a contemporary phenomenon
within some real-life context." Accordingly, case studies are a common approach
to research in psychology, urban planning, sociology, business, law enforcement,
public administration, military science, medicine and management. Public policy
also has been a focus of research using the case study approach (Ingram and
Mann, 1980). Some of the most prominent academic centers, such as the
Harvard Business School, John F. Kennedy School of Government and the Yale
School of Organization and Management, use case studies as a main teaching
element. It is believed that by studying past examples of innovations and their
diffusions, new innovations can be more readily developed and rapidly diffused.
Business schools recognize the economic importance associated with innovation.
Government also is interested in innovation and the public sector benefits that
result from same (Roessner, 1989-A and B). Therefore, the availability of existing
case studies and the development of additional works which examine new
situations or subject matters provide a rich source of materials for persons,
organizations, and public sector entities engaged in innovation diffusion activities
Case Studies Within a Case Study
North Carolina has 100 counties; the N.C. Office of Emergency Medical
Services was charged with implementation of comprehensive EMS development
in all (Figure 3.1). In North Carolina, "The most significant political subdivision
below the state level...has been the county. Although this type of geographic
unit does not have the same measure of importance throughout the country, it
has deep roots in North Carolina and the South..." (Clay et al., 1975:6).
Therefore, counties will be the important reference point in this study. As will
be clearly demonstrated through this thesis, not all counties (and, specifically,
regions within the state) progressed at the same pace toward EMS development,
As might be expected, counties vary in size, population, stages of development,
and, therefore, tax base. This is important from the overall perspective of "the
North Carolina case study." As examples in Chapter V demonstrate, the overall
North Carolina case study is actually a series of smaller (geographic specific) case
studies. Thus, we are examining numerous counties within at least three regions
of the state (Mountains, Piedmont, and Coastal Plain), all with different
characteristics, resources (Figure 3.2).
This fact allows for comparative analysis, which contributes significantly to the
value of the umbrella study involving the entire state. According to Yin
(1989:21), "...scientific facts are rarely based on single experiments; they are
usually based on a multiple set of experiments which have replicated the same
phenomenon under different conditions. The same approach can be used with
multiple-case studies." Regarding this thesis, we will examine EMS diffusion
across a wide range of geographic, political, and resource environments within
one state. As we shall see, local responses to state directed EMS diffusion efforts
vary considerably. Of particular interest are the differences between rural-urban
population distribution and activities regarding EMS implementation and
development. With this in mind, it is important to note that North Carolina
"...is one of the few states that has always been predominantly rural. (By
definition, rural persons are those living outside places with 2,500 or more
inhabitants.)...By 1970, the state had its largest number and population of urban
residents ever, yet with 45 percent so classified, it was still well behind the
national proportion of 73.5 percent" (Clay et al., 1975:34-35).
Throughout this thesis the terms "urban" and "rural" will be used in
many of the reports from interviews and, independently, by the author. In this
thesis, the term urban will be synonymous with metropolitan. According to the
Department of Commerce, SMS As are, "...a county or group of counties having
at least one central city of 50,000 or more inhabitants" (Flora et al., 1992:7). The
Bureau of the Budget notes, "SMSAs are composed principally of cities of 50,000
people or more, their surrounding county, and other contiguous counties that
qualify in terms of specific measures of both metropolitan character and
interactions with the core county" (Clay et al., 1975:9). Accordingly, rural
communities (and regions) become everything else (i.e., non-metropolitan
counties). It should be noted, however, that the Farmers Home Administration
defines rural areas not only as, "Open country, and communities up to 20,000
residents in non-metropolitan areas," but also as, "...towns of up to 10,000
having a rural character but located within metropolitan counties" (Hora et al.,
Those persons interviewed for this study referred to urban areas as being
related to, or in fact constituting, a city. Most often, the term urban was used in
relationship to population size and government resources (via the tax base).
Thus, in North Carolina, urban areas were identified by persons interviewed for
this thesis as being generally the same areas that would fit the federal
government definition based on SMSAs (e.g., Asheville, Charlotte, Fayetteville,
Greensboro, High Point, Wilmington, Winston-Salem, etc.). The term rural was
most often used to mean towns, counties or regions outside metropolitan areas.
Also, the issues of population, tax base, and attitude (e.g., willingness to accept
change) frequently entered into discussions related to urban and rural areas.
Personal interviews were conducted by the author over a period of
months in 1991. Both field and telephone interviews were conducted. In some
cases, one-on-one interviews were followed by telephone contact(s) to allow
clarification of points from transcribed interviews.
A majority of the in person interviews were conducted in North Carolina.
However, one principal subject, former N.C. OEMS Chief Jim Page, was
interviewed in California and by telephone. During the visit to California, copies
of a considerable number of personal files and documents were secured through
Although a similar line of questioning was used for the early interviews,
the overall technique was open ended (i.e, a technique known as "snow-
balling"). The subjects were asked to provide answers to specific questions, with
each answer leading to another question of the same genre or to a newly
identified pathway. Likewise, as the number of completed interviews increased,
new questions were generated through information obtained or learned through
previous contacts. Of particular interest were points of conflict, information
variation and personal opinions.
Initial selection of persons to be interviewed was based solely on job
position, in relation to EMS in North Carolina, during the time period under
consideration (i.e., Secretary of Human Resources, chief-OEMS, etc.). Other
persons were added to the list based on the previously mentioned snow-balling
technique (i.e., one person being interviewed would recommend another person
as key, important or informed). Using this approach, the following individuals
Steve Acai -- former volunteer rescue squad member, current deputy
chief- transportation, North Carolina OEMS