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Public Health Leaadership

Putting Priciples Into Practice Third edition

Louis Rowtz PHD

Professor Emeritus School Of Public Health

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Library of Congress Cataloging-in-Publication Data

Rowitz, Louis.

Public health leadership : putting principles into practice / Louis Rowitz.—3rd ed.

p. ; cm.

Includes bibliographical references and index.

ISBN 978-1-4496-4521-2 (pbk.)

ISBN 1-4496-4521-6 (pbk.)

I. Title.

[DNLM: 1. Public Health Administration. 2. Leadership. WA 525]

362.1068—dc23

2012033832

6048

Printed in the United States of America

17 16 15 14 13 10 9 8 7 6 5 4 3 2 1

CHAPTER 1

The Basics of Leadership

In a society capable of renewal, [leaders] not only welcome the future and the changes it brings but believe they can have a hand in shaping that future.

—J. W. Gardner, Self-Renewal

The 21st century has not unsurprisingly increased the amount of attention paid to the concept of change. Yet change has always been and always will be a fact of life. For instance, the passage of a national health reform package in the first decade of the 21st century provides evidence that accelerated change may occur in the public health field. However, the passage of this legislation in the United States has led to major turmoil among the two major political parties in the United States. With major federal deficits, this legislation may be substantially revised or appealed during the second decade of this new century. An increasing connection between primary care and public health seems to be happening as well. Public health is in constant flux and will continue to be in the future. To cite two contemporary examples where change is demanded, large segments of the U.S. population are unemployed or employed in low-paying jobs and thus remain uninsured or underinsured. Certain culturally diverse racial and ethnic groups, as well as many if not most illegal immigrants, have less access to health care than the population as a whole. The health reform legislation, if sustained, should address this for large segments of the population.

Public health agencies and professionals are experiencing an identity crisis because of the recent reconfiguring of their emergency preparedness and response leadership and service roles and responsibilities since the terrorist events of September 11, 2001, and the many natural disasters during the first decade of this new century. Adding to these crisis events is the public’s lack of awareness of the nature of public health and the accomplishments of the public health system. Parents and friends still ask public health professionals what they do for a living. Of course, confusion about professional identity exists elsewhere in the health professions. Physicians who work for managed care organizations resist the restrictions placed on their ability to provide the tests and services they feel their patients require, not to mention the limitations on their salaries. The traditional caregiving roles of nurses are also changing as hospital bed utilization declines and many hospitals close their doors.

In order to manage the changes that are occurring, health care and public health professionals need to become involved in advocacy at the political and policy development levels. They need to create their own vision of what personal health care and population-based health should be and to act in concert to realize that vision, and for these tasks to be accomplished, some of these professionals must acquire the full range of leadership skills and translate these skills into action. In 1988, The Future of Public Health made the argument that the creation of effective leaders must not be left to chance. 1 In line with this view, the report also stated a concern that schools of public health were not teaching the necessary leadership courses. This was reinforced in the 2003 report on The Future of the Public’s Health, where a recommendation was made that leadership training needs to be a requirement for public health professionals working in the governmental public health sector. 2 In 2007, the Institute of Medicine listed leadership development as one of the 16 critical public health content areas in the training of physicians for careers in public health. 3

The training of future leaders is critical. Public health leaders will need training not only in the specialties of public health but also in the latest management techniques and tools. To support public health activities at the local, state, and federal levels, they will require good communication, problem-solving, decision-making, and policy development skills, and skills in addressing all public health emergencies, among others. Leaders must learn how their organizations function; how to work across organizations, which has been called meta-leadership or boundary-spanning leadership; and how to integrate their organizations’ activities into the communities they serve. In addition, the changing demographics of the U.S. population will lead to the need for ethnically diverse public health professionals to accept leadership positions in the governmental and primary care sectors.

There is a major difference between managing change and leading change. 4 To lead change, leaders must be able to develop a vision to partially define the future. They must then get others to share their vision and help realize it. Of course, managing change and performance management are also important, for they keep the system running smoothly.

Selling a vision to others can be especially difficult for people from ethnically diverse groups, people with disabilities, and women, for the vision they are trying to sell might well involve cultural, ethnic, community, and gender issues, and they will probably have to disseminate it to people who have a different background than they do. 5 Developing a vision that can be shared is critical in a society where diversity is the rule rather than the exception. Any vision will remain just a vision if it falls outside the belief system of the managers and the leaders.

In 1996, the Institute of Medicine released a report on the first year of its committee on public health. The report, Healthy Communities: New Partnerships for the Future of Public Health,6 reviewed the 1988 Future of Public Health report and concluded that progress had occurred in leadership development in the 1990s. Among other signs of progress was the creation of a national public health leadership program and a number of state and regional leadership development programs. As I write this, the funding of these programs at the federal level (Centers for Disease Control and Prevention) has stopped. The training of public health leaders needs to continue, especially in this new era of health reform. Stress must be placed on the multidimensional aspects of leadership as well as the multidisciplinary approaches of the public health field as a whole. Building and strengthening the infrastructure of public health requires strong and effective leaders to address emergency situations as well as more traditional public health situations.

Note, however, that until now leadership development has been based on an industrial or agency paradigm of leadership. 7 Leaders of the 21st century must possess different skills with a systems thinking and complexity focus. They will also need to recognize that leading is a process in which they must pursue their vision through influencing others and the places they work. Leaders will find that advancing the skills of their workforce will increase the chance that their vision will become a reality. In addition, they will have to break down the barriers between organization and community to create an environment in which a shared value system and a shared vision for the future can come into being.

The remainder of the chapter comprises two short sections containing a definition of leadership and five essential skills for a public health leader and a long section that discusses 16 important principles of public health leadership. As part of their effort to understand the nature of leadership, students should do Exercise 1-1, which provides an opportunity for students to express what they believe about leadership in general and public health leadership in particular. This exercise also presents the option of developing a journal to record ideas, leadership notes on papers or books read, and personal reflections on leadership experiences.

DEFINITION OF LEADERSHIP

Leadership is creativity in action. It is the ability to see the present in terms of the future while maintaining respect for the past. Leadership is based on respect for history and the knowledge that true growth builds on existing strengths. Leading is in part a visionary endeavor, but it requires the fortitude and flexibility necessary to put vision into action and the ability to work with others and to follow when someone else is the better leader. Leaders also need resilience to function in normal and not-so-normal times.

Public health leadership includes a commitment to the community and the values for which it stands. A community perspective requires a systems thinking and complexity orientation. Community refers not only to the local community in which a person works but also to the larger global community that can affect the health of the public over time. Whatever health crises occur in other parts of the world will have an effect on what will eventually affect the health of the public in our local communities. It also includes a commitment to social justice, but public health leaders must not let this commitment undermine their ability to pursue a well-designed public health agenda. In addition, public health leaders need to act within the governing paradigms of public health, but this does not mean they cannot alter the paradigms. Leaders propose new paradigms when old ones lose their effectiveness. The major governing paradigm today relates to the core functions and essential services of public health.

LEADERSHIP ESSENTIALS

Over the past 20 years, I have read probably more than 1,000 books on leadership and management. A large number of these books present theories about what leadership is and how it works. Many leaders have embraced one theory, a combination of theories, or their own theory about leadership and how they practice it. As these theories are examined (see a sample of well-known books that present differing approaches in Case Study 1-A), it becomes useful to try to determine the essential skills of successful leaders. To simplify this task, let’s limit the essentials to the five most important skills:

1. Ability to identify the most useful information and to use it. Leaders are bombarded with new information on a daily basis from new health data statistics, new public health technical reports, new funding opportunities, and new demands for service based on emerging threats or program emphases. All this new information has to be translated into the context of public health and the governing paradigms that drive public health action.

2. Ability to motivate and work with others. Leaders have learned that the technological expertise that brought them into public health careers is secondary to their relationships with colleagues and external partners. Leaders must have the social skills necessary to collaborate with others with ease. This set of basic skills has come to be called emotional intelligence in recent years.

3. Ability to take risks and follow through. Not only do leaders need to be visionary and creative, they need to be able to take risks and to translate their ideas into action with well-defined projected outcomes. Every new vision or creative idea has a potential risk associated with it. Many people are fearful of change. Risk taking is the attempt to change the status quo and move in new directions.

4. Ability to communicate at many different levels. Leaders have to learn to communicate both verbally and in writing. They need to listen to others carefully. They may also have to communicate cross-culturally or to others who do not speak their native language. They need to be able to communicate through the Internet. Social networks can become critical to their work. Most leaders are excellent at using real-life events to show how their theories work. They can also be excellent storytellers.

5. Ability to act as systems thinkers with an understanding of how complexity affects their work. Leaders understand that they need to concentrate on the big picture. They look at their agency as a whole organization with interacting parts. They see their agency in the context of a whole community. They understand that most of their work is about upsetting the status quo in order to change things for the better. Public health leaders think about the population and how to improve the health of everyone in their geographic jurisdiction. They also understand that the best plans may still lead to unanticipated consequences.

All the other leadership skills that are described by the many leadership writers and by leaders themselves grow out of these five essential skills.

PUBLIC HEALTH LEADERSHIP PRINCIPLES

One way of filling out the definition of public health leadership in particular is to consider some of the principles that public health leaders should use to guide their actions. Following is a list of 16 such principles. In a study of 130 public health leaders in the United States, England, Scotland, and Ireland during 1996, the author conducted an hour-long conversation with each of these leaders to find out his or her view of the future role of public health agencies. The perspective of these leaders is still relevant today.

The public health leaders interviewed generally thought that they and business leaders have much in common. Good leadership is essential for the effectiveness of companies engaged in business and can increase the effectiveness of public health agencies as well. But although the leadership practices of business and public health leaders are similar, there are also important differences. For example, the social justice perspective that characterizes public health is more or less absent from the business world where a profit motive predominates. One of the leaders interviewed argued strongly that the social justice perspective is critical for public health but that public health leaders must be careful not to let this value interfere with the work that public health needs to do. One way of putting this is that social justice is only part of the leadership value system. Gardner 8 integrates that value with the values of freedom, social and ethnic equality, the worth and dignity of each individual, and the brotherhood of all human beings.

Principle 1

The public health infrastructure and the system in which it is embedded must be strengthened by utilizing the core functions of public health and its essential services as a guide to the changes that should occur. The future of public health will be determined by the way in which core functions are carried out and essential services are provided. Public health leaders must evaluate the health status of the population, evaluate the capacity of the community to address its health priorities, and implement preventive measures to reduce the effect of or even avoid public health crises. Leaders must not rely on the current assurance models (service interventions) but need to implement new assurance models built on integrated and collaborative systems of service and program delivery. Leaders must also help to restructure the policies and laws that govern health and public health. Leaders must be policy makers who have a view of the future grounded in the realities of the present and built on the experiences of the past.

Principle 2

The goal of public health is to improve the health of each person in the community. Public health leaders believe deeply that health promotion and disease prevention are possible. In fact, a focus on prevention is intrinsic to public health. In this regard, public health contrasts with the medical care system, which places an emphasis on treatment and rehabilitation. Every citizen needs to learn about the benefits of public health and how quality of life can be greatly improved if certain rules are followed and if people take personal responsibility for their own health needs.

A public health leader who truly believes in this principle will become a teacher and mentor for the community. Education will be the prevailing program model rather than medical care. The leader will reach out to schools, churches and synagogues, businesses, physical fitness centers, households, and healthcare providers and promote the vision of good health for all throughout life. The leader will also be concerned with the quality of care. If someone becomes ill, access to the best possible care is a community requirement. A visionary leader sees the total health system existing in the community and helps to ensure that the system is integrated and comprehensive, provides the services that are necessary, and does not contain duplicate services and programs, which are a waste of valuable resources.

A public health leader can play an important role in promoting a sense of community among community members. The leader might help define the values of the community and clarify the cultural aspects of the community life. Not all geographic areas have a cohesive cultural infrastructure. In an area that lacks such an infrastructure, the public health leader can help the community to define itself.

Principle 3

Community coalitions need to be built to address the community’s public health needs. Public health is both a community responsibility and a population-based activity. This means that the mission of public health is to work with all groups in a community to improve the health of all members of the public.

All communities have assets and all sorts of community resources. Unfortunately, communities, like people in general, tend to be careless with their assets. 9 Consequently, each community needs to learn how to manage its assets if it doesn’t know how to do that already. In short, it needs to take responsibility for its future. It may be too dependent on those who work in human services. Promoting good health is every citizen’s responsibility. Public health leaders can play a critical role in helping the community move from a value system based on dependency to one based on shared responsibility. Public health leaders and their cousins in the human services field are thus the true servant leaders. 10

Coalition building and other forms of collaboration require knowledge and creativity. First, coalitions made up only of managers are doomed to failure. 11 Coalitions need leaders to guide the process. Second, coalitions require trust among their members. If there is no trust, change will not occur. Third, there must be positions of power in a coalition. Key players must not be excluded or the process will fail. Expertise is also necessary so that informed decision making will occur. Fourth, the coalition must have credibility so that it will be taken seriously by others (both inside and outside the community) who can affect the implementation of the change agenda.

Principle 4

Local and state public health leaders must work together to protect the health of all citizens regardless of gender, race, ethnicity, or socioeconomic status. Public health leaders firmly believe in the principle that all people are created equal. Several U.S. public health leaders interviewed by the author stated that the U.S. public health system must be understood within the context of the American political tradition and that it is impossible to be an effective public health leader without knowing about that tradition.

Access to service is sometimes affected by who you are. Women have found that the healthcare system does not always respond to their special medical needs. Public health leaders see that they have a responsibility to press for improvements in health care for women. They also have a responsibility to develop health promotion programs for women as well as men. For example, local health departments can take a leadership role in the development of breast examination programs for cancer prevention. Cultural and ethnic groups often have difficulty in accessing health programs because of color, language, or socioeconomic status. Diabetes-screening programs are often the first programs to go when funding cuts occur, despite the critical need for these programs in our communities. Public health leaders have important tasks to perform in protecting the rights of the unserved and underserved.

We live in a culturally diverse society. Our diversity is a strength as well as a weakness. Public health leaders must deal with their personal prejudices each day and consciously move beyond them to create a public health system that respects the needs of every citizen. State public health leaders must monitor the needs of all citizens as well as create the policies of inclusion that will lead to an improvement in the public’s level of health. In addition, these leaders must make state legislators and other elected officials partners in this enterprise. The other critical partner is the local public health leader, who, in conjunction with the local board of health or county board of commissioners, is the gatekeeper for the community. What the state proclaims, the local leaders must adapt for local implementation. Local public health leaders must be extremely creative in the adaptation process. They must also speak loudly for the unique needs of their local community and take the local public health agenda to places where the state leaders do not tread.

Principle 5

Rational community health planning requires collaboration between public health agency leaders, the local board of health (if such a board exists), other local and county boards, and other external community stakeholders. The relationship between the administrator of the local health department and the chair of the board of health needs to be a close one and based on a philosophy of equality and trust. The chair and the other members of the board of health do more than approve the health department budget and select the health administrator. The board members are residents of the community. They are the protectors of the community’s interests and, with the administrator, serve an important gatekeeper function. Shared leadership and a shared vision are critical here. The health department and the board of health must be partners, not adversaries, which means they must work collaboratively to achieve agreed-upon outcomes. The exchange of information is an important part of the relationship, because relevant information is essential for the making of good public health decisions.

Principle 6

Novice public health leaders must learn leadership techniques and practices from experienced public health leaders. Mentoring is a critical part of leadership. A mentor is a person who helps another person learn about the world and how it works. 12 Mentors also help people in their care choices. Mentors tend to be well-known individuals who help their protégés meet their major goals. 13

Murray 14 discusses what she calls “facilitated mentoring,” which is a process designed to develop effective mentoring relationships. It is also designed to guide the teaching of the person being mentored. If the mentoring experience is successful, there will be an effect on the mentor, the person mentored, and the agency promoting the mentoring experience.

Mentors are ideally not threatened by the professional progress of their protégés. They personally feel good about the mentoring experience. All of the leaders interviewed by the author said that they had been mentored at various times in their public health careers. They thought that mentoring was important and that the need for mentoring does not stop with the attainment of a leadership position. Mentoring is beneficial to leaders throughout their careers. Furthermore, leaders who have been mentored have a responsibility to pass on the gift of learning they received.

Principle 7

One issue of import is whether leaders are born or made. If leadership is innate, leaders wouldn’t need to develop their skills, but if leaders are made, anyone has the potential to become a leader. The most defensible position is that leaders are both born and made—that some people are natural leaders with the talents necessary for successful leadership but nonetheless need to develop their leadership abilities. 15

In fact, public health leaders must continuously work to develop their leadership skills. Leaders never stop learning. They are like detectives who pick up clue after clue in order to find the solution to a mystery. Leaders seek solutions to challenges rather than to mysteries, but the attainment of new knowledge is just as important for finding these types of solutions. Furthermore, each solution leads to new challenges and the need for additional learning.

Support for programs for lifelong learning is critical. There has been a tendency in recent years not to allocate funds for learning activities, based partly on the argument that the public does not want to pay for training programs. When the funds are available, they tend to be classified as discretionary and used for purposes other than training. Yet allowing leaders to improve their skills can lead to substantial benefits. 16 Very few public health practitioners have ever received major job-related training, to the detriment of the agencies they work for.

Over the past 20 years, a unique experiment occurred, funded by the Centers for Disease Control and Prevention and state health departments. A national public health leadership institute and a number of state and regional leadership programs were created to help state and local health department professionals, board of health members, local and state legislators, faculty members, and community leaders develop their leadership potential. The programs, which teach public health theory and practice, promote the education of public health professionals and, through them, the education of all citizens in a community. Public health leadership development, at its best, can create a partnership between public health leaders, the public health academic community, and the public health professional community in the public and private sectors. The main lesson learned from this experiment is that public health leadership development must build on the mission of public health but must orient itself to the future of public health. A second lesson is that these programs need to be experientially based and need to focus on projects that strengthen the infrastructure of the public health system. These programs also have the value-added result of increasing networking among the public health leaders who attend these programs.

Principle 8

Leaders must be committed not only to lifelong learning but to their own personal growth. Self-esteem is a key factor in personal growth and is essential to the personal competence necessary to cope with life’s challenges. 17 Furthermore, the higher a leader’s self-esteem, the more able the leader is to inspire others. Research on children has shown that children with high self-esteem are more willing to take risks and to assume leadership roles than children with low self-esteem. 18 Sethi has described the seven R’s of self-esteem: 19

1. Respect. It is necessary to respect and trust your employees.

2. Responsibility and Resources. Encouraging creativity among employees and delegating responsibility for tasks are essential.

3. Risk Taking. Only through risk taking can innovation occur.

4. Rewards and Recognition. People need to be recognized for their accomplishments.

5. Relationships. The quality and quantity of personal relationships have an effect on self-esteem.

6. Role-Modeling. The work practices of an organization should be consistent with its values.

7. Renewal. It is critical to maintain a strong belief in lifelong learning.

Self-esteem is tied to each of the seven R’s. Each factor affects the self-esteem of the leaders and their associates inside the agency and in the community. Building the self-esteem of leaders and associates is a prerequisite for the building of strong organizations. 20

Principle 9

The infrastructure of public health must be built on a foundation of health protection for all, democratic ideals and values, and respect for the social fabric of American society. The assumption underlying this principle is that physical, psychological, emotional, economic, and social health are all elements of the health of a community. By acting as role models for the community, public health leaders strengthen the infrastructure of public health in the community. This infrastructure is not just a physical building or an official agency called the department of public health; it comprises the entire community.

Principle 10

Public health leaders should think globally but act locally. Although public health professionals practice their craft primarily at the community level, they should not ignore the rest of the world. Emerging viruses know no boundaries. Disease is carried not only on the wind but even in airplanes. Public health leaders need to be vigilant in looking for potential health problems. The Centers for Disease Control and Prevention has a national center for infectious disease that monitors emerging diseases globally, and public health professionals located throughout the world are investigating potential worldwide health problems such as the possibility of a pandemic influenza outbreak. Some multiregion crises have been documented in books such as R. Preston’s The Hot Zone, 21 L. Garrett’s The Coming Plague, 22 and J. B. McCormick and S. Fisher-Hoch’s Level 4: Virus Hunters of the CDC. 23 When a crisis hits, the international public health community must work together on the problem. Public health leaders thus have several overlapping communities to which they owe allegiance, and they must understand how to coordinate their multiple allegiances.

Principle 11

Public health leaders need to be good managers. In the above-mentioned interview study of public health leaders, the leaders pointed out that they, as heads of agencies, not only define their agencies’ practice activities but also help to implement those activities. Managers do not have to be leaders, but tomorrow’s leaders will need to possess both management and leadership skills (see Table 1-1 ). Reconciling these two sets of skills will not be easy, because they are based on two different ideological and talent perspectives. Managers are oriented toward ensuring that current systems are functioning smoothly. They tend to orient their activities to strengthening the public health agency in which they work. Leaders are change agents who are concerned with moving their agencies forward. Because change is unavoidable, today’s managers will become obsolete if they cannot keep up with the ever-increasing pace of change. Leaders and dynamic managers will have to steer their organizations in new directions, and they will have to utilize cutting-edge leadership skills and managerial tools to do this.

Principle 12

Public health leaders need to walk the walk. They must not only define a vision but sell the vision and inspire others to accept it and try to realize it. 24 ,25 In his book on visionary leadership, Nanus 26 pointed out that there are four major types of leadership activity. First, a leader has to relate to the managers and other workers in the organization. The leader should be the guide to and motivator of action in the organization. Second, the leader has to relate to the environment or community outside the organization. A public health leader, for example, must carry the agency’s vision and message into the community. Third, the leader has to influence all phases of the operation of the organization. Finally, the leader has to anticipate future events and move the organization forward in a manner that takes these events into account. If it is clear that managed care organizations will provide medical care for all members of a community, then the public health leaders of that community need to get the public health department out of the direct service business and into population-based health promotion and disease prevention. In general, this has occurred since 1996. The deterioration of the economy since 2008 has led to some reevaluation of this argument as the community health center movement has gained prominence, with some local health departments getting back into the direct service business by opening community health centers with federal funds.

TABLE 1-1 A Comparison of the Characteristics and Responsibilities of Practitioners, Managers, and Leaders

Practitioners	Managers	Leaders
The practitioner implements.	The manager administers.	The leader innovates.
The practitioner follows.	The manager is a copy.	The leader is an original.
The practitioner synthesizes.	The manager maintains.	The leader develops.
The practitioner focuses on programs and services.	The manager focuses on systems and structures.	The leader focuses on people.
The practitioner relies on compliance and behavior change.	The manager relies on control.	The leader inspires trust.
The practitioner has a narrow view.	The manager has a short-range view.	The leader has a long-range view.
The practitioner asks who and where.	The manager asks how and when.	The leader asks what and why.
The practitioner’s eye is on the client and the community.	The manager’s eye is always on the bottom line.	The leader’s eye is on the horizon.
The practitioner separates programs from services.	The manager imitates.	The leader originates.
The practitioner protects the status quo.	The manager accepts the status quo.	The leader challenges the status quo.
The practitioner is in the infantry.	The manager is the classic good soldier.	The leader is his or her own person.
The practitioner is a conflicted pessimist.	The manager is a pessimist.	The leader is an optimist.
The practitioner is a reflective thinker.	The manager is a linear thinker.	The leader is a systems thinker.
The practitioner follows the agency agenda.	The manager does things right.	The leader does the right things.

Principle 13

Public health leaders need to be proactive and not reactive. Up to the present, they have mostly tended to respond to public health crises as they occurred rather than focus on preventing crises. A reactive stance will probably always be part of the strategy of any state or local health department. However, reactivity tends to tarnish a health department’s image. Public health agencies and professionals need to develop action plans to address the health needs of the citizens in their service area. Assessment activities will help to evaluate the health status of the community and give guidance for action. Action planning is more than planning for a crisis, which is an anticipatory activity that assumes a problem is on the horizon. Action planning is essentially preventive. Its goal is to create programs to prevent the occurrence of problems rather than create programs to deal with problems after they occur.

Principle 14

Each level of the public health system has a need for leaders. 27 In fact, a leader does not need to have an official position to be a leader, and nonpositional power is likely to become more and more important. However, a defined leadership position does not hurt. Change will come from many different sources, and leaders will step forward to make sure the required tasks are accomplished. For example, if an environmental crisis occurs in a community, the environmental director from the health department, a community resident who is an engineer, a firefighter, a police officer, and others may form a leadership team to deal with the crisis. When the crisis has passed, the members of this ad hoc leadership team will step back into their normal roles. Much has been written on this issue since the tragedy of September 11, 2001. The National Incident Management System (NIMS) is one example of this team effort to address a public health emergency.

Each level of an organization also has a need for leaders. 28 And like members of a community, members of an organization often share leadership tasks by forming a team to tackle issues. These critical shared leadership experiences are often ignored in the leadership literature.

Principle 15

Public health leaders practice their craft in a community setting and must understand what a community is. Shaffer and Anundsen stated that Americans are searching for a revitalized sense of community. 29 A community is more than a place; it consists of people living together who “participate in common practices; depend upon each other; make decisions together; identify themselves as part of something larger than the sum of their individual relationships; and commit themselves for the long term to their own, one another’s and the group’s well-being.” 30 (p.10)

Human beings have a desire to be free and independent, but those who take independence as an absolute value risk becoming profoundly lonely by not including other people in their lives. 31 Being part of the community involves inclusivity, commitment, and consensus. It also can lead to a sense of realism, because communities, through the actions of individual members, contemplate and evaluate themselves. Finally, communities tend to be safe places, which is one reason Americans, with their increasingly well-founded fear of violence, have a renewed interest in the sense of community.

In the now classic book Habits of the Heart, 32 Bellah and his collaborators argue that we Americans have become committed to the lexicon of individualism and have consequently lost our way morally. We are losing our sense of community and our commitment to improve society at large. Everyone from our politicians to our educators is pushing for a return to our moral roots, by which is meant a return to community.

Public health leaders have traditionally had a strong belief in community. Their focus, after all, is on improving the health of the communities they live and work in. Public health leaders also believe they can strengthen their communities by working with community leaders to bring about change. If they are to be effective in bringing about change, they need to study and learn how their communities function. In particular, they need to know how to empower the members of their communities and get them to take their share of the responsibility for improving their own health.

Leadership Tip

Read your mail or answer e-mails when your energy level is low. Do important tasks when your energy levels tend to be high.

Principle 16

Public health leaders must practice what they preach. If they are promoting family values, they must live lives that are consistent with these values. If they are promoting good health and developing programs to get people to stop smoking, they should not smoke themselves.

This principle is not always easy to abide by. Some of our most successful leaders have personal lives that are in shambles. O’Neill called this the paradox of success. 33 Leaders often become prisoners of their official position and are unable to find a workable balance between their professional commitments and their private lives. Indeed, achieving a balance between work and home is becoming more difficult, as individuals are required to work harder due to such factors as downsizing. Decisions regarding the balance between work and home must be built into the culture of the places where we are employed,34 especially as nowadays both spouses in a marriage usually work. The costs of not achieving a proper balance are high. Conflicting pressures and stresses can have serious health consequences.

I was running a leadership program and was planning for a six-month follow-up meeting to an initial program. All trainees from the first meeting were expected to come to the second meeting. One day before the second meeting was to occur, I received a telephone call from one of the trainees. She told me that her son was ill and that she was trying to find someone to take care of him. She was worried about missing the meeting. I asked her what she thought she needed to do. She said she felt she needed to stay with her son. I told her she had made the right choice. Balancing is making the right choice.

SUMMARY

The one thing that a review of the leadership literature makes clear is that leadership is a complex series of processes affected by many factors. These factors, for public leaders in particular, include the principles described above, which apply to leadership style, leadership practices, the public health system, the core functions and essential services of public health, and leadership tools (see Figure 1-1 ).

Leading is a multidimensional activity. Every leader uses leadership skills in his or her own way, which is to say that every leader has his or her own leadership style and unique set of personal talents. Every leader engages in a set of leadership practices and uses a unique set of tools. All these elements determine whether a leader is successful. In Case Study 1-B, I interview Dr. Virginia Caine, a former president of the American Public Health Association and director of the Marion County Health Department in Indianapolis, Indiana, about leadership in public health.

FIGURE 1-1 Conceptual Model of Public Health Leadership.

Case Study 1-A

Leadership Bookshelf

Louis Rowitz

1. Stephen Covey, The Seven Habits of Highly Successful People . Covey is one of the most read of the leadership authors. This book has become a classic in its discussions of the seven habits of being proactive, being oriented to end actions, dealing with important things first, having a win-win orientation, increasing understanding of other people’s positions, being synergistic, and being oriented toward continuous improvement.

2. John Gardner, On Leadership . The complexity of modern-day events and increasing complexity of our organizations has pointed to the need for strong leadership. It is important that leaders understand the needs of the people they work with and the needs of people outside their organizations. Gardner explores these issues extensively in one of the most important leadership books in the field.

3. Peter Senge, The Fifth Discipline . This book lays the groundwork for the need for leaders to be systems thinkers. The archetype of systems thinking is also developed.

4. Ronald Heifetz, Leadership Without Easy Answers . By studying famous leaders, Heifetz explores leadership and what makes leaders succeed and sometimes fail. This book begins the exploration of adaptive behavior that Heifetz explores in later books like Leadership on the Line .

5. James MacGregor Burns, Leadership . Burns, who is a historian, has written an excellent book about the differences between transactional and transformational leaders.

6. Daniel Goleman, Emotional Intelligence . Goleman is credited with being a major voice in recognizing the importance of emotional intelligence (EI) skills for leaders. EI involves self-awareness and awareness of others.

7. John Kotter, Leading Change . This is an excellent book about change and how it works.

8. Ken Blanchard, Leadership and the One Minute Manager . Blanchard’s books are all based on the idea that different situations require leaders to act in different ways. He uses stories to explain his leadership principles.

9. Edward De Bono, Six Thinking Hats . This is one of my favorites. It presents a great tool for generating new ideas and solutions to old problems.

10. Bernard Turnock, Public Health: What It Is and How It Works . This is the best book for leaders who want to understand how public health in the United States works.

11. James M. Kouzes and Barry Z. Posner, The Leadership Challenge . This is a very practical book that explores the five practices that make great leaders.

12. Max DePree, Leadership Is an Art . This is a wonderful little book. Leadership is about ideas. It is about relationships and drawing your personal strength from others. The art of leadership is trusting others to find the way to do things in the most effective and efficient manner. Servant leadership is very important.

13. Warren Bennis and Burt Nanus, Leaders . This classic book addresses such issues as the importance of character, the ability to build organizations and systems, the importance of passion for work, the need for a vision, the ability to communicate trust through positioning, and the ability to empower others. It was hard to choose between this book and Bennis’s On Becoming a Leader .

It would be interesting to see what books you would put on your bookshelf. The only challenge for me is that when this bookshelf was completed, I wanted to add a second bookshelf with other books. Reading about leadership is always a fun activity. That may be why I wrote my books. In your comments, I hope you will add your favorite books.

Source: Reprinted from L. Rowitz (2010, February 1). A Leadership Bookshelf [Web log]. Retrieved from http://rowitzonleadership.wordpress.com/2010/02/ . Accessed June 24, 2012.

Case Study 1-B

Public Health Practice Quiz for Virginia Caine

1. How would you define leadership? Leadership is

• Creating a vision others can see

• Promoting the capacity of other people to take action on that vision

• Taking a diverse group of people with different backgrounds and ideas, focusing the group on a common goal, and motivating the group to overcome obstacles and reach the goal

2. What do you think are the critical strengths needed to be a successful public health leader?

Successful public health leaders are those who are visionary, decisive, good communicators, change agents, and risk takers. They have the conviction of their values and are deeply committed to improving the health of everyone in this country.

These leaders are also politically astute, are able to listen and hear what people are really saying, are respectful of different cultures, have emotional intelligence, are resilient and future focused, and have a love for public health.

They understand that relationship building and collaboration are the cornerstones of public health work.

3. What will be the major challenges of public health in the next 10 years?

The major challenges for public health in the next 10 years include the following: the improvement of the health of everyone in the country; the strengthening of the public health infrastructure; the aging of the public health workforce; the changing demographic populations (age distribution, cultural diversity) and their impact on disparities; chronic diseases; lack of access to health care and the uninsured; global health; health promotion and behavior change; environmental hazards and global warming; and the integration of public health and traditional medical information systems.

Other challenges for public health include genomics and ethical issues, credentialing and accreditation, emerging infectious diseases and drug-resistant bacteria, and the ability to convene and collaborate with people across the political and opinion spectrum.

4. What needs to be done to develop a culturally diverse leadership workforce?

We need to encourage and promote diversity in our public health leadership training across the entire public health system, not just the public health departments. Also, public health agencies in collaboration with the education system, from preschool to the academic institutions, that is, colleges, need to create opportunities for students of all cultures to gain the knowledge and skills needed. Public health agencies need to promote more recruitment where it’s robust and not passive of a culturally diverse workforce.

Some of these opportunities may include partnerships with diverse populations and organizations, providing scholarships, peer counseling, internships, and outreach educational endeavors for students of all cultures to gain the knowledge and skills needed to be 21st-century public health leaders with appropriate incentives.

5. Is leadership in the private sector similar to leadership in the business sector?

Leadership is leadership no matter what system you are in.

Leadership Tip

Think and act locally with global health issues involved in your activities.

DISCUSSION QUESTIONS

1. What is your personal definition of leadership?

2. Who is a living person whom you define as a leader and why?

3. What, in your view, are the differences between business leaders and public health leaders?

4. How does creativity play a role in leadership activities?

5. How is collaboration related to leadership?

6. What role does social justice play in public health?

7. What are the main goals of public health?

8. What does it mean to say that public health leaders should think globally but act locally?

9. Is leadership different from management?

EXERCISE 1-1: Course Expectations

Purpose: to explore the expectations that students have at the beginning of a leadership course

Key concepts: expectations, leadership development, preconceptions

Procedure: Each student writes down initial thoughts or preconceptions about leadership and also writes down expectations for the course and for leadership training in general. The class then divides into groups of 5 to 10 members, and each group discusses the preconceptions and expectations. The students should keep the lists they have created. One way to make this a meaningful experience is for students to start a leadership journal in which their list becomes the first page of a journal.

REFERENCES

1 . Institute of Medicine, The Future of Public Health (Washington, DC: National Academies Press, 1988).

2 . Institute of Medicine, The Future of the Public’s Health (Washington, DC: National Academies Press, 2003).

3 . Institute of Medicine, Training Physicians for Public Health Careers (Washington, DC: National Academies Press, 2007).

4 . J. P. Kotter, Leading Change (Boston: Harvard Business School Press, 1996).

5 . S. E. Melendez, “An Outsider’s View of Leadership,” in The Leader of the Future, ed. F. Hesselbein et al. (San Francisco: Jossey-Bass, 1996).

6 . Institute of Medicine, Healthy Communities: New Partnerships for the Future of Public Health (Washington, DC: National Academies Press, 1996).

7 . S. M. Bornstein and A. F. Smith, “The Puzzles of Leadership,” in The Leader of the Future, ed. F. Hesselbein et al. (San Francisco: Jossey-Bass, 1996).

8 . J. W. Gardner, Self-Renewal (New York: W.W. Norton, 1981).

9 . J. McKnight, The Careless Society (New York: Basic Books, 1995).

10 . R. K. Greenleaf, The Servant as Leader (Indianapolis, IN: Greenleaf Center for Servant Leadership, 1970).

11 . Kotter, Leading Change.

12 . F. Wickman and T. Sjodin, Mentoring (Chicago: Irwin Professional Publishing, 1996).

13 . L. Phillips-Jones, The New Mentors and Proteges (Grass Valley, CA: Coalition of Counseling Centers, 2001).

14 . M. Murray, Beyond the Myths and Magic of Mentoring, rev. ed. (San Francisco: Jossey-Bass, 2001).

15 . P. Hersey et al., Management of Organizational Behavior, 9th ed. (Upper Saddle River, NJ: Prentice Hall, 2007).

16 . P. M. Senge et al., The Fifth Discipline Handbook (New York: Dell, 1994).

17 . N. Brandon, “Self-Esteem in the Information Age,” in The Organization of the Future, ed. F. Hesselbein et al. (San Francisco: Jossey-Bass, 1997).

18 . D. Baumrind, “An Exploratory Study of Socialization Effects on Black Children: Some Black-White Comparisons,” Child Development 43 (1972): 261–267.

19 . D. Sethi, “The Seven R’s of Self-Esteem,” in The Organization of the Future, ed. F. Hesselbein et al. (San Francisco: Jossey-Bass, 1997).

20 . K. Blanchard and N. V. Peale, The Power of Ethical Management (New York: Fawcett Columbine, 1988).

21 . R. Preston, The Hot Zone (New York: Random House, 1994).

22 . L. Garrett, The Coming Plague (New York: Farrar, Straus & Giroux, 1994).

23 . J. B. McCormick and S. Fisher-Hoch, Level 4: Virus Hunters of the CDC (Atlanta: Turner Publishing Co., 1996).

24 . J. M. Kouzes and B. Z. Posner, The Leadership Challenge, 4th ed. (San Francisco: Jossey-Bass, 2007).

25 . P. M. Senge, The Fifth Discipline: The Art and Practice of the Learning Organization (New York: Doubleday, 2006).

26 . B. Nanus, Visionary Leadership (San Francisco: Jossey-Bass, 1992).

27 . S. Helgesen, “Leading from the Grass Roots,” in The Leader of the Future, ed. F. Hesselbein et al. (San Francisco: Jossey-Bass, 1996).

28 . J. W. Gardner, On Leadership (New York: The Free Press, 1990).

29 . C. R. Shaffer and K. Anundsen, Creating Community Anywhere (New York: Jeremy P. Tarcher and Perigee, 1993).

30 . Shaffer and Anundsen, Creating Community Anywhere.

31 . M. S. Peck, “The Fallacy of Rugged Individualism,” in In the Company of Others, ed. C. Whitmyer (New York: Jeremy P. Tarcher and Perigee, 1993).

32 . R. N. Bellah et al., Habits of the Heart (Berkeley: University of California Press, 1985).

33 . J. R. O’Neill, The Paradox of Success (New York: Jeremy P. Tarcher and Putnam, 1994).

34 . J. Kofomidos, The Balancing Act (San Francisco: Jossey-Bass, 1993).

CHAPTER 2

Leadership Styles and Practices

But leadership in public health involves more than individual leaders or individuals in leadership positions. Public health is intimately involved in leadership as an agent of social change by identifying health problems and risks and stimulating actions toward their elimination.

—B. J. Turnock, Public Health

This chapter begins by examining several styles of leadership. Leadership style generally refers to the way a leader provides direction to his or her organization, how plans and programs get implemented, and how staff are motivated to do their work. The first model describes McGregor’s distinction between two main leadership styles, referred to as Theory X and Theory Y. It then discusses another way of categorizing leadership styles, based on the Leadership Grid, and explores the view that a leader needs to use different styles in different situations. The next section of the chapter is devoted to an account of the characteristics that a leader must possess in order to lead effectively. The last section presents a discussion on the importance of talent as a critical component in leadership.

LEADERSHIP STYLES

Theory X and Theory Y

In a classic study, McGregor discussed two leadership styles, Theory X and Theory Y, which are appropriate for different types of organizations. 1 Theory X is more suitable for an organization in which the employees do not like their work situation and will avoid work whenever possible. In this case, the employees have to be forced, controlled, or reprimanded in order for the organization to meet its goals and objectives. The employees are looking for control because they are not willing to guide the work process themselves. The thing they are most interested in is security.

McGregor noted that a situation in which employees are unhappy and need to be controlled will push leaders toward an autocratic style of leadership. Theory X represents a mainly negative approach to leadership. I had dinner with a local public health administrator at an American Public Health Association annual meeting several years ago. During the discussion, the question of why this administrator did not send any of his staff to a leadership program was raised. His answer—that he was the leader and his staff did not need leadership development—exemplifies the Theory X style of leadership.

Theory Y is appropriate for an organization in which the employees like their jobs and feel that their work is natural and restful. Furthermore, because they accept the goals and objectives of the organization, they tend to be self-directed and even to seek higher levels of responsibility. Finally, decision making occurs at all levels of the organization. Theory Y is essentially a democratic form of leadership. A public health administrator who had completed a state public health leadership program decided that he had benefited greatly from the training. Over the following five years, he sent most of his executive staff to the program to develop their leadership skills. After 10 years passed, this director began to send his new staff through the same leadership development program. His actions exemplify the Theory Y style of leadership. His successor was an individual whom he had sent to the leadership development program. The new director continues the practice of sending her staff through the leadership program. Exercise 2-1 is intended to help elucidate the difference between Theory X and Theory Y.

In the context of today, Theory X has more commonly been referred to as the “command and control” form of leadership. In the emergency preparedness area, the leader of the Incident Command Structure tends to be seen as this type of leader and also as more of a manager than a leader. Theory Y leaders are seen as democratic or collaborative and empower their staffs to take similar approaches to problem solving.

Managerial Grid

Blake and Moulton adapted the Managerial Grid, a tool devised by Blake and his colleagues, to form the Leadership Grid ( Figure 2-1 ). 2 There are 81 positions on the grid and five different leadership styles. The vertical axis represents concern for people, and the horizontal axis represents concern for production (task-oriented behaviors). The location of each style on the grid is determined by where the style falls with respect to the two dimensions. For example, the country club management approach is characterized by a high level of concern for people and a low level of concern for production and is thus placed in the upper left-hand corner of the grid. This managerial approach creates a relaxed atmosphere and makes people happy to come to work in the morning.

FIGURE 2-1 The Leadership Grid®. Source: Blake, R., Moulton, J. (1964). The Managerial Grid: The Key to Leadership Excellence. Gulf Publishing Company.

If a leader is not seriously concerned about the well-being of the employees or about production, the result is impoverished management. In this style of leadership, the leader engages in the least amount of work necessary to solve a production problem.

The third approach is team management, in which the level of concern for employees and production is high. Strong, trusting relationships develop, and all or most employees feel a commitment to accomplish the tasks at hand.

In the authority-obedience approach, the primary concern of the leader is to control the production process and increase productivity. The leader’s concern for the employees’ well-being is minimal.

Organization man management tries to balance the needs of the employees and the needs of production.

Situational Leadership

Instead of using just one leadership style, leaders should use different styles for different situations, according to some authors. 3 – 6 The series of One Minute Manager books, by Blanchard and others, tries to integrate the needs of organizations with the needs of both employees and customers. Blanchard and his coauthors designated their approach Situational Leadership II. 7 ,8 As with the Managerial Grid, leadership behavior is evaluated along two dimensions: directiveness and supportiveness. The type of leadership that is relatively nonsupportive and nondirective is termed a “delegating” style of leadership. The type that is supportive but nondirective is termed a “supporting” style of leadership. Leadership behavior that is highly supportive and highly directive constitutes “coaching,” and leadership behavior that is highly supportive and highly directive is called “directing.”

The model is intentionally flexible. A leader will need to relate to an employee in a given situation using a specific leadership style, a style partly determined by the task and the employee’s years in the organization. There are certain assumptions here. First, there is the assumption that people want to learn and develop their skills over time. Second, Blanchard pointed out that there may be no guaranteed best leadership style to make this happen. Some people may have a better capacity for learning than others do.

There are clear overlaps between McGregor’s analysis of leadership styles and Blanchard’s. Theory X involves directing and some coaching. Theory Y involves some coaching, supporting, and delegating. However, the Situational Leadership II model is the more adaptive of the two. Hersey, Blanchard, and Johnson noted an overlap between McGregor’s model and the Situational Leadership II model, but they thought that Theory X and Theory Y represented leaders’ and managers’ assumptions about leadership and that these assumptions often did not get translated into action. 9

It is clear that leaders must use different strategies for different employees. Leadership occurs in a social context in which values and norms cannot help but influence the process of leading. One leadership approach will not work for every individual in an agency. Unfortunately, some public health leaders are inflexible and use one style predominantly. For instance, one local public health administrator believed it was necessary for him to use an authoritarian approach for managing his staff. Years later, he moved to a new public health agency that he discovered to be more democratic in form. He changed his leadership style but did not seem to learn that leadership style needs to be tied to the situation at hand and not to the agency.

Other Analyses of Leadership Style

In a classic paper, Tannenbaum and Schmidt explored how a leader-manager might be democratic in some situations and autocratic in others. 10 As can be seen in Figure 2-2 , both leadership styles are used to carry out the activities of the organization. In fact, most leadership practices fall between the two extremes. For example, the action of presenting ideas to subordinates and inviting questions from them involves the use of authority by the manager but also gives to the subordinates a degree of freedom or power. Tannenbaum and Schmidt’s analysis is similar to the work of Lewin and his colleagues at the University of Iowa. 11 ,12 The Lewin group distinguished three leadership styles: autocratic, democratic, and laissez-faire. Their research showed that the democratic style seemed to be especially suitable for group process-oriented activities.

FIGURE 2-2 Continum of Leadership Behavior. Source: Reprinted from Harvard Business Review. “How to Choose a Leadership Pattern” by R. Tannenbaum and W. H. Schmidt, May–June 1973. Copyright © 1973 by the President and Fellows of Harvard College; all rights reserved.

Bass found that leaders differ in the approach they take to leading their organizations, in part because of the variation in the issues they need to address. 13 Furthermore, he noted that leadership behaviors generally fall on a continuum between task-oriented and relationship-oriented behaviors.

Fiedler explored the relationship between three factors that affect leadership effectiveness: personal relationships with work associates, the structure of the task to be performed by the work group, and the power associated with the leader’s position in the organization. 14 These three factors can be combined in eight ways. According to Fiedler, leaders who are task oriented tend to be more effective in very favorable or very unfavorable situations than those who are relationship oriented. Leaders who are relationship oriented, in contrast, perform better in situations that fall between the two extremes. Note that public health leaders must be both task and relationship oriented, because public health programs demand good communication between public health leaders and their constituents.

Hersey, Blanchard, and Johnson developed a typology of task- and relationship-oriented behavior: high-task and low-relationship behavior, high-task and high-relationship behavior, high-relationship and low-task behavior, and low-task and low-relationship behavior. 15 The authors added effectiveness-ineffectiveness as a third dimension. As noted above, public health leaders need to exhibit high-task and high-relationship behavior, which is effective in groups being able to set goals, arrange work activities, and create a positive set of work relationships. It is ineffective in sometimes creating an inflexible structure and not enough solid interpersonal relationships.

In the 1940s, a series of studies was done by the Bureau of Business Research at Ohio State University. 16 The researchers defined leadership as the direction of group activities for the purpose of attaining a goal. Leadership, in their view, involved two types of behavior: initiating structure (task-oriented behavior) and showing consideration for the needs of employees (relationship-oriented behavior). The researchers hypothesized, on the basis of their data, that both types of leadership behavior are necessary, but they found little relationship between the two types of behavior.

Utilizing the Ohio State model elements, House formulated a path-goal model. 17 According to this model, a leader’s task was to help followers attain their goals through appropriate direction and support. In other words, the leader points the way to the right path to enhance the ability of followers to reach their goals. In addition, House characterized leadership behaviors as directive, supportive, participative, or achievement oriented.

Researchers at the University of Michigan followed the Ohio State model by dividing leadership behaviors into those that were employee oriented (roughly equivalent to showing consideration for employees) and those that were production oriented (roughly equivalent to structure initiation activities). 18

A recent look at leadership style presents the view that leaders are either multipliers or diminshers. 19 Multipliers are leaders who bring out the best in people, whereas diminishers do the opposite. The five disciplines of the multipliers and helping individuals develop their talents, promoting the best thinking in others, providing challenges, allowing debates to occur, and delegating accountability to others.

When leaders have an idea, a new program to develop, a cause, or a new paradigm for action, they want to see these things work. They jump in immediately and do the detail work necessary to bring these processes to life. Some of the ideas work and some do not. Even when these new directions seem to take flight, outsiders may or may not buy these processes, ideas, or techniques. These leaders need to convince people inside their agencies or organizations and external stakeholders why this innovation is useful and worth supporting. These leaders develop the style of a champion.

Champions are leaders who support causes and new ideas and who think what they are doing and developing needs a wider audience. These champions fight for the cause. They talk to politicians, foundations, government agencies, community leaders, and others to make this new thing work and become valued. They sell the ideas and programs. Champions are multipliers who allow others to move their ideas forward.

LEADERSHIP TRAITS

Those who study leadership traits usually attempt to create an interface between the way leaders think and the ways they tie their thoughts into action on a daily basis. It is these traits that are reflected in the leadership styles of individuals. Traits seem to combine some innate qualities with qualities that seem to be learned. Bass and Stogdill reviewed studies of leadership traits and abilities done between 1948 and 1970. 20 Table 2-1 contains a list of all the traits and abilities reported in three or more of the studies. Leading the list are technical skills, social nearness and friendliness, task motivation and application, supportiveness toward group activities, social and interpersonal skills, emotional balance and control, and leadership effectiveness and achievement.

After 1970, the idea of universal leadership traits was abandoned. Bass studied the trait issue for the period from 1970 to 2006. 21 Personality and character traits were still seen as important. Task competence and socioemotional performance were also seen as important. Verbal and nonverbal communication skills have become critical for the successful leader as well. Bass also pointed out that much research has shown that both nature and nurture are important in leadership.

TABLE 2-1 Factors Appearing in 3 or More Studies of the 52 Surveyed

Factor	Number of Studies Found
Technical skills	18
Social nearness, friendliness	18
Task motivation and application	17
Supportive of the group task	17
Social and interpersonal skills	16
Emotional balance and control	15
Leadership effectiveness and achievement	15
Administrative skills	12
General impression (halo)	12
Intellectual skills	11
Ascendence, dominance, decisiveness	11
Willingness to assume responsibility	10
Ethical conduct, personal integrity	10
Maintaining a cohesive work group	9
Maintaining coordination and teamwork	7
Ability to communicate; articulativeness	6
Physical energy	6
Maintaining standards of performance	5
Creative, independent	5
Conforming	5
Courageous, daring	4
Experience and activity	4
Nurturant behavior	4
Maintaining informal control of the group	4
Mature, cultured	3
Aloof, distant	3

Source: Modified with permission of The Free Press, a Division of Simon & Schuster, Inc. From Bass & Stogdill’s Handbook of Leadership: Theory, Research, and Management Applications, Third Edition by Bernard M. Bass. © 1974, 1981, 1990 by The Free Press. All Rights Reserved.

Kouzes and Posner compared the traits identified in 1987 and again in 2010 as the chief characteristics of admired leaders ( Table 2-2 ). 22 The five most frequently mentioned leadership traits of the most admired leaders in 1987 were honesty, forward-lookingness, the ability to inspire, competence, and intelligence. In 2010, the same five traits headed the list. Honesty was also reported as the number-one trait in Canada, Brazil, Australia, Japan (tied with forward-looking), Korea (tied with forward-looking), the Philippines, Malaysia, Mexico, South America, and United Arab Emirates. Being forward-looking was reported as the number-one trait of admired leaders in Turkey.

TABLE 2-2 Characteristics of Admired Leaders (Percentage of People Selecting Characteristic over the Years)

Source: Reprinted with permission of John Wiley & Sons, Inc. From J. M. Kouzes and B. Z. Posner, Credibility, 2nd ed. (San Francisco: Jossey-Bass, 2011).

A determination of the traits expected of leaders is used by the military in an effort not only to designate traits but also to use these traits as indicators of those that will reflect the values and culture of the military service and the country. For example, the Marine Corps lists 14 traits for people in the military who wish to become Marine leaders. Many if not all of these traits may also reflect the expectation of a leader in public health. These 14 traits are:23

1. Justice, which is the practice of being fair and consistent;

2. Judgment, which is the ability to think clearly and in an orderly fashion for decision making;

3. Dependability, which reflects the ability to perform duties properly;

4. Initiative, which is taking action with or without orders;

5. Decisiveness, which is making good decisions expeditiously;

6. Tact, which is dealing with people in a way that maintains good relations;

7. Integrity, which is honesty and truthfulness;

8. Enthusiasm, which is sincere involvement and enthusiasm in work;

9. Bearing, which is the way the leader conducts and carries him- or herself;

10. Unselfishness, which is the avoidance of self-comfort at the expense of the comfort of others;

11. Courage, which is calmness while recognizing fear;

12. Knowledge, which is acquiring the knowledge necessary to carry out one’s work;

13. Loyalty, which is devotion to one’s country; and

14. Endurance, which is physical and mental stamina.

Leadership is dynamic, and there is probably no universal list of leadership traits that apply to all situations. 24 Nonetheless, whereas all the traits and abilities presented in Tables 2-1 and 2-2 are capable of enhancing the effectiveness of a leader, at least in certain circumstances, the 10 leadership abilities and practices described next have been singled out as especially important for successful leadership in the 21st century.

Leadership Practices

First, leaders must be knowledge synthesizers. They must bring intelligence to the leadership enterprise. They need to know about past events, understand the realities of the present, and have a vision of the future. They must not only be experts in their chosen field but be familiar with many other areas as well. Good leaders know how to use their knowledge to carve out a perspective and move their organization forward. Intelligence alone is not enough. 25 Self-awareness, self-control, self-confidence, commitment, integrity, the ability to foster change, and the ability to communicate with and influence others are all necessary.

Second, leaders need to be creative. They must not only manage large amounts of information but use it creatively to guide action. To do this successfully, they must ignore information that is not pertinent. It is hard to teach people to be creative, although most individuals tend to be creative in areas where they have high interest. When you have enthusiasm for what you are doing, there seems to be a natural flow to the process. It is possible for individuals to expand their creative abilities through practice, including through interacting with others in a social context. 26 Exercise 2-2 is designed to explore the creativity of the team members engaged in devising a solution to a public health problem.

Third, leaders need to be able to create a vision and get others to share the vision and demonstrate a commitment to the vision and the mission it represents. Creating a vision is not an easy thing to do, because it requires careful consideration of different scenarios that might occur if certain factors are present. Furthermore, creating a vision is next to pointless unless others can be convinced to share the vision. Pfeffer stated that a vision gets others to see beyond the obstacles of things to the important possibilities that can ensue in the future. 27 Long-term visions tend to allow people the opportunity to create many innovations, whereas short-term visions seem to be limited by the barriers that today’s reality presents. Leaders also need to be flexible enough to modify the vision to better satisfy their partners in the visioning process. Finally, leaders need to fit the vision to a mission and devise an action plan to realize the vision.

Fourth, leaders need to foster and facilitate collaboration. No one in an organization exists in a vacuum, nor does anything get done in a vacuum. Turning a vision into reality requires the development of partnerships with external stakeholders and, in fact, the sharing of leadership. In shared leadership, each partner must respect the needs and wants of each of the other partners.

Fifth, leaders need to possess entrepreneurial ability. Traditional approaches to running companies and agencies no longer seem to be working. Leaders will increasingly need to explore alternate funding sources for their programs and learn how to use their resources in new ways. 28

Leadership Tip

Keep your knowledge and skills up to date. Be committed to lifelong learning.

This change in perspective will increase not only program efficiency but also program effectiveness. Perhaps surprisingly, leaders in the governmental public health sector need to learn these skills.

Sixth, successful leaders are systems thinkers who must also address the needs of complex environments. Acting as a change agent for an organization requires mastering the techniques of systems thinking as well as looking at the organization systemically. 29

Systems thinkers are consciously aware that everything is connected to everything else. The obvious problems plaguing an organization may be symptoms rather than root causes. A systems approach to change allows leaders to logically analyze the dimensions of the problems.

One way to put systems thinking into practice is to turn the organization into a learning organization—“an organization that is continually expanding its capacity to create its future.” 30 (p.14)

In a learning organization, the system becomes the guiding mechanism for change. This allows the organization to keep pace with the rapid rate of change in today’s world, to function in a more interdependent manner, and to respond to the changing needs of society. 31 In a system, all the parts are interrelated, and activities that occur in one part affect all the others. The traditional linear approach to decision making is not appropriate for a true system. Systems thinkers see the big picture and are interested in the ways organizations and individuals interrelate. They are students of change and the transformational patterns that affect change. Systems thinkers also think strategically. They try to determine strategies for facilitating change as they address the challenges of the system.

Seventh, leaders must set priorities. They have to determine what issues will be addressed by the organization. Because of the current focus on team development and community coalition building, leaders often set priorities in concert with team or community partners. Public health places a strong emphasis on the community assessment of health and disease, which helps in setting health priorities for a community. Because the health priorities are determined with partners, subjective and objective factors tend to influence the priority-setting process. Decisions about priorities are often determined by political issues and community concerns.

Eighth, leaders need to form coalitions and build teams. They no longer practice the leader’s craft in a vacuum, and they must be aware that their success depends on their being able to work with others. Because different individuals bring different expertise to the decision-making environment, teams are created to solve problems and make decisions. In teams, leadership is shared and different members move into the leadership position at different phases of the problem-solving process. Because of public health’s strong community perspective, building coalitions to support the local public health agenda becomes critical. A community coalition is a team in which many community groups are represented, and it is a means of empowering the community to address its own problems.

Ninth, leaders, as pointed out previously, must not only bring a creative spark to the organization but also help put innovative ideas into practice. Therefore, they must become masters of the latest management and leadership techniques. This does not mean they should adopt all the latest management fads. Rather, they should explore new techniques and integrate into their repertoire those techniques that will likely make the organization stronger, more productive, and more customer oriented. 32 The overall objective of managing is to guide the organization toward achievement of its vision. (Note that new management techniques will occasionally have to be adapted to the systems perspective, because even now many new techniques are linear in nature.)

Tenth, a successful leader acts as a colleague, a friend, and a humanitarian toward everyone in the organization. Leaders must be effective communicators and be able to empathize with colleagues, peers, and customers. They should protect the values of their organizations as well as the values of the communities in which they live. In fact, they will occasionally need to help define organizational and community values.

Most leaders of the 21st century, to be fully effective, will need to possess these 10 leadership abilities and characteristics. These abilities and characteristics provide a solid foundation for the activity of leading the process of developing a vision (and a mission) and bringing that vision to fruition.

THE TALENT ISSUE

In the past several years, there has been an emergence of a new dimension of leadership that is tied to the relationship of talents of people and how these talents are reflected in the work of managers and leaders. Talent becomes a filter in which knowledge and skills get translated into action. Thus, it is more than a series of traits in that the combination of specific talents is unique in each individual. The following formula puts these new trends into perspective:

The traditional view was that knowledge, attitudes, and skills led to action. Recent research shows that the process is more complicated.

In a number of books, the Gallup Organization has investigated the critical aspect of talent and how it affects action. 33 ,34 What was discovered was that most organizations stressed the weaknesses of employees rather than their personal strengths. In order to address these weaknesses, individuals were often sent for training related to these weaknesses rather than training to make personal strengths stronger. In a study of 80,000 people in administrative positions, Buckingham and Coffman said that our orientation to weaknesses was incorrect. 35 Training does not substantially improve an individual’s weaknesses. Our brains are wired to support our strengths rather than our weaknesses. This is the talent dimension. Thus, administrators have discovered that it is necessary to change our approaches to training and performance improvement. It is better to train people to use their personal talents more effectively.

The authors also pointed out that effective administrators have to become more expert at dealing with human capital issues. This means they need to become more ready to hire people on the basis of their talents and not just on their technical knowledge and skills. It is in the day-to-day activities that an individual’s talents are displayed. The administrator needs to let his or her direct reports define process on the basis of these personal talents. If this happens, then the administrator can concentrate on helping individuals determine outcomes and then measure performance on these outcomes. Thus, performance plays out on an individual’s strengths rather than on his or her weaknesses. The challenge then is to find the best fit for jobs on the basis of the combination of knowledge, skills, and talent.

In order to explore talent from the vantage point of strength, the Gallup Organization began an extensive research process to investigate what are the major talents of individuals. Buckingham and Clifton discussed this study of more than two million people. 36 They reported that this research made the assumption that all individuals have a different combination of talents and strengths. Whereas using trait approaches tries to match individuals to the traits required for a job, talent research pointed out that each individual is different and that it is important to create the best fit between these personal talents and strengths and the tasks to be performed. Because our brains are wired for our strengths, the combination of talents is unique to each of us. It is to our personal strengths that we need to move in our pursuit of knowledge and skills.

Out of the Gallup surveys was developed an instrument called Strength Finder, which is now in its second iteration. 37 This instrument measures 34 trait categories. The 34 talents are organized around four key themes, which are discussed by Coffman and Gonzalez-Molina. 38 First, there are themes involving relationships and how well we perform in these talents related to other people. The second theme involves our abilities to create impact in how we motivate people to act. Kouzes and Posner also listed enabling other people to act as a key leadership practice. 39 The third theme involves talents associated with our abilities to be action oriented. The final theme relates to our thinking talents. Table 2-3 lists the 34 talents related to the four themes.

An important lesson from this research is that an individual can become a strong performer in a particular job category and not be a strong performer in a higher level that requires a different set of talents that the individual may not have. The other part of the formula presented at the beginning of this section relates to the attitude that a person brings to his or her performance. Rath discusses how his grandfather, Donald Clifton, who helped develop an instrument to measure strengths related to talent, also discussed the importance of positive thinking for managers and leaders. 40 The more positive reinforcement the individual gets, the better the work performance becomes. The other numerator variable relates to the values we bring to a job and to our other life activities. These values are also a guide to how we view our actions. The denominator of the formula on page 24 adds the way organizational values and our personal strengths filter the way we practice leadership and action. Our leadership style grows out of many of the factors listed in the formula, which affects the actions we take in problem solving and decision making. Experiment with the concepts in this section by doing Exercise 2-3.

SUMMARY

Traditional theories of leadership have tended to ignore situational factors that can influence which leadership style is best for a given set of circumstances. In addition, most of the leadership literature concerns leadership in the business sector, yet public and not-for-profit agencies seem to work differently than for-profit companies. William Foege, a former director of the Centers for Disease Control and Prevention, has said on numerous occasions that social justice is the value that most motivates leaders in public health. Another way of saying this is that concern for people’s well-being is primary. Case Study 2-A reviews some of the concerns and motivations of public health leaders.

TABLE 2-3 Talent Categories of People

* Previously “inclusiveness”

† Previously “fairness”

Given this fact of a people rather than a product orientation, the most balanced type of leadership in public health should probably be called not organization man management (as it is designated in the Leadership Grid), but something like community collaboration leadership. A public health leader’s concern for people encompasses many constituencies other than his or her work associates. Furthermore, production, in a public health setting, includes all sorts of programs and activities, from community assessment to the development of effective community interventions.

Case Study 2-A

Inner World to the Future: Leaders’ Perspective on the Future

Louis Rowitz

We are at a crossroads. Public health agencies appear to be under attack from multiple sources, including government entities, government superagencies, managed care organizations, the mass media, community groups, and disgruntled citizens. There is confusion about what the thing called “public health” is. There is concern about the involvement of public health agencies in direct medical service activities. Perhaps, some say, it is time for government to get out of the public health service business and spin off public health agency activities to the private sector.

To these concerns must be added a strong belief that leaders make a difference. Leaders bring hope and vision and have an ability to find solutions for the challenges that face the field of public health. It is to the training of public health professionals that the public health community looks as a possible way to strengthen the infrastructure of public health in this country and to clarify the vision of public health for the 21st century. There is a strong belief in the public health community that leadership skills can be taught. There is also a strong belief that a commitment to lifelong learning is critical. For the past several years, national, regional, and state public health leadership programs have been developed. These programs have helped public health leaders increase their leadership skills and learn the latest techniques for improving and strengthening organizations. These programs have also trained public health leaders to work with communities to help define the role of public health at the community level. These programs have also stressed the importance of promoting the public health paradigm of core functions and essential public health services and of urging leaders to use their skills to build the public health system. These programs have developed unique approaches to training that promote an experiential application of all training materials back to the workplace and the community. The greatest challenge for these programs, other than the obvious one of financial sustainability, is the measurement of their long-term effect on the infrastructure of public health.

The combination of public health’s challenges and the present-tense quality of our public health leadership programs, even when we talk about the future, raises an important series of issues related to where public health needs to go over the next several decades. The perspective is partly one of vision, but it is also one that goes to the very soul of the beliefs of public health leaders around the world. The experience of public health work changes us as professionals. Our inner world processes all our experiences and creates what the experimental psychologist Edward Tolman called a cognitive map. Each experience changes the topography of our lives. This includes our personal experiences and our community living experiences as well as our professional experiences.

Interviews with Public Health Leaders

During 1996, I began a personal odyssey to find out what public health leaders think about public health today and what they perceive will be public health’s future. I traveled throughout the United States, England, Scotland, and Ireland conversing with public health leaders about the future of public health. I talked to more than 130 leaders in conversations that lasted about an hour. These conversations changed my cognitive map and my inner world by showing me the field of public health in ways that I had never perceived it. I talked to leaders at all levels of government. I talked to public health professionals at the federal, state, and local levels in the United States as well as to academics. I talked to foundation professionals as well as professional trainers. I also talked to public health leaders who moved to the private sector. These leaders have given me insights about ways to strengthen our training programs in the future so that we can make public health more responsive to the needs of the public. They have also taught me what we do wrong and the importance of blending our strengths in solutions of our problems.

Lessons Learned

Public health leaders live the reality of their chosen profession on a daily basis. They struggle with the crises of the day as well as with the concerns that public health faces as it progresses into the 21st century. Leaders in the United States face concerns with the impact of managed care on the public health field. Leaders in the United Kingdom and Ireland see public health within the context of a nationalized health service where managed care is a reality rather than a specter on the horizon. As I talked to U.S. leaders at the federal, state, and local levels as well as in both the public and private sectors, I found that all the leaders struggle with what that elusive field called public health is. The confusion extends to the issue of whether public health as a profession is different from public health as an organizational entity. U.S. public health is multidisciplinary as well as multisectorial in perspective. This means that we speak with many voices and do not always convey a unified message. Despite this multidisciplinary orientation, public health has a strong medical perspective and an increasingly economic one as well. One result is that the primary prevention goal of public health is sometimes lost as we pursue treatment and rehabilitation programs for underserved or unserved populations. Many leaders argue that the local public health agency must be a provider of last resort when there are limited medical services available for the people in local communities. As local public health agencies continue to act as direct service providers, leaders argue that managed care organizations’ move into the local area of service is a threat to local health agencies that rely heavily on the service dollars received for direct service. However, public health needs to be seen as a partner in a total integrated health program in the community. Some leaders see public health agencies as playing the leading role in a comprehensive community-based healthcare system.

There is increasing acceptance of the core functions paradigm of assessment, policy development, and assurance, along with a lesser degree of acceptance of the essential public health services perspective. There is a concern that the core functions terminology is too abstract and confusing to people outside the public health field. U.S. leaders feel that we perform assessment activities fairly well, although we tend not to be conversant with the latest technology advances in informatics. Leaders at all government levels feel that they have a critical role in policy development but do not always exercise the policy opportunities that they have. Several leaders pointed out that public health leaders need to be students of the democratic process and understand how our political process works. The leaders are concerned that politicians and local board of health members or county board members have most of the control of the budget that drives the public health machine. They also believe that the relationship between the local health agency and its boards is often adversarial. Leaders argue that boards could become more of a voice for public health in the community than they currently are. In addition, these issues point to the question of how public health leaders can affect the decision-making process.

Most questions were raised about the assurance function and the difficulties in specifying completely our assurance role, because this is the role that underwent the most change during the last decade of the 20th century. There is agreement that public health needs to support a lifelong learning perspective and encourage and support continued educational and training opportunities for the public health workforce. However, training dollars are currently scarce.

Many leaders express concern about the future of public health in the United States and the increasing split between national public health concerns and state and local concerns. The agenda of each level of government is different and often not integrated with the issues of concern at other levels. In addition, we have not explored the possibilities of regional collaboration as a viable way to share programs across counties and other local entities and across states in different geographic areas. An added challenge concerns the absorption of public health into state human services umbrella agencies. However, some leaders feel that the umbrella agency model may increase the importance of public health agencies and leadership at the local level. Public health practice is really a local concern and needs to be protected. It must not become too parochial, because public health has a global perspective. State and local public health leaders need to think globally but act locally.

There are several other issues of concern to public health leaders. First, our assessment activities tend to ignore the important perspective of epidemiology, which provides methods for interpretation of data. Leaders often do not know how to use data for effective decision making. Second, public health needs to reclaim its primary prevention perspective and its key role in health promotion. Educational models should predominate in health promotion activities. Third, public health is developing academic and practice linkages, but not too many successful ones. Next, public health needs to do a better job in the areas of social marketing and health communications, because the public still does not know what public health is. Finally, public health needs to do a better job building community coalitions to address community public health needs. However, there is much to learn about the development of coalitions and how to keep up the interest of these coalitions over time.

In England, Scotland, and the Republic of Ireland, I saw national health systems in which public health often played a secondary role. In all three countries, public health is dominated by physicians. All other public health–related groups are in secondary support roles. Only physicians can head a public health program in a district. If other professionals want to move into a leadership role, they are often limited to roles in academic teaching settings. However, all public health physicians have received training in public health and have passed national credential examinations.

Purchasing of services becomes the primary role of the health service public health physicians. Primary prevention programs may exist in some areas, like immunization, but these programs are contracted out to local physicians or hospitals and clinics. A common complaint of the district physicians was their inability to use their public health knowledge in the health districts. They felt that a large amount of their professional energies was expended on conflicts with local managers, who are often not health trained. In England, public health physicians felt that public health is losing its foothold and becoming less visible. In the Republic of Ireland, public health offices were abolished for 20 years under the mistaken belief that all of the public health concerns of Irish society had been solved. Only in the past few years has public health been re-established in the districts. However, it is taking time for these offices to re-create public health programs. Scotland is an interesting case, in that community-based programs are being developed and supported within the Scottish office of the national health service.

The major lesson to be learned is that public health often has trouble surviving in a system in which all the citizens have access to services. However, primary prevention programs do not flourish in this environment without a vigorous struggle. Time pressure resulting from calendar overload becomes a problem. Bureaucracy and an overabundance of meetings at the local and national levels are the rule rather than the exception. In addition, each public health profession has its own organization, the agendas of these organizations conflict, and there is a consequent lack of agreement between these groups as to how to pursue a common public health agenda. However, these European countries are small, and most public health people know each other. This does offer opportunities for collaboration that are not often pursued.

The Future

Public health concerns never go away. Although it is possible to see variations in the ways public health is practiced, there will continue to be crises and issues of concern to the public health profession. There is growing anxiety about emerging infections and increasing resistance to the effects of antibiotics. Money available for health services is shrinking. Managed care and primary care organizations do not seem to hold all the answers for the healthcare needs of the American public.

The changing demographics of our population require public health interventions. The need for primary prevention activities and the development of health promotion and disease prevention initiatives remains critical. Ebbs and flows in the support for government-based public health programs will continue.

Public health leaders remain hopeful. They see growing support for leadership programs for the public health workforce. They project a growing influence of public health activities undertaken by local health departments. They are ambivalent about the movement to create superagencies at the state level, although they recognize that public health agencies need to work closely with other human services agencies. Our technology knowledge will increase significantly over the next several decades. The Centers for Disease Control and Prevention will continue to be a major public health voice in this country. Public health will work more closely with its healthcare partners to develop more integrated systems of care. Some leaders see this collaboration as occurring from within an integrated healthcare system. Other leaders believe that public health agencies will remain part of the government system, because their oversight function must not be compromised. Closer linkages will evolve between academic institutions and public health agencies. Finally, public health’s emphasis on core functions and essential services will lead to increased infrastructure strength in the future.

In summary, public health leaders bring a message of hope for the future. Public health will survive.

Source: Reproduced from L. Rowitz (1997). “Inner World to the Future: Leaders’ Perspective on the Future,” Journal of Public Health Management and Practice, 3, 4, 68–71, July 1997.

DISCUSSION QUESTIONS

1. What are the differences between the Theory X and Theory Y leadership styles?

2. What are the five leadership styles defined in the Leadership Grid?

3. What is an example of high-task, low-relationship leadership behavior?

4. How would you describe your dominant leadership style?

5. How flexible are you in modifying your dominant leadership style in situations that require a different style?

6. What are two examples of how you practice leadership?

7. What are five of the most cited traits of admired leaders?

8. What do you think are the most important traits a leader needs to possess?

9. Why do leaders of public organizations need entrepreneurial ability?

10. What are the similarities and differences between traits and talents?

EXERCISE 2-1: Authoritarian and Democratic Leadership Styles

Purpose: to explore alternative approaches to decision making and to investigate how alternative leadership styles can influence program outcomes

Key concepts: authoritarian leadership style, democratic leadership style, decision making

Procedure: The class or training group should divide into two or more groups. Each group has the assignment to create a plan for developing a community’s public health infrastructure using a given set of resources. The plan should address core infrastructure elements, including the local public health workforce, public health facilities and services, public health surveillance and information systems, and relationships with medical, social, community, government, and business organizations. To develop this plan, each team chooses a leader, who is given an envelope containing a note designating the leader as a supporter of the Theory X or the Theory Y leadership style. The leader guides the group through a planning process according to the characteristics of the leadership style assigned but does not inform the other team members which leadership style he or she is using. After half an hour, each team reports back to the class or training group as a whole, describing the exercise process, evaluating the leader, and describing the infrastructure plan chosen by the team and what its ramifications are.

EXERCISE 2-2: An Exercise in Creativity

Purpose: to generate solutions to a public health problem from several leadership perspectives and to learn how to use creativity to discover the best solution for a problem

Key concepts: community coalition, creativity, problem solving, team

Procedure: The class or training group should divide into small teams of five to eight people. Each member of each team should select a public health problem that concerns the particular member. The team then chooses one of the problems and tries to solve it from a personal perspective, a public health agency perspective, and a community coalition perspective. The exercise is repeated using the supposition that the mayor of the town or the governor of the state does not want public funds expended on the problem. The entire team should explore the advantages and limitations of the alternative solutions and the role that creativity plays in developing the solutions.

EXERCISE 2-3: Talent and Strength

Purpose: to become aware of when we make strong decisions and explore the underlying talents we have as leaders

Key concepts: talent, personal strengths, decision making

Procedure: Jot down in your journal or on a sheet of paper the last three decisions you made that demonstrate your effectiveness as a leader. Break down the class or training group into small teams of five to eight and discuss one example with your team where you showed your strength in making a decision. Looking at the list of talents in Table 2-3 , determine what talents you displayed in your decision-making style.

REFERENCES

1 . D. McGregor, The Human Side of Enterprise (New York: McGraw-Hill, 1985).

2 . R. R. Blake et al., The Leadership Grid (Houston: Gulf Publishing Co., 1991).

3 . K. Blanchard and S. Johnson, The One Minute Manager (New York: Morrow, 1982).

4 . K. Blanchard and R. Lorber, Putting the One Minute Manager to Work (New York: Morrow, 1984).

5 . K. Blanchard et al., Leadership and the One Minute Manager (New York: Morrow, 1985).

6 . K. Blanchard et al., The One Minute Manager Builds High Performing Teams (New York: Morrow, 1990).

7 . Blanchard et al., Leadership and the One Minute Manager.

8 . Blanchard et al., The One Minute Manager Builds High Performing Teams.

9 . P. Hersey et al., Management of Organizational Behavior, 9th ed. (Upper Saddle River, NJ: Prentice Hall, 2007).

10 . R. Tannenbaum and W. H. Schmidt, “How to Choose a Leadership Pattern,” Harvard Business Review (March–April 1958): 95–102.

11 . K. Lewin and R. Lippitt, “An Experimental Approach to the Study of Autocracy and Democracy: A Preliminary Note,” Sociometry 1 (1938): 292–300.

12 . K. Lewin, “Field Theory and Experiment in Social Psychology,” American Journal of Sociology 44 (1939): 868–896.

13 . B. M. Bass, The Bass Handbook of Leadership (4th ed.), (New York: The Free Press, 2008).

14 . F. E. Fiedler, A Theory of Leadership Effectiveness (New York: McGraw-Hill, 1967).

15 . Hersey et al., Management of Organizational Behavior.

16 . R. M. Stogdill and A. E. Coons, eds., Leader Behavior: Its Description and Measurement, Research Monograph No. 88 (Columbus: Ohio State University, Bureau of Business Research, 1951).

17 . R. J. House, “A Path-Goal Theory of Leadership,” Administrative Science Quarterly 16 (1971): 321–338.

18 . R. L. Kahn and D. Katz, “Leadership Practices in Relation to Productivity and Morale,” in Group Dynamics: Research and Theory, ed. D. Cartwright and A. Zander (Evanston, IL: Peterson & Co., 1960).

19 . L. Wiseman, Multipliers: How the Best Leaders Make Everyone Smarter (New York: Harper Business, 2010).

20 . Bass, Bass Handbook of Leadership.

21 . Bass, Bass Handbook of Leadership.

22 . J. M. Kouzes and B. Z. Posner, Credibility, 2nd ed. (San Francisco: Jossey-Bass, 2011).

23 . http://www.au.af.mil/au/awc/awcgate/usmc/leadership_traits.htm

24 . Hersey et al., Management of Organizational Behavior.

25 . D. Coleman, Working with Emotional Intelligence (New York: Bantam, 1998).

26 . M. Csikszentmihalyi, Creativity (New York: HarperCollins, 1996).

27 . J. Pfeffer, “No Excuses Leadership,” Leader to Leader 46 (Fall 2007): 31–34.

28 . D. Osborne and T. Gaebler, Reinventing Government (Reading, MA: Addison-Wesley, 1992).

29 . D. L. Kauffman Jr., Systems 1: An Introduction to Systems Thinking (Minneapolis: Future Systems, Inc., 1980).

30 . P. M. Senge, The Fifth Discipline: The Art and Practice of the Learning Organization, rev. and updated ed. (New York: Doubleday, 2006).

31 . Senge, The Fifth Discipline.

32 . S. P. Robbins and M. Coulter, Management, 8th ed. (Upper Saddle River, NJ: Prentice-Hall, 2005).

33 . M. Buckingham and C. Coffman, First Break All the Rules (New York: Simon and Schuster, 1999).

34 . M. Buckingham and D. O. Clifton, Now, Discover Your Strengths (New York: The Free Press, 2001).

35 . Buckingham and Coffman, First Break All the Rules.

36 . Buckingham and Clifton, Now, Discover Your Strengths.

37 . T. Rath, Strength Finder 2.0 (New York: Gallup Press, 2007).

38 . C. Coffman and G. Gonzalez-Molina, Follow This Path (New York: Warner Books, 2002).

39 . J. M. Kouzes and B. Z. Posner, Leadership Challenge, 4th ed. (San Francisco: Jossey-Bass, 2007).

40 . T. Rath and D. O. Clifton, How Full Is Your Bucket? (New York: Gallup Books, 2004).

CHAPTER 3

The Interface Between Management and Leadership

A manager is responsible for the application and performance of knowledge.

—Peter Drucker

There is an interesting training exercise called the Human Likert, which has a large group line up along an imaginary continuum.* The general instruction is to decide how each individual defines his or her professional life. On one side of the line are individuals who define themselves as public health practitioners with a major specialty, such as an environmental health professional. In the middle of the line are those who define themselves as managers or administrators, and at the end of the line are those who define themselves as public health leaders. The facilitator then goes down the line asking people why they placed themselves as they did and whether they see themselves as moving along the line as they professionally advance in their chosen public health field. What this exercise does is demonstrate how people view their professional training, their personal definitions of management, and what they perceive as leadership. In a recent use of the Human Likert by me, one individual who defined himself as an environmental health professional said that he wanted to become an expert in his chosen field. He saw this as a demonstration of leadership without a specific designated leadership position in his organization. Those in the management position also saw that leadership could be demonstrated in a management position as well. Thus, it is possible to move horizontally as well as vertically in an organization. Horizontally, you advance by becoming the best public health practitioner that you can or the best manager or the best leader. If you want to move to a higher administrative position in your organization—a vertical move—it is necessary to move in the direction of your strengths rather than your weaknesses.1 What the Human Likert exercise teaches the participants is that practitioners develop expertise in their disciplinary specialty; managers maintain the organization and develop people; and leaders define the system, build relationships, and create visions for the future.

This chapter explores the connections between management and leadership. The following section examines the management issues and is followed by an example of matrix forms of organization that was tried by the Centers for Disease Control and Prevention (CDC) through its goals management initiative in the Gerberding administration (2002–2008). This is followed by a discussion of the starfish organizational model. Next is a discussion of some of the connections between management and leadership with a discussion of transactional and transformational leadership. A discussion of meta-leadership is then presented as one way to look at the interface between management and leadership. The final section of the chapter presents a road map that begins to demonstrate how these management and leadership functions interrelate.

MANAGERS AND MANAGEMENT

There are clear distinctions between managers and leaders. Managers are tied to the present and to the mission of the agencies they serve. Leaders tend to be less bound by their home agencies or their positions, although they need to be concerned about their vision for the agency and the support of the individuals who work in the agency to move the agency forward into the future. Leaders in public agencies allocate much of their time to building relationships with external stakeholders in the public health enterprise.2 Although both managers and leaders tend to be tied to a specific agency position, the manager seems to be more locked into the requirements of the job than the leader does. Leaders are more oriented to their vision and the overall public health system, whereas the manager needs to concentrate on making the agency effective and efficient. The effective manager makes the dreams and visions of the leader real.

Another reality is that a specific individual may be hired into an administrative position (management) and be expected to carry out both management and leadership activities. This may not always be an easy task. People are different, and they view the world in different ways. Browning has pointed out that people have different thinking attributes.3 There are people who tend to be linear thinkers and are intrigued with rules, regulations, and protocols. They are structured in the way they do things. They tend to be organized and to resist change. These structured thinkers can be contrasted with people who tend to be analytical in their thinking. These are the problem solvers who are very logical and like abstract thinking. They like to put facts and numbers together. If we extend this structural and analytical thinking to the organizational level, we are probably talking about many governmental agencies that like process, analyze facts, follow rules and protocols, and tend to support a status quo perspective. Many managers tend to fall into this classification of structural and analytical.

Browning stated that there are two other major thinking preferences. There are the conceptual thinkers who tend to want to view the big picture. They like change and tend to stir things up. For example, you think that you have the last draft of a technical report, and the conceptual thinker will ask if you have thought about solution X. Conceptual people tend to be creative and look at new ways to achieve their visions and goals. The fourth thinking attribute is social. Those strong in this thinking preference tend to like to work in teams and show great concern for others. They tend to be empathic. Some literature has pointed out that managers need to have strong people skills in today’s environment.4 Managers have to be able to fit people’s talents into appropriate jobs that fit the needs of the organization.5 The Browning Emergenetics Model can be seen graphically in Figure 3-1 , where the analytical and structural half of the diagram represents left-brain thinking, and the conceptual and social half represents right-brain thinking.6 Most people will show preference in more than one thinking attribute. All sorts of combinations are possible, from strong preference in one, two, three, or four thinking attributes. However, the thinking preferences of an individual are filtered and affected by their behavioral attributes of expressiveness, assertiveness, and flexibility.

Management takes place in the context of an agency or an organization. In 1916, Fayol defined the five elements of management as prevoyance (planning), organizing, commanding, coordinating, and controlling.7 Planning involves a series of actions to achieve organizational goals. Organizing involves the assignment of tasks to employees, fitting assignments into the existing hierarchical structure of the organization, and tying organizational goals to these work processes. Commanding is about leadership inside the organization. Some writers discuss the issues of employee productivity, turnover and absenteeism, job satisfaction, and other human capital issues for this function.8 Wagner and Harter of the Gallup Organization strongly argue for following a 12-step model for engaging employees that will be the orientation of great managers.9 Part of the motivation of employees involves the leaders in the organization sharing their vision with the managers. The coordinating and controlling elements involve the necessity for the manager to monitor activities of the agency and make corrections and realignments as necessary. Drucker defined the three tasks of management as determining the mission of the organization, creating a work environment that is productive and leads to worker achievement, and recognizing the social impact and social responsibility of the organization’s activities.10 It is interesting to note here that businesses as well as governmental public health agencies have a social impact and social responsibility dimension that for public health is related to the philosophy of social justice.

FIGURE 3-1 Your Thinking Attributes. Source: Reprinted with permission from G. Browning, Emergenetics (New York: HarperCollins, 2006). With permission of the author.

Fayol also developed a 14-principle guide for management that is as relevant today as it was when he formulated it early in the 20th century.11 As can be seen in Table 3-1 , the 14 principles cover all aspects of an organization’s management, from a division of work to the creation of a positive environment in which people may work. A clarification regarding management needs to be made. Management activities will differ at different levels of the organization. Robbins and Coulter point out that technical skills will be necessary at the program level of the organization, with people skills becoming more important as you move up horizontally in the organization.12 Conceptual skills become critical for the top managers and leaders in the organization. The leaders create change.

TABLE 3-1 Henri Fayol’s 14 Principles of Management

1. Division of work (specialization)

2. Authority

3. Discipline

4. Unity of command (one supervisor)

5. Unity of direction

6. Subordination of individual interest

7. Remuneration

8. Centralization (or decentralization)

9. Scalar chain (organizational hierarchy)

10. Order

11. Equity

12. Stability of tenure of personnel

13. Initiative

14. Esprit de corps

Source: Data from Fayol, General and Industrial Management (Paris: Dunod, 1916).

Administrators of state or local public health agencies or offices are generally appointed by elected officials or by local boards of health. New public health administrators tend to be seen as political appointees. These appointments to so-called leadership positions are in reality perceived to be high-level management positions. The job of these appointees is to manage the official public health agency. The new administrators face all types of organizational challenges during the early part of their tenure. As they accommodate to their new positions, demands from external community stakeholders need to be addressed. As community issues take precedence, the administrator may need to delegate managerial responsibilities to other people in the department.

Working in government is not the same as working in business. It is not that the tools or skills necessary to work in these two sectors are very different, but rather that the public health leader needs to adapt these tools and skills to the public sector. There are at least four challenges for leaders who work in the public sector:13

1. The public sector administrator has to work within the framework of laws, rules, regulations, and procedures defined by governmental entities. These laws, rules, regulations, and procedures put limits and restrictions on the public agency executive, which can affect mission, vision, performance, and progress at addressing public health issues.

2. The performance of the agency is extremely visible to the outside world through legislative oversight and media scrutiny. Moore has stated that performance is affected by the challenge of creating public value for public sector issues.14

3. The internal and external stakeholders that are affected by the work of public agencies are more numerous and representative of diverse value perspectives than in the business world. Each stakeholder has unique issues. There are multiple and diverse demands and levels of influence on the work of the agency.

4. The realities of bureaucracy often impede or delay the ability of administrators to carry out the public’s work in an effective, efficient, and timely manner.

Even though we live in a democratic society, people who work in government often seem to feel limited in their ability to move their agency agendas forward because of external scrutiny as well as political agendas.

It is incorrect to assume that all agencies are the same. Different agencies require different types of administrators to address these differences. There are at least five different organizational settings for the new administrator. Daly and Watkins define these settings as a startup situation, turnaround, realignment or shift in priorities, accelerated growth, and maintaining a successful organizational strategy.15,16 In startup and turnaround situations, the new administrator needs to make changes quickly and does not have the leisure to learn about the organization and its staff, as in realignment and success-sustaining situations. Accelerated growth refers to organizations going through a major growth spurt. Exercise 3-1 will allow the class or training group to experiment with Daly and Watkins’s five organizational settings, utilizing a public health scenario.

During 2007, the National Association of County and City Health Officials (NACCHO) undertook a process of developing a plan for a new local health official orientation program (now called the Survive and Thrive Program). In concert with a NACCHO committee, the staff of the association began an interactive process of developing this program. The committee, NACCHO staff, and curriculum design consultants developed the curriculum.17 It became clear early that the program needed to be strong on management issues because the committee, composed of several seasoned health administrators, strongly argued that new administrators needed to spend time on management issues. Five specific competency expectations for new health officials were determined.18 New health officials should:

1. Clearly describe to their staff and variety of public audiences the roles and responsibilities of the new administrator within local health departments (LHDs) and the LHD’s roles and responsibilities within the local health system.

2. Effectively engage elected officials, governing boards, and the state health department in carrying out the roles and responsibilities of the LHDs.

3. Effectively manage their LHDs, including providing insight and direction of strategic planning and the agency’s human, financial, and information resources.

Leadership Tips

Treat your board members as supporters and not enemies.

4. Effectively engage community partners in developing local public health systems for community health improvement and community preparedness initiatives.

5. Rapidly access peer and coaching resources that may assist in developing leadership skills for addressing and resolving problems and issues that challenge local health officials.

Competency 3 clearly involves management competencies. Competencies 1 and 2 require both management and leadership activities. Competencies 4 and 5 are leadership competencies. What this means is that public health administrators have to do both management and leadership activities to carry out their jobs effectively. The cautionary consideration is that some people are great managers and some are great leaders. Bringing the two sets of talents and skills together may not always be possible.

It is clear that public health needs both excellent managers and excellent leaders. In order to address the management domain, the University of North Carolina School of Public Health and the Kenan-Flagler Business School have developed a model training program for managers. The Management Academy was created to develop teams of health professionals to address management challenges in community health.19 The training curriculum helps individuals to improve their management skills, work in small groups on interactive management exercises, transfer new skills into action, build teams, create networks, and learn how to develop business plans. The curriculum includes information on managing people, business planning, human resources development, financial management, civic entrepreneurship, marketing, communication, partnerships, negotiation, program implementation, and team building. Steve Orton, director of the Management Academy, answers the public health practice quiz in Case Study 3-A.

Case Study 3-A

A Public Health Practice Quiz for Steve Orton

1. What types of management training do public health professionals need?

Public health professionals have widely varied skills and backgrounds, so individuals have different needs. Public health work does seem to present some specific challenges, though—and I believe that the current environment creates some challenges for managers across the board.

For public health, I think managers need training that builds skills in managing teams, because so much of the high-yield work they do involves convening teams, bridging differences, translating across disciplines and/or organizations, and sustaining effort (often without positional authority).

They need training in managing money, because so few of them have a background in finance. We have done pre-course assessments in the Management Academy for many years: too many public health managers have no confidence in their abilities to read a spreadsheet, create a budget, calculate a break-even point for a program, or understand the financial reports for the programs they manage. Few managers have taken finance in school, even those with MPH preparation. And few public health organizations have a culture of attending to finances, so managers don’t have to learn money management to succeed. External pressures are building, though—I think many managers now feel the need to develop finance skills.

Managers generally, not just in public health, need training that they can quickly translate into practice. I see a need for training in managing people effectively, so that they are engaged and committed and well deployed.

Clearly, in each of these areas, it isn’t sufficient to read the book or listen to the lecture about the topic: these are skills. It isn’t even sufficient to have the individual ability, because in these areas the “competence” is in some sense collective: teamwide, organization-wide, even community-wide.

2. How do we evaluate the effectiveness of this type of training?

Very carefully. I think that evaluating management training for professionals should make sure the process is working (and constantly improving), and should also seek measures of impact on behaviors and ultimately organizations, where management gets enacted. Training transfer to the workplace should always be the goal.

My own experience with this process convinces me that evaluation, and evaluators, should be integrated into design and quality improvement. Don’t expect to determine effectiveness by hiring an evaluator after the program runs.

I say “very carefully” because I worry that some people have unrealistic expectations of what an educational intervention can accomplish, when so many forces act on organizations and communities. But I also worry that other people have such low expectations.

3. How is management training different from leadership training?

Short answer: leadership training is big-picture; management training is nuts-and-bolts. At UNC, this is how we differentiate our leadership and management programs in executive education. For instance, leadership communication is about message mapping and media skills. Management communication is about communicating in a work team, writing e-mails, or crafting a good PowerPoint presentation.

4. How do we create an interface between management and leadership training?

Education is not inoculation. Workforce development isn’t a one-time shot; it’s an individual and organizational commitment to keep learning. The best leaders, and the best organizations, are seeking out training continually, assessing themselves, strategizing, learning new skills, practicing, stretching, staying fresh. Personally, I think the individuals and organizations that get that are already doing a good job of integrating learning from lots of different sources.

The challenge for producers of training is to stay in touch with the needs of the audience to keep training relevant. The integration, ultimately, happens at the consumer level—so those of us funding or implementing training programs need to stay tuned in.

5. What is the next level of management training for public health professionals?

I think there is plenty of need for manager development at the current level! To me, the “next level” would be to have many more public health managers developing new skills. Systemwide, we have plenty to do to make sure managers have reasons and resources to develop themselves in relevant areas.

MATRIX ORGAN IZATIONSIN PUBLIC HEALTH

In recent years, there have been discussions about the difficulties of working in traditional hierarchical organizations. The concept of a silo has been used to reflect what goes on in vertical organizations when programmatic units become insulated from other programs in an organization or agency. There have also been discussions about changes in the way work is done in the public sector. Goldsmith and Eggers have discussed these issues in a governance by network model.20 We are seeing the rise of third-party government where we contract with private firms and nonprofit organizations to do the work of government. There are also joined-up government activities where partnerships are created between two or more governmental entities to provide an integrated approach to delivering public programs. Changes in technology are also affecting our work relations in that it is possible to work on common projects from great distances using the Internet. Friedman described this process as evidence of a flattening world.21 Goldsmith and Eggers also described consumer demand and the possibilities of customized service models in the future. Governmental employees involved in these new initiatives will find that the way they work will change. Instead of supervising employees in the agency, these new managers will find themselves managing portfolios of projects being done outside their home agency.

Leadership Tip

Without trust, leaders often fail.

With these changes possible, it becomes necessary to change our agencies as well. One model builds on the matrix form of management with the goal of leveling the organization to be more project or goal focused with techniques for coordinating activities across projects. Robbins and Coulter have defined a horizontal matrix structure as a form of organizational model involving program specialists from various functional units in an organization to work on a multidisciplinary team to carry out a project-or goal-based program.22 Figure 3-2 graphically shows a sample matrix structure model. The model labels each unit as a portfolio to reflect that the project or goal approach will allow the individual unit to manage all parts of a project or projects related to the unit program. The role of the steering committee is to be a group that includes a representative of each project or goal unit to supervise the whole project and to prioritize all the projects and goals of the organization.23 The steering committee can also be the manager of the overall strategic plan of the organization.

FIGURE 3-2 Mapping the Horizontal in Matrix Structure: Overall Strategic Plan.

On the positive side, this organizational model is flexible and allows for projects and goals to be added or subtracted as appropriate. This model also allows new projects to draw on the talents and strengths of people in the agency who will help benefit a specific project. Each unit staff also requires that both management and leadership processes happen. Creativity in the developing of new projects or subprojects will also be encouraged.

There are also difficulties with the design. First, the matrix model is often superimposed on a traditional vertical organization. What this does is complicate the processes and work of the organization. On the one hand, the programmatic silos continue to exist at the same time as the matrix units are developed. The challenge then becomes how to have the silo teams buy into the matrix units’ projects and goals. Marketing within the organization needs to be done to support the matrix structures.

There may also be control and communication difficulties with the model as well as resistance to the design by the established vertical organization. Some staff of the agency sometimes believe that they have two bosses and have to report to their silo supervisor as well as the team leader of the matrix unit. There is also the issue of power and the difficulty to share power. Credibility and trust issues also have to be addressed. There are possible methods for addressing some of these silo concerns. Lencioni has delineated a four-part model for this.24 The model, if addressed early, may prevent some of the resistance to a project-or goal-based horizontal matrix model. There needs to be a clear vision for the agency that is shared by all of the silo directors serving as a leadership team for the agency. Agency goals also need to be determined. These goals are then translated into clearly defined objectives or projects that can evolve into matrix units around these objectives or projects. These objectives then need to be aligned to standard operational requirements. Finally, there needs to be a methodology for measuring the results of the agency’s activities and programs.

TABLE 3-2 Management and Leadership Outputs

Goals aligned with customers and partners

Processes aligned with customers

Capacity in line with the strategic plan

Resources deployed effectively

Performance improvement implemented as needed

Create standards and use common methodologies

Develop teams that produce results

Promote organizational learning

Collaborative leadership

Creation of an innovative portfolio

Shared leadership

High-performing teams

Working inside the organization and with external partners

Source: Courtesy of The New Matrix Management, P. Martin, Cincinnati, OH: Martin Training Associates, 2005.

There are both management and leadership outputs from matrix structures. Table 3-2 , which is adapted from the work of Paula Martin, shows these outputs.25 The CDC provides us with an intriguing variation of the matrix model in its reorganization and goals development program. The next section will look at the CDC Health Protection Goals agenda during the Gerberding administration as an example of the application of a modified matrix management program.

CDC Futures Initiative

Dr. Julie Gerberding, director of the CDC from 2002 to 2008, announced in June 2003 the start of a Futures Initiative to restructure the CDC, prioritize its strategies for the 21st century, revamp its programs, and determine resources and needs.26 CDC professionals assigned to the Futures group collected information from CDC partners and customers. An extensive review was made of the agency’s performance, organization, and operations. From all these deliberations, six strategic directions were formulated for the agency:

1. Health Impact Focus

2. Customer-Centricity

3. Public Health Research

4. Leadership

5. Global Health Impact

6. Accountability

Dr. Gerberding and her leadership team said that it was necessary for the CDC to address the many new health and safety challenges for the 21st century in the United States and globally. These activities began with a project called the Futures Initiative. The major determination was to develop a management and strategic plan for the agency that would address many of these concerns. Gerberding had to sell the plan at a national level as well as at the agency level before many of the details of the initiative could be implemented.

There were two major changes that came about as a result of the Futures Initiative. The first was a major restructuring of the agency in April 2005 in an attempt to break down the silo model that had existed for a number of years and decrease the number of programs that reported directly to the CDC director. The second change involved the development of a number of health protection goals that would provide the direction for the CDC’s work in the future. Ideally, these two changes would become integrated in a holistic manner. The new structure designated eight national centers:

1. Environmental Health

2. Injury Prevention

3. Global Health

4. Health Promotion

5. Infectious Diseases

6. Public Health Information, Health Marketing, and Health Statistics

7. Terrorism Preparedness and Emergency Response

8. Workplace Health and Safety

These national centers had a number of programmatic divisions with their own financial resources. These divisions had their own directors and tended to be resistant to many of the changes within the CDC. As can be seen in Figure 3-3 , there were six coordinating centers and the National Institute for Occupational Safety and Health. The directors of these coordinating centers were supposed to work together to provide direction to the activities of the agency as well as provide mechanisms for the implementation of the CDC Health Protection Goals.

The Coordinating Center for Environmental Health and Injury Prevention included the National Center for Environmental Health and the National Center for Injury Prevention and Control. The Coordinating Office for Global Health included all global health initiatives. The Coordinating Center for Health Promotion included the National Center on Birth Defects and Developmental Disabilities, the National Center for Chronic Disease Prevention and Health Promotion, and the Office of Genomics and Disease Prevention. The Coordinating Center for Infectious Diseases included the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention; the National Center for Immunization and Respiratory Diseases; the National Center for Zoonotic, Vector-Borne, and Enteric Diseases; and the National Center for Preparedness, Detection, and Control of Infectious Diseases. The Coordinating Center for Health Information and Service included the National Center for Health Marketing, the National Center for Health Statistics, and the National Center for Public Health Information. The Coordinating Office for Terrorism Preparedness and Emergency Response covered the preparedness initiatives for the CDC. The National Institute for Occupational Safety and Health covered the programs related to workplace safety and health. As pointed out, the national centers, with their individual directors and the divisions within centers, were to work horizontally with each other (modified matrix model) as well as vertically with their coordinating centers (a silo model). The National Centers have a leadership committee but not a steering committee, which is more traditional in matrix systems.

In addition to the coordinating centers, there were a number of offices tied to the director of the CDC. These offices include:

1. Office of the Chief Science Officer

2. Office of Chief of Public Health Practice

3. Office of Chief Operating Officer

4. CDC Washington Office

5. Office of Strategy and Innovation

6. Office of Workforce and Career Development

7. Office of Enterprise Communication

8. Office of Chief of Staff

9. Office of Dispute Resolution and Equal Employment Opportunity

FIGURE 3-3 CDC Organizational Chart (2007). Source: Reproduced from the Centers for Disease Control and Prevention (2007). CDC Office for Enterprise Communications: Organizational Chart and CDC Structure under Julie Geberding.

The advantage of this new structural model was that it better programmatically represents the real program emphases of the agency as a whole. It also cut down the number of direct reports to the CDC director.

Structurally, the new organization was extremely complex. It did not do away with silos. In fact, it created silos within silos and several different matrices as well. It became structurally hard to maintain over time. The leaders at the top provided general management oversight to the agency as a whole, but communication throughout the new system was difficult in an agency oriented to both science and practice. The top leadership was insulated from the divisions in the national centers, which were embedded within the coordinating centers and affected morale and commitment to both the agency leadership and the goals and objectives of the agency programs. Each coordinating center and its national centers had the potential for creating all the negatives of a silo-based organization. Good management was definitely possible at the program level even though it is difficult for CDC leadership to get a grasp of all the activities in which the agency is engaged. Wagner and Harter stated that employees need to know what is expected of them at work.27 The CDC structure limited communication to the front lines of the organization. There were now so many different organizational levels with managers at each level that many professionals felt removed from the decision-making activities of the agency. This could be observed by visiting and reading the entries on the blog site called CDC Chatter.28 The site was closed down in 2010. However, it becomes critical for meta-leadership techniques to be utilized in complex organizations that will help alleviate the frustrations tied to communication difficulties. Meta-leadership concepts will be introduced later in this chapter.

The second product of the CDC had been the development of health protection goals for the future. There were four major overarching goals for these now 14 strategic goals. Table 3-3 lists the overarching and strategic goals. Two of the overarching goals became Strategic Goals 13 and 14. At an organization level, a determination was made to create a goals action team for each of the major goals. A matrix approach was taken. A goals team leader was recruited from other organizational units within the CDC, and team members were also selected. Thus, another level of organization was created, which led to a second matrix structure within the agency. Each goals team leader and team were responsible to a steering committee. Team members were responsible to the goals leader and the supervisor from the units in which they worked. Each goals team had the responsibility for the development of an action plan for its goal. These plans were reviewed from November 2007 into 2008. The alignment of the goals to budget was to occur in 2008.

This CDC example represents the difficulty in changing a major governmental agency. Daly and Watkins would call this reorganization a turnaround model with the need for a strong leader who would need to utilize a command and control approach to create the changes necessary.29 The director of the agency clearly had a vision for the future of the agency that is creative and innovative. She supported the organizational changes that she thought would do away with the silos of the past. She met with external stakeholders to explain the plan and gain their support. She assigned the new Office of Strategy and Innovation with the development of protocols to make the plan work. The reorganization was done, but new silos and several matrix structures came into being. The professional staff, including many researchers within divisions, resisted the changes and argued that the new organization did not reflect the work that needed to be done or the work in which they were engaged.

TABLE 3-3 Centers for Disease Control and Prevention Health Protection and Strategic Goals

Overarching Goal 1: Healthy people in every stage of life

Strategic Goal 1: Start strong (0–3 years)

Strategic Goal 2: Grow safe and strong (4–11 years)

Strategic Goal 3: Achieve healthy independence (12–19 years)

Strategic Goal 4: Live a healthy, productive, and satisfying life (adults, 20–49 years)

Strategic Goal 5: Live better longer (ages 50 and over)

Overarching Goal 2: Healthy people in healthy places

Strategic Goal 6: Healthy communities

Strategic Goal 7: Healthy homes

Strategic Goal 8: Healthy schools

Strategic Goal 9: Healthy workplaces

Strategic Goal 10: Healthy healthcare settings

Strategic Goal 11: Healthy institutions

Strategic Goal 12: Healthy travel and recreation

Overarching Goal 3: People prepared for emerging health threats (Strategic Goal 13)

Overarching Goal 4: Healthy people in a healthy world (Strategic Goal 14)

Source: Reproduced from the Centers for Disease Control and Prevention (2007). CDC Health Protection Goals and Strategic Goals under Julie Geberding.

The new organizational structure was seen as overly complex, with elements of traditional bureaucratic hierarchies still in place as well as matrix structures that were superimposed on the organization. Changes like those that had been made do not occur overnight. There was cultural change going on. Both leadership and management relationships needed clarification. Different scenarios can be tested. Exercise 3-2 will help you experiment with different options for change that might expedite the process. From 2008 to 2012, Dr. Thomas Frieden, the successor to Dr. Gerberding, dismantled the Gerberding structure and replaced it with a new one that is in many ways as complex as its predecessor model, with several offices that replace the coordinating centers and also the continuation of a number of national centers. The deputy director of each office reports to the CDC director.

STARFISH ORGANIZATIONS IN PUBLIC HEALTH

In traditional organizations, an organization dies if its major reason for existence is gone. Brafman and Beckstrom use the analogy of a spider when you cut off its head.30 However, when you cut off one of the limbs of a starfish, it grows a new limb. The starfish model is an example of a completely decentralized organization where no specific person is in charge. Rather, all the participants share in the leadership of the organization. Offices may exist in different places, depending on the project, which means that information and knowledge management may also be decentralized. Power is also distributed. Funding is mostly project or program based. Roles and responsibilities change as projects diversify. All people are equal in the core. Decisions about the organization as a whole are made by all participants as core members of the organization. Individuals may be hired for a specific project or program and leave when the project is over.

Figure 3-4 graphically shows the starfish model. Some public health academic units, like research, academic, or satellite agency centers, may use this organizational model. The core leadership group may be a group of researchers with a common multidisciplinary research perspective like public health systems research or center for public health practice. Because the center is probably funded primarily through grants and contracts, each limb represents one of these projects. The staff of the project includes several core researchers, academics, or practitioners and staff funded by the grant or contract. When the project is over, project staff leave or move to another project. The core staff stay and look for new grants or contracts.

FIGURE 3-4 Starfish Organizational Model. Source: Adapted from O. Brafman and R. A. Beckstrom, The Starfish and the Spider (New York: Portfolio Books, 2007).

For a comparison of the different public health organizational models presented, Table 3-4 shows the differences in the traditional hierarchy, a transitional model not presented specifically above, the matrix model, and the starfish model. Structurally, we have looked at these models from centralized to decentralized. More centralized organizations tend to be focused operationally in more of a linear way than a systems way. The more decentralized, the more systems-based or complexity oriented. Hierarchical organizations tend to be more authoritarian and tend to move toward being more democratic as the organization begins to move toward fewer organizational levels in a transition from hierarchy to matrix. The management focus tends to concentrate on the organization and less on the people. People management becomes more important in the transition model and the other decentralized models.

TABLE 3-4 Comparison of Several Organizational Issues in Public Health

TRANSACTIONAL AND TRANSFORMATIONAL LEADERSHIP

The CDC example above demonstrates how the line between what is leadership and what is management often becomes blurred. This relationship becomes even more complicated when we look at the issue of transactional leadership and transformational leadership, where the management role seems to vanish altogether. Most discussions about leadership concern vision and change. Burns has pointed out that leadership is about reciprocity.31

Through the development of relationships between partners with varying perspectives on values and motivation, the partners are often in conflict and competition in relation to the overarching goals, which should bring the leaders together to realize their goals and to work together to reach these goals. Moreover, these goals are influenced by the realities of the environment or communities in which these leaders come together.

Burns defined two critical types of leadership: transactional and transformational.32 The transactional leader engages others in the reciprocal activity of exchanging one thing for another. Most management and leadership activities are related to the exchange of one thing for another. Transformational leadership examines and searches for the needs and motives of others while seeking a higher agenda of needs. Transformational relationships are intense and raise the participants to a higher level of mutuality and morality so that the interaction between leaders or between leaders and followers changes both parties. From these definitions, it can be argued that both transactional and transformational skills are important for leaders. They are complementary types of skill. Transformational leadership demands higher-level negotiation activities and will lead to change at both the organization and systems levels.

The attempt to put the concept of transactional leadership into action has led to a reinterpretation of this type of leadership to be a reconceptualization of management. The exchange of work for various types of rewards seems tied to the organization where there is an attempt to maintain the stability of the organization. Transformational leadership seems to be more about change. Table 3-5 demonstrates how these two leadership concepts are viewed today and also puts managers in the leadership camp.33 In recognizing that public health leaders need to transform the public health system in which they work and also change the understanding and commitment to the work of public health with their internal and external partners, the National Public Health Leadership Development Network had to define the characteristics and competencies of a transformational leader.34 The three major activities of the public health transformational leader involve the skills necessary to engage in the development of mission and vision as well as the development of skills related to monitoring and facilitating the process of change.

In order to begin to clarify distinctions between management and leadership, it is possible to begin this dialogue by creating a continuum from management to leadership. Figure 3-5 does this by putting management at the left side of the continuum and covering traditional management processes. Transactional leadership is at the center of the continuum and blends traditional management with the reciprocity concerns discussed by the Gallup Organization in its look at great managers. It is with transactional leadership that we can begin to see the interface between management and leadership. Transformational leadership and its change and vision agenda are on the extreme right side of the continuum. Most leaders need to have both transactional and transformational talents and skills.

TABLE 3-5 Transactional vs. Transformational Leadership: Differences Between Managing and Leading

	Transactional Leadership or Management Skills	Transformational Leadership or Leadership Skills
Performance:	Considered by leadership writers to produce ordinary performance	Considered by leadership writers to produce extraordinary performance
Goal:	To maintain the status quo by playing within the rules	To change the status quo by changing the rules
Goals arise out of:	Necessity, are reactive, and respond to ideas; they are deeply imbedded in the organization’s history and culture	Desires; they are active, shaping ideas; may be a departure from organization’s history and culture
Emphasis:	Rationality and control, limits choices, focuses on solving problems	Innovation, creativity to develop fresh approaches to long-standing problems, and open issues to new options
Attitudes toward goals:	Impersonal, if not passive, attitude	Personal and active attitude
Incentives:	Based on exchange of needs (i.e., “tit for tat”)	Based on the greater good
Locus of reward:	Maximize personal benefits	Optimize systemic benefits
Requires:	Persistence, tough-mindedness, hard work, intelligence, analytical ability, tolerance, and goodwill	Genius and heroism
View work as:	Enabling processes, ideas, and people to establish strategies and make decisions	Creative, energizing, and emerging
Tactics employed:	Negotiate and bargain, use of rewards, punishment, and other forms of coercion Strive to convert win-lose into win-win situations as part of the process of reconciling differences among people and maintaining balances of power	Inspire followers, create shared vision, motivate Strive to create new situations and new directions without regard to reconciling groups or power

Source: Reproduced from Robertson, T. D., Fernandez, C. S. P., and Porter, J. E., “Leadership in Public Health,” in Novick, L. F., Morrow, C. B., and Mays, G. P. (eds.), Public Health Administration, 2nd ed. Sudbury, MA: Jones & Bartlett, 2007.

In order to put this leadership continuum in a clearer perspective, the continuum can be viewed as a leadership change triangle in which change affects the way a leader will function. Two other forms of leadership practice need to be added to the continuum. Managerial leadership is a transitional phase in which the public health professional blends the skills of management with the transactional skills of people development. Strategic leadership blends the needs of making transformational change work strategically in the interface between choosing the right people to help in transformational and systems change. Leaders need to learn when to use their management skills and when to use their various leadership skills. In change, leaders needs to work within their home organizations and externally with their various stakeholders. Transformational and systems change must be translated into action through transactional relationships and eventually to application at the organizational level.

FIGURE 3-5 The Leadership Change Triangle. Source: Reproduced from L. Rowitz (2009, February 3). The Leadership Change Triangle [Web log]. Retrieved from http://rowitzonleadership.wordpress.com/2009/02/. Accessed June 26, 2012.

META-LEADERSHIP—A NEW PERSPECTIVE

In 1990, in the last edition of their now classic textbook, Pickett and Hanlon pointed out that change is inevitable in public health.35 Public health will have to work in new ways. This will require a flexibility that is often missing in governmental organizations. This work will occur in a transorganizational environment where public health leaders will work with partners outside their home agencies. In this new environment, leaders will have to understand the values that drive the different agendas of their partners. It will be necessary to build coalitions and other forms of external alliances and partnerships. Negotiation will be an important element in these new relationships. These transorganizational activities will demonstrate transformational leadership in action.

Meta-leadership is the new terminology for working across organizations. Leaders need to move outside their organizational positions and utilize their talents, knowledge, and transactional and transformational skills to create new models for collaboration with partners. It requires a systems perspective, an understanding of how values shape action, and risk taking related to initiatives that may in part negatively affect their home organization. Henderson has defined the meta-leader as an individual who is able to connect the purposes, activities, and work of different agencies and organizations and their program components to achieve a greater good at the systems level.36 Public health requires actions that cross agency boundaries. The meta-leader is able to align the core interests, motivations, and values of different organizations into a new synergistic value orientation (meta-values) that will create an integrated vision and set of actions to create change. Marcus and his colleagues have used the word “connectivity” to refer to this process.37

The traditional leader gains power from the position that he or she holds in the organization that he or she represents. This power from the home organization can be called silo power. This power is closely allied to what we called transactional leadership. Meta-leaders need to gain trust, credibility, and power in their external collaborations as well as they demonstrate their transformational leadership skills. There are five dimensions to meta-leadership ( Figure 3-6 ).38 The meta-leadership model was developed to gain a better understanding of how leaders function in crisis. Some event will affect how leaders will function. There may be challenges to defining the event from the vantage point of size and scope, scale, and the substance and understanding of what may have triggered it.

Some of the expected qualities of a leader in crisis include courage, curiosity, imagination, organizational sensibilities, persuasion, conflict management, crisis management, emotional intelligence, and persistence.39 I have included in my discussions of crisis leaders such additional skills as systems and complexity thinking, collaboration skills, concerns for community safety, understanding of health law and ethics, understanding of risk and health communication, ability to determine tipping points and change strategies, and community building.40 Not only do meta-leaders have to be masters of the ability to work within and between organizations, but they also have to be able to influence action inquiries and plans to make the results of the collaborations work in the real world. There may be a need to develop meta-managers as well as meta-leaders.

Leading up has challenges. The meta-leader has to learn how to deal with boards, county commissioners, other elected officials, and subject matter specialists. American public health leaders feel weakest in their policy development and advocacy roles. Henderson has pointed out that all crisis events in the United States are political. In fact, almost all public health decisions also have political implications. When the leader is not successful in advocacy and other political relationships, it can affect the agency in a number of ways. Staff morale may be affected and the trust in the leader may decline as a result. The credibility of many local activities (scientific findings as well as agency decisions) may be questioned. This lack of credibility and trust may make it more difficult to resolve the conflict or crisis in a timely manner. Henderson recommends that meta-leaders manage up one level at a time.

FIGURE 3-6 Dimensions of Meta-Leadership. Source: Reprinted with permission from L. J. Marcus, I. Askenazi, B. Dorn, and J. Henderson.

Leading within the silo is important if followers are going to have trust in their leaders and believe in the vision and strategy formulated by the leader. Gaining input from all staff during the formulation of vision and strategy is important. External stakeholders from the political and nonpolitical realms need to be involved in this process as well. Good managers are needed in the silo to carry out the vision and strategy of the leader through agency operations and execution of strategy through action and through the connection of the strategy to activities of the agency as a whole. Henderson has pointed out that after leadership and management there needs to be a third phase to the process: evaluation. The evaluation phase involves measuring impact, monitoring change, measuring productivity and performance, and ensuring that all public health systems support a continuous quality improvement process.

It is in connectivity that meta-leaders shine. It is their work to connect the purposes and activities of the many organizations with whom they partner for the good of the public health agenda in their communities. Their curiosity and need to explore many creative avenues should affect the process of collaboration. They need to become experts in conflict leadership and how to resolve the differences in ideas that arise. The meta-leader is a risk taker and needs to be able to address the consequences of his or her actions. Meta-leaders also need to be able to determine when their shared goals have been met.

Over time, theories and practice related to a leadership perspective evolve. As a model fans out from its original development site, questions arise and further refinements of the paradigm occur. The important issue in meta-leadership relates to whether connectivity really occurs and whether the results of the collaboration are effective. In addition, when we work across organizations, networks are created. Using some form of social network analysis will help determine how leaders work together in terms of information processing, knowledge management, the resolution of differences, and the social skills of the participants.41 Network analysis will help to determine who the meta-leaders are in the network and how they relate (connect). Second networks are composed of individuals who are interested in the issue or the problem to be addressed. This demonstrates that leaders will be involved in several networks, depending on the issue to be addressed. For example, crisis network membership will differ from non-crisis public health networks. Networks will also be involved in better understanding how a silo functions within an organization. The end result of network analysis is the ability to determine how effective the silo work is and how effective the multi-organization collaboration is working.

THE PUBLIC HEALTH MANAGEMENT AND LEADERSHIP ROAD MAP

Now it is necessary to put the management and leadership puzzle together. By adapting the Gallup Path to the governmental sector and adding the leadership dimension as well, it is possible to develop a public health management and leadership road map such as that shown in Figure 3-7 .42 Because public health has strong roots in the community, it is important to look at the context of public health as the starting point in our understanding of how the work of public health is accomplished. The public health agency becomes the coordinating organization from which to view the public health system and the specific activities of public health. The leader who is engaged is one who is able to work outside the agency with stakeholders from the political realm as well as from other sectors to improve the health of the public. This is meta-leadership in action. This high level of planning, negotiation, and action is tied to the role of the public health administrator leader in the transformational leadership role. The public health leader is often engaged in these activities as a major part of the job of promoting the public’s health. Because of the time-intensive nature of these activities, the leader often has to rely on engaged managers in the agency to carry out the day-to-day activities of the agency itself. In some instances and especially in smaller health departments, the leader may also have to carry out the activities of the manager as well.

The development of the public health workforce within the agency is often the responsibility of management. Following the work of the Gallup Organization on talents, the manager has to be able to identify the talents of workers and fit those talents within the system requirements of the agency and its programs.43 In traditional management jargon, this involves the organizing function of management. The excellent and great managers also have control and coordination responsibilities. These managers also have to engage the agency employees in the work of the agency so that they understand the vision of the agency leadership. The management staff and the engaged employee have to interact on planning and action protocols as well because this is often a team effort.

FIGURE 3-7 Management and Leadership Road Map in Public Health. Source: Adapted from C. Coffman and G. Gonzalez-Molina (2002). Follow This Path. Grand Central Publishing.

As the leader continues to work with external stakeholders, engaged employees get to work with other staff of the engaged stakeholder groups in coalitions and other groups to carry out the specific tasks necessary to help the public improve its health status. If these leadership and management tasks are carried out well, there should be sustainable growth of both the public health agency and its community partners. With this growth, the infrastructure of public health and the public health system as a whole will be strengthened. The outcome of all these activities will be improved health outcomes in the community being served.

SUMMARY

This chapter has addressed the complex relationship between management and leadership. The functions of leaders and managers are clearly different even though it is necessary for leaders and managers to work together. In smaller jurisdictions, public health administrators will have to be both manager and leader. However, this marriage is not an easy one because the role of manager/leader requires multiple sets of skills. The individual may have the talent to carry out one set of skills better than the other. It is important for the individual to understand his or her personal strengths and fit his or her talents to the needs of the organization in its current state of development.

DISCUSSION QUESTIONS

1. What are the differences between management and leadership?

2. Do you think it is possible to be a great manager and a leader at the same time?

3. What are the differences between working in the governmental and business sectors?

4. Distinguish between hierarchy, matrix, and starfish organizations.

5. What are the relationships among traditional management, transactional leadership, and transformational leadership?

6. What is meta-leadership, and why is it an important leadership approach?

7. What are organizational silos, and how can communication between these silos be improved?

8. Give examples of how the public health management and leadership road map might work.

EXERCISE 3-1: Organizational Development and Strategic Health Priorities (Application of Daly and Watkins Model)

Adapted from P. H. Daly and M. Watkins, The First 90 Days in Government (Cambridge, MA: Harvard Business School Publishing, 2006).

Purpose: to see the relationship between the organizational structure of a public health agency and the way it addresses local public health priorities

Key concepts: startup, turnaround, accelerated growth, realignment, success-sustaining perspective, health priorities

Procedure: Scenario: The American County Health Department has been involved in carrying out a community health assessment in its county. American County has come up with four strategic health priorities:

1. Strengthen the public health workforce.

2. Address the needs of those who require public health services.

3. Improve health outcomes for cardiovascular diseases.

4. Create a broader sense of community connectedness.

The class or training group will be divided into four groups of 8 to 10. One group will discuss the problem from the perspective of a startup agency. The second group will address the problem from the perspective of an agency in a turnaround situation. The third group will discuss the scenario from the perspective of a realignment organization. The final group will discuss the priorities from the perspective of a success-sustaining organization. Your task as a leadership team for your county is to determine how to address these priorities when your agency is in one of the four organizational development phases discussed by Daly and Watkins. You have an hour to discuss these issues. Your team will then report to the class or training group as a whole on how you addressed these issues.

EXERCISE 3-2: Scenario Building for the CDC

Purpose: to explore different approaches to organizational development and the CDC Health Protection Goals that might have increased the chance of success for the goals program

Key Concepts: scenario building, organizational restructuring, goals alignment, health protection goals, coordinating centers, silos, leadership, management

Procedure: Utilizing the CDC example in this chapter, divide the training group or class into teams of 8 to 10. Each team is to develop two to three different scenarios for ways to integrate the Health Protection Goals into the CDC structure or to make proposals for the reorganization of the CDC in a more efficient and effective manner to make goals a part of the total CDC organization.

REFERENCES

1. M. Buckingham, Go Put Your Strengths to Work (New York: Free Press, 2007).

2. J. H. Fleming and J. Asplund, Human Sigma (New York: Gallup Press, 2007).

3. G. Browning, Emergenetics (New York: HarperCollins, 2006).

4. C. Cherniss and D. Goleman, The Emotionally Intelligent Workplace (San Francisco: Jossey-Bass, 2001).

5. M. Buckingham and D. O. Clifton, Now, Discover Your Strengths (New York: Free Press, 2001).

6. Browning, Emergenetics.

7. H. Fayol, General and Industrial Management (London: Pittman Publishing, 1949).

8. S. P. Robbins and M. Coulter, Management, 11th ed. (Upper Saddle River, NJ: Prentice-Hall, 2011).

9. R. Wagner and J. K. Harter, 12: The Elements of Great Managing (New York: Gallup Press, 2006).

10. P. F. Drucker, The Essential Drucker (New York: Harper Business, 2001).

11. Fayol, General and Industrial Management.

12. Robbins and Coulter, Management, 11th ed.

13. P. H. Daly and M. Watkins, The First 90 Days in Government (Cambridge, MA: Harvard Business School Publishing, 2006).

14. M. H. Moore, Creating Public Value (Cambridge, MA: Harvard University Press, 1995).

15. Daly and Watkins, The First 90 Days in Government.

16. M. D. Watkins, “Picking the Right Transition Strategy,” Harvard Business Review 87, no. 1(2009): 49–53.

17. B. J. Turnock and L. Rowitz, NACCHO New Local Health Official Orientation Curriculum: Final Design (Washington, DC: National Association of County and City Health Officials, 2007).

18. Turnock and Rowitz, NACCHO New Local Health Official Orientation Curriculum.

19. S. Orton, K. E. Umble, B. Rosen, J. McIver, and A. J. Menkens, “Management Academy for Public Health: Program Design and Critical Success Factors,” Journal of Public Health Management and Practice 12, no. 5 (2006): 409–418.

20. S. Goldsmith and W. D. Eggers, Governing by Network (Washington, DC: Brookings Institution Press, 2004).

21. T. L. Friedman, The World Is Flat (New York: Farrar, Straus, and Giroux, 2006).

22. Robbins and Coulter, Management, 11th ed.

23. P. Martin, Quick Guide: The New Matrix Management (Carmel, NY: Martin Training Associates, 2005).

24. P. Lencioni, Silos, Politics, and Turf Wars (San Francisco: Jossey-Bass, 2006).

25. Martin, Quick Guide: The New Matrix Management.

26. http://www.cdc.gov

27. Wagner and Harter, 12: The Elements of Great Managing.

28. http://cdcchatter.net

29. Daly and Watkins, The First 90 Days in Government.

30. O. Brafman and R. A. Beckstrom. The Starfish and the Spider (New York: Portfolio Books, 2007).

31. J. MacGregor Burns, Leadership (New York: Harper and Row, 1978).

32. Burns, Leadership.

33. T. D. Robertson, C. S. P. Fernandez, and J. E. Porter, “Leadership in Public Health,” in L. E. Novick, C. B. Morrow, and G. P. Mays (eds.), Public Health Administration, 2nd ed. (Sudbury, MA: Jones & Bartlett, 2007).

34. K.S. Wright, L. Rowitz, A. Merkle, et al., “Competency Development in Public Health Leadership,” American Journal of Public Health 90 (August 2000): 1202–1207.

35. G. Pickett and J. J. Hanlon, Public Health: Administration and Practice, 9th ed. (St. Louis: Times Mirror/Mosby College Publishing, 1990).

36. J. M. Henderson, Meta-Leadership and the Challenge for Public Health (talk) (Raleigh: North Carolina State Health Director’s Conference, 2007).

37. L. J. Marcus, B. C. Dorn, and J. M. Henderson, Meta-Leadership and National Emergency Preparedness (Cambridge, MA: Harvard Center for Public Leadership Working Papers, 2005).

38. Henderson, Meta-Leadership and the Challenge for Public Health.

39. L. Rowitz, Public Health in the 21st Century: The Prepared Leader (Sudbury, MA: Jones & Bartlett, 2006).

40. Henderson, Meta-Leadership and the Challenge for Public Health.

41. R. Cross and A. Parker, The Hidden Power of Social Networks (Boston: Harvard Business School Press, 2004).

42. C. Coffman and G. Gonzalez-Molina, Follow This Path (New York: Warner Business Books, 2002).

43. Buckingham and Clifton, Now, Discover Your Strengths.

*I learned this exercise from Dr. Magda Peck of the University of Wisconsin-Milwaukee as she did this exercise before a maternal and child health leadership group.

CHAPTER 4

A Systems and Complexity Perspective

Life was simple before World War II. After that, we had systems.

—G. Hopper

All types of health-related events have effects on the community, whether the event affects one organization in the community or many organizations or residents of the community. The prepared public health leader knows that an event, whether a crisis or a non-crisis one, is the community’s business and that the event needs to be addressed from the vantage point of the community. It is for this reason that systems thinking skills are so critical for successful leadership. To be a systems thinker, a leader needs to see and talk about situations in a way that helps others to better understand and carry out activities within organizations and agencies that affect the lives of people who live in the community. A prepared public health leader must see the big picture. An interesting demonstration of the complexities involved in the issue of infectious disease outbreaks related to monkeypox can be seen in Case Study 4-A. It demonstrates the systemic aspects of disease and the importance of knowing global disease trends and their potential applications at the local level. What happens in one part of the world can affect other parts of the world very quickly.

This case not only points out the issue of systems analysis but also shows the importance of collaboration at a local level in addressing the threats associated with the outbreaks of infectious disease. This latter point is extremely important because the importance of collaboration to bring about change is not directly addressed by writers in the discussion of systems thinking approaches. The systems approach becomes problematic because the systems thinker is often at odds with others within the home organization or with partners who do not think in a systems way. In addition, the tools of systems do not take into account the collaborative nature of social relationships. It is the social relationships within an organization or community that are the most important. The structure of the system is less important. If it is people who create the system, then the system will be fluid and ever changing. In actuality, people do create social structures and do collaborate, but the social structure and cultural norms and rules that guide action also are affected. The leadership challenge relates to the necessity of the leader working with his collaborators to use a systems framework to better understand problems so that the solutions become more comprehensive and more likely to work to improve the functioning of the community. To paraphrase an old popular song, the system and partners need to go together “like a horse and carriage.”

Case Study 4-A

Monkey on Our Backs: Identifying and Containing an Outbreak of Monkeypox on a Regional Basis

Douglas Beardsley, MPH; Christine Borys, BSN, MPH; Cheryl Lee, BA, MS; Jean McMahon, MS, BSN; Heather Miller, BS; Larry Swacina, MS

Introduction

In the spring of 2003, it was discovered that prairie dogs originating from a pet distributor became infected with monkeypox (MP). The infected prairie dogs had been sold directly to distributors who in turn sold them to consumers in several neighboring states. Communicable disease personnel at various local health departments and the state department of public health began contacting pet owners to investigate possible MP cases in humans. Personnel from the state’s department of agriculture and investigators from the Centers for Disease Control and Prevention were also involved in the investigation. Because this was the first time that MP had been seen in the Western Hemisphere, staff at all levels had many questions and came to the situation with a great deal of zeal and energy. All persons involved made every effort to be thorough, but this had the unintended effect of creating redundancy, uncoordinated effort, and lack of information sharing. As investigators worked with family members of infected individuals, they found that one investigator was leaving through the side door as another was coming in the front door. Pieces of information known to one agency, which potentially could have been critically important to the human investigation, had to be accidentally discovered at a later time by personnel from another agency. Fortunately, all of the persons exposed to MP made a full recovery, and the cases were not widespread.

This case study will examine the events leading up to the incidents of human cases of MP and the events surrounding the investigation, containment, and remediation of the cases. The case will present policy questions surrounding legal authority to act, when to seek legal counsel, coordinating the activities within and between agencies, and developing incident command and unified command approaches as applied to public health investigations.

The focus of this case study is to address the core function of policy development. According to the three core functions, this case study will explore the need for developing policy to address the steps needed to take action when a public health emergency arises that needs immediate and effective response.

Introduction and Background

Even before the catastrophic events of September 11, 2001, public health began to recognize the need for emergency preparedness plans related to potential bioterrorism events. For many state and local health departments, emergency preparedness and planning were neglected. Post 9-11, emergency response plans and training were accelerated. Although new funding was in the pipeline for many of these activities, policy makers tried to emphasize that preparedness for an emergency should be a process of strengthening the overall infrastructure and competency of the public health system and should not become an activity divorced from day-to-day public health functions.

The investigation of a new or unknown disease and that of a potential bioterrorism event have many parallels. Both share a number of the same assumptions, procedures, and resources. Much of the training made available to local health departments (LHDs) emphasized the need to communicate and cooperate across various agencies and jurisdictions through the use of incident command. The rationale behind this concept was that an investigation might have already been initiated before knowing if an event was related to terrorism. Consistent communication on a regular basis with other agencies will facilitate more efficient and effective action when a public health emergency occurs.

Monkeypox is a rare viral disease caused by the monkeypox virus, which belongs to the orthopoxvirus group of viruses. (Other orthopoxviruses that cause infections in humans include variola [smallpox], vaccinia [used for smallpox vaccine], and cowpox viruses.) It occurs mainly in the rainforest areas of central and west Africa. The disease was first discovered in laboratory monkeys in 1958. Blood tests of animals in Africa later found evidence of monkeypox infection in a number of African rodents. The virus that causes monkeypox was recovered from an African squirrel. Laboratory studies showed that the virus also could infect mice, rats, and rabbits. In 1970, monkeypox was reported in humans for the first time. In June 2003, monkeypox was reported in prairie dogs and humans in the United States.

In humans, monkeypox is similar to smallpox, although it is often milder. Unlike smallpox, monkeypox causes lymph nodes to swell (lymphadenopathy). The incubation period for monkeypox is about 12 days (range 7 to 17 days). The illness begins with fever, headache, muscle aches, backache, swollen lymph nodes, a general feeling of discomfort, and exhaustion. Within 1 to 3 days (sometimes longer) after the appearance of fever, the patient develops a papular rash (i.e., raised bumps), often first on the face but sometimes initially on other parts of the body. The lesions usually develop through several stages before crusting and falling off.

Brief Description of Scenario

On June 7, Midwest State Department of Public Health (MWSDPH) informed the Simian County Health Department (SCHD) that it was investigating a potential exposure of monkeypox (MP) to customers of a pet shop in Primate County (a county in the same state, about 60 miles west of Simian County). SCHD was asked to follow up with customers in its jurisdiction. SCHD was provided with information specific to its jurisdiction and was not made aware that similar investigations would be taking place in other counties. The only information shared between all parties was that the suspected exposure was through Gambian rats and prairie dogs, which had been sold by Rod’s Pox Pets in Primate County.

On June 8, Simian County Health Department (SCHD) personnel contacted a family in their jurisdiction that had bought a prairie dog at a swap meet. The prairie dog had originated from Rod’s Pox Pets. The 9-week-old prairie dog appeared healthy when bought on May 18. Sonny, the 10-year-old boy in the family, was the primary caretaker of the prairie dog and regularly played with and cuddled the prairie dog, in addition to the 1-year-old prairie dog he had raised. Upon arrival at the family’s house, SCHD Communicable Disease (CD) investigators learned that inspectors from the State Department of Agriculture (SDOA) had already been working with the family for more than a week. One week after purchase, the new prairie dog had become ill, showing aggressive behavior, loss of appetite, eye discharges, and lesions on its face. Three days later the new prairie dog died and the father disposed of it in the trash. SDOA personnel had instructed the family to isolate the surviving prairie dog from other animals but had not given any instructions about human contact.

CD personnel educated the family on MP and took health histories of all family members. The family was strongly advised not to travel and to limit contact with others as much as possible until the incubation period for MP had passed in two more weeks. The family was somewhat upset because of a planned vacation the following week. Investigators were unsure if they had authority to “officially quarantine” the family or otherwise restrict their movements. The SCHD contacted the State Attorney’s office to get clarification on the health department’s authority to quarantine.

The State Attorney’s office said they would check into the matter. Ironically, this happened to be an election year. SCHD was told the State Attorney would not be taking a position on this matter.

SCHD personnel followed up with the family by phone on a daily basis to monitor the family’s health. On June 11, the CDC issued its first case definition of human MP for this incident. None of the family members reported any illness.

On June 12, SCHD personnel were unable to contact the family by phone. Investigators were sent to the family’s home, but no one was present. Neighbors told the investigators the family, father, mother, and their three sons, had left that morning on vacation to Montana for two weeks. When asked about the remaining prairie dog, the neighbor said the family told her that “some government agency” had taken the prairie dog and put it to sleep. SCHD personnel were not able to confirm this with SDOA until three days later.

The investigators then called the MWSDPH for recommendations on the situation, with the family away on vacation. During the course of the conversation, the MWSDPH adviser informed SCHD personnel of several cases of MP in Primate County. SCHD personnel were somewhat disturbed that they had not been informed of these cases. SCHD wanted more details on the signs and symptoms experienced to better detect a case and to provide physicians with this information. The MWSDPH adviser indicated that he thought CDC had contacted SCHD with this information because they were running the investigation.

Later that day, SCHD learned that several dead mice had been discovered at the family’s residence a week earlier and were taken by the CDC for examination. SCHD environmental personnel were concerned that the mice might have been infected. The disease could potentially spread throughout the community and become permanently established in the rodent population. Results ultimately showed that the mice had died of rat poisoning and were not diseased.

In the meantime, the MWSDPH issued a press release on the monkeypox situation, including the current number of cases and the precautions being implemented. One of the cases included a 17-year-old in Primate County. The family contacted the television media, who in turn made assumptions prior to confirming facts with the Primate County Health Department (PCHD). The PCHD responded with a press conference to clarify the situation and provide accurate information. Daily updates were then provided.

On June 18, the family who left the state against medical advice visited the Mountain County Health Department (MCHD) in Montana. Sonny had developed approximately 20 lesions on his trunk and complained of tender cervical lymph nodes. Sonny had pharyngeal lesions, which increased the chance of spreading the virus by air transmission whenever Sonny coughed. The MCHD strongly advised the family not to travel back to Midwest State but rather to seek medical care in Montana. The family decided to return to Midwest State, ignoring health department advice for the second time. This meant the family would spend over 24 hours in a car together, with the potential of spreading the virus to other family members by air transmission from coughing. The family also stopped frequently at fast food establishments en route.

The MCHD contacted SCHD to inform them of the contact with the family and that the family was en route to Midwest State against MCHD’s recommendation. On June 19, the family called SCHD and informed them they should be arriving the next day. They mentioned Sonny had a fever and was quite uncomfortable with the lesions and would need to see a doctor right away. The family informed SCHD that their insurance would only allow them to go to Simian Community Hospital (the Hospital).

SCHD personnel immediately contacted the Hospital to prepare for an infectious patient. Although the Hospital had an infectious disease plan and had been participating in the county’s emergency preparedness activities, including smallpox exercises, no personnel at the hospital had received the smallpox vaccine prophylactically. The Hospital was reluctant to admit a patient with MP. Prior to this event, the hospital had withdrawn its phase one emergency response smallpox vaccination program. After much deliberation and negotiation, the Hospital allowed a nonaffiliated physician who had received the smallpox vaccine to have temporary treatment privileges at its hospital to administer healthcare services to Sonny.

The family arrived at the Hospital, and after initial examination, the child was admitted. The mother, exhausted from the long trip, became upset when seeing her child in pain and connected to multiple tubes and monitors. The distraught mother removed the tubes from the child. She attempted to leave with the child against medical advice and without signing required release forms. Security was called and physicially blocked the exit, at which point the mother reluctantly complied with medical treatment. Four days later, the child was discharged and eventually made a full recovery without any long-term effects.

Conclusion

Even though this was a fictional account with a factual basis, the local health departments responded well and effectively within their jurisdictions. Each responding agency had a protocol for responding to such an event; however, there was an initial lack of communication and coordination within and between the agencies involved and a lack of an incident command structure. The situation was further complicated by misinformation in the media, family noncompliance with medical advice, questions on legal authority in the investigation protocols, political consideration expressed by the State Attorney’s office during election year, the lack of regulation of exotic pets, the lack of a timely response to address the wild mice population as a potential reservoir for MP, and the Hospital’s questionable adherence to its own emergency response plan.

Public health is about the system. Medical care is more about management than leadership. Public health moves from a focus on the individual to a focus on all the people in a community. The change in focus requires a systems orientation with the need for public health leaders to understand systems and how they work. The 1998 Institute of Medicine report on public health defined the mission of public health from a systems perspective.1 The mission involved the fact that society and thus the community have an investment in their population, and this investment involves making sure that the health of the population is protected. This assurance activity includes the utilization of most current scientific and technical expertise available. All community stakeholders need to be involved in this process. The local public health agency will usually take a lead role in these activities. Thus, leadership within a systems perspective is critical.

Public health is a clear example of a complex adaptive system, within which public health practice takes place. Public health as a complex system has several properties:2

1. A focus on emergent patterns related to health outcomes of the population.

2. The health of the individual is affected by the body as a complex system in itself that interacts with many environmental factors.

3. Social networks and the interactions between people in many social situations bring an additional complexity issue to the occurrence of disease events.

4. Public health has a strong, unpredictable political dimension that affects how public health issues affect communities.

5. Public health systems are affected by the array of healthcare programs in communities as well as the complex nature of insurance coverage.

6. Public health systems are affected by the education of the public health workforce as well as the location and size of the community, municipality, or county. Rural health jurisdictions are not the same as large urban ones.

In the next section, we will explore systems thinking and then introduce the archetype tools of systems. A discussion of leadership and power will be followed by the complex issue of systems relative to management inside an agency and working outside that agency. Finally, a short note discusses some new systems possibilities.

SYSTEMS AND SYSTEMS THINKING

The modern emphasis on systems and systems thinking began to occur in the years after World War II but was affected by the Macy Conferences from 1942 to 1951. These conferences involved many important thinkers of the time, including anthropologists Margaret Mead and Gregory Bateson; the early computer scientist John von Neumann; the early leader on the issues of artificial intelligence, Warren McCulloch; and Norbert Weiner, who founded the field of cybernetics.3 In two influential books published in 1948 and 1950, Weiner discussed a new field called cybernetics and systems.4,5 His perspective becomes clearer in his 1950 book on the human use of human beings. Cybernetics is the science of steering rather than rowing. Society can be mainly understood by the study of messages and the way these messages are communicated between man and machines. Cybernetics relates to the way systems function regardless of whether the system is mechanical or social. Weiner also discussed the importance of feedback. Feedback is tied to performance and the importance of previous information and experience guiding present performance, especially when some unexpected event occurs. Both people and modern machines thus function in a similar way.

In the 1950s, the biologist von Bertalanffy pointed out that structure was a critical component in systems.6 In fact, structure is more important than function. These principles can be applied not only to biology but to such diverse fields as sociology and electronics. In the 1960s, Forrester studied economic and social systems using computer simulation techniques.7 The difficulty in understanding all aspects of the systems approach is that systems tend to be viewed from different perspectives by scientists and practitioners. Churchman viewed the systems approach from the perspective of the business community.8 All approaches seem to see the system as a set of coordinated parts that pursue the accomplishment of a series of goals. Thus, an animal is a system, as is a community. The management scientist as well as the leader attempt to define the parameters of the system. The managers and leaders also define the environment in which the system will be viewed. This translates into the need to define goals, objectives, actions, resources, management requirements, and performance measurements as they affect the parts of the system. According to Churchman, it is important to be aware that the systems approach is sometimes seen as too general for some management/leadership professionals who feel that it eliminates the specificity of problems that also need to be addressed.

Senge expanded the issue of systems to the leadership and management area in the 1990s.9 Systems thinking was seen as important for leaders. They need to see the big picture if they are to solve organizational and community problems. A systems perspective allows us to build learning organizations where people are able to systematically understand challenges to their organizations and communities as a methodology for getting the results that will help their organizations and communities to grow. In learning organizations, people expand their thinking and learning in a nurturing way.

Senge defined five disciplines to guide the work and understanding of learning organizations.10 These five disciplines work together. The first discipline relates to personal mastery, which involves each person in a learning organization working to expand his or her knowledge and skills over time as well as building upon personal strengths. The second discipline involves the critical cultural dimension of mental models. Each individual has an outlook on the world based on personal values and experiences. It is important that the individual learn to understand these factors if he or she is going to work in organizations and communities to create change. Values clarification is an important component of learning organization activity. The third discipline is shared vision, which involves the buy-in of all people in an organization to the vision. Commitment to the leader’s vision is a requirement for successful change strategies to come into being. The fourth discipline is team learning, in which the members of a team, coalition, or partnership work together in a coordinated fashion. The fifth discipline is systems thinking, in which all need to work together and view problems and challenges from the wide perspective of the total organization or the total community. In essence, a system is composed of a purpose, its components, and the inter-connectedness of its parts.11 Exercise 4-1 looks at the differences in solving a community health issue when the perspective is limited to public health and when it expands to the community as a whole. Other exercises on the five disciplines can be found in Rowitz.12

In recent years, Senge and his colleagues have been exploring the effect on the individual of working in learning organizations on systems issues. They have pointed out that the core capacity needed to look at the future collectively is called presence.13 Systems thinking involves a change in perspective. It involves looking at the world in new ways. Status quo is no longer an option. Change is the reality. This new perspective means that our old ways of identifying ourselves and what we do must also undergo change. Our view must be forward-looking and not constantly on re-creating our past. These shifts in perspective mean that leaders will shift from a concentration on organizational hierarchies to an approach in which those leaders will work through shared social networks. This new view leads to a new model for this collective type of learning—Theory U.

Theory U is a new approach to integrating the five disciplines to these new approaches to collective learning and practice. Figure 4-1 shows the relationship between the five disciplines and the Theory U approach.14 Working with others requires that the team inquire in depth as to the source and understanding of their mental models to see reality more clearly (“co-sensing”), find ways to increase the connections with the mission or purpose and the vision of the problem (“co-presencing”), and translate these visionary activities into feedback-based working action models (“co-realizing”). As can be seen in Figure 4-1, mental models, team learning, and systems thinking come into play in the processes of co-sensing and co-presencing. Co-presencing also shows the disciplines of personal vision and shared vision as happening. In the move from co-presencing to co-realizing, team learning and systems thinking play critical roles in the process.

Scharmer clarifies Theory U by defining five movements toward change as the U Process evolves.15 He first adds the movement of “co-initiating,” which involves the process of engagement between people and environmental contexts with the importance of listening to others and what you perceive that you will need to do. This stage precedes “co-sensing” and starts the U Process. He then clarifies the movements after “co-presencing,” when reflection and deep understanding need to occur. Then the movement of “co-creating” occurs when different strategies and scenarios for the future are explored. The final movement stage is “co-involving,” when new models and innovations occur from the strong interrelationships between the people who are involved in the change process. This is the stage of transforming action that is shown in Figure 4-1 as “co-realizing.” Scharmer points out that Theory U redefines leadership as a collective activity that will occur at all levels of the organization or community.

FIGURE 4-1 The U Process and the Five Disciplines. Source: From The Fifth Discipline by Peter M. Senge, copyright © 1990, 2006 by Peter M. Senge. Used by permission of Doubleday, a division of Random House, Inc.

Leadership in a Systems Environment

The importance of systems thinking for public health leaders became extremely visible as a result of the events of September 11, 2001. A number of training programs and modules related to crisis leadership have developed with this strong systems orientation. It is not that systems thinking has been absent from traditional leadership development programs; it just has become more critical in the training of crisis leaders who need to work in a public health preparedness environment. In this section, the relationship between management and leadership will be explored in the context of a systems-based world where there are connections across organizations (meta-leadership), across jurisdictions from local to state to national, and eventually around the globe.

The traditional management approach is linear in perspective. It involves rules, regulations, and procedures to make an organization work more effectively and efficiently. Leadership in today’s knowledge, skills, talents, and practice world is more of a systems set of issues. Cabrera has developed a systems organizing model that is based on the four components of vision, structure, learning, and action (VSAL).16 Figure 4-2 shows this model. These four components have a role in traditional linear and hierarchical organizations as well as in more systems-oriented or community-based organizations. In each of the Cabrera quadrants, there is a continuum to demonstrate this move from traditional to systems orientations. The components are shown in a two-by-two contingency table format to show that all four parts are interactive with each other. Another important aspect to the model is that it builds on a theory, research, and action interrelationships, which for us is a demonstration of public health practice in action. The National Cancer Institute has used this model to show systems thinking in tobacco control initiatives.17

FIGURE 4-2 Systems Organizing Model. Source: Reprinted with the permission of Derek Cabrera. From Cabera, D. 2001. Knowledge Age Operating System: Four Principles of Project Design, Version 1.0. Loveland, CO: Project N Press.

Starting with the quadrant labeled vision, it is important to recognize that vision has generally been part of a consistent set of visioning tools tied to leadership in traditional as well as systems-oriented organizations. Vision is closely allied with the planning activities in an organization or agency. For most organizations and agencies, the top administrator as leader has set the tone for the work of the organization through defining a vision, living the vision, and inspiring others in the organization to support and take ownership of the vision.18,19 The top administrator, as lead manager, and other organization managers have the critical role of making the organization vision work in a practical way.

In a systems organizing perspective, vision becomes a collective activity in which a leadership network approach defines a shared vision. Leadership becomes more a demonstration of empowering others and facilitating the visioning process. Here, we see the use and development of many tools to help in the process. For example, there is brainstorming where ideas get generated;20 the six thinking hats framework for generating ideas and solving problems;21 the use of logic models to link planning and evaluation;22 future search techniques to define the future and how to get there;23 the Search Conference, which is a participatory model for visioning, creating strategic goals, and developing action plans;24 facilitation to create participation, address conflict, make effective decisions, manage meetings, and show how to use process tools for a group’s work;25 and Communities of Practice, where leaders from the community as well as other stakeholders, including public health practitioners, meet face-to-face and virtually to learn and share ideas for the possible development of resources to support programs in a special area of interest.26

Leadership Tip

Root your vision in reality .

The second quadrant relates to structure, which involves the movement from organizing people and activities by managers and leaders to the systems orientation of self-organizing, which is a critical component in complexity thinking.27 In traditional organizations, the structure is fairly well defined. There are organization charts and individual performance appraisal processes, and individuals’ work often seems to be defined through inflexible job descriptions. This inflexible structure often limits the problem-solving possibilities and the decisions that are made because of the rules, regulations, and protocols that define action. Traditional structure also defines who you can talk to as well as the ability to work with external stakeholders.

The structure of the system is self-organizing and encourages leaders to interact with all types of people and organizations. The structures that evolve are tied to the networks that are created to support collaboration between the partners. However, our present reality is that traditional and systems structures coexist. Systems thinkers struggle with understanding and interpreting how traditional organizations work in a systems world. A whole series of systems tools has been developed to increase this understanding. Systems archetypes are one such set of tools, where problems are viewed through a number of graphic representations to show the underlying framework for success and failure of programs and events.28–30 These archetypes are used more in understanding why things are as they are rather than determining how to solve these problems or events. Self-organizing systems do provide a different approach to these issues by creating an environment that allows for the structure to evolve as needed to address community and systems challenges.31

The third quadrant involves action. In traditional organizations, the leaders and managers tend to delegate work to their staff. How delegation occurs is important. People need incentives, rewards, and recognition for their work.32 They are willing to do the work if it is tied to their talents, knowledge, and skills. Managers who are able to fit the talents of each staff member to the tasks that are to be done are critical in today’s organizations, whether these organizations are traditional in nature or more systems-based. The subtle but critical dimension here is for systems-organizing leaders to work with their organizational colleagues to connect their work to the larger collective vision of the community or system as a whole. The philosophy is more than the original belief of thinking globally and acting locally. In systems, the philosophy now becomes acting locally for the benefit of the community and society as a whole. Local work has global consequences. It is at the local level that mission leads to the goals that bring vision into reality. Social entrepreneurs are leaders who use systems solutions to address global, national, and local social problems.33

The final quadrant involves the differences in learning in traditional organizations in contrast to systems organizations and communities. Best and his colleagues see learning in an evaluation context.34 In traditional organizations, this evaluation learning is tied to the linear perspective related to planning, implementing, and carrying out programs. This type of evaluation is discrete and done as required by the project but tends not to be ongoing. Systems work that is ongoing is about creating learning organizations and learning collaboratively. Whereas the researcher or leader/manager defines activities for the organization, systems research is more participatory in nature. In systems, the needs of the researcher and the practitioner must be collaborative in nature.

In their simplest form, logic models involve the process of defining inputs, throughputs, and outcomes. They are oriented more toward traditional program structures and try to simplify discussions of cause-and-effect relationships and link them to process and outcome considerations. Best et al. see logic models as more traditional in nature and see systems dynamics with the important component of feedback as necessary to link the effects of programmatic actions as they influence factors such as those inputs in the logic model.35 The effect of actions also affects the relationships between these actions and the outcomes that occur. The Centers for Disease Control and Prevention has developed a systems framework for evaluation. Figure 4-3 shows the elements of a systems approach to evaluation as a series of steps.36 The inclusion of feedback opportunities at each step of the process would make this model even more acceptable to systems thinkers.

There are two interesting examples that will allow you to see the leadership issues in systems change. In November 2007, the Commonwealth Fund released a report outlining the issues necessary for the development of a high-performance health system for the United States.37 First, it will not be possible to create such a system without a concern for public health issues. There will need to be an alignment between the healthcare system and the public health system in the areas of health promotion and disease prevention. Public policy and the political structure must find ways to promote healthy lifestyles. Without these public health dimensions, a reform of the American health system cannot occur. These public health concerns need to be aligned at a systems level with affordable coverage for all people with improvements in access to care and quality, efficiency, and cost control; aligned incentives and cost control through better information systems, payment reforms, better management of high-cost and chronic conditions, transparency through public reporting, improved administrative efficiencies, and elimination of unnecessary waste; accountable coordinated care; quality control and efficiency; and accountability among health leaders.

FIGURE 4-3 Elements of Evaluation Framework for a System. Source: Reproduced from Framework for Program Evaluation in Public Health, Morbidity and Mortality Weekly Report, Vol. 48, 1999, the Centers for Disease Control and Prevention.

The second example, which illustrates the application of the systems-organizing VSAL model, is presented in Case Study 4-B. This study was developed by a team of public health professionals from Quebec who attended the Mid-America Regional Public Health Leadership Institute in 2002 and 2003 and undertook a study of ways to restructure the Quebec Public Health Program. The team also was concerned with the ways that leadership works in a systemwide program change.

Case Study 4-B

Leadership Issues Associated with the Development of the Quebec Public Health Program

André Dontigny, Céline Farley, Isabelle Garon, Odette Laplante, Mariette LeBrun-Bohémier, Guy Poudrier, Jocelyne Sauvé, Lise Renaud

Once upon a time there was a program …

In November 2002, Quebec’s department of health and social services (ministère de la Santé et des Services sociaux, MSSS) made public its national public health program. This program defines the scope of public health action in Quebec and sets out the priorities and activities to be undertaken for the regional partners of public health departments (DSPs) and local partners (the local community service centers, or CLSCs).

Our case study focuses on the challenges involved in developing this program and the leadership exercised by various stakeholders to meet these challenges. This document is an initial assessment resulting from consultation with several key stakeholders. It will serve as a basis for a discussion of the challenges with a group of Quebec’s public health leaders. This discussion will allow us to gather ideas to help implement the program and prepare and implement the action plans resulting from it.

Context and Stakeholders

Quebec’s health and social services network, a deconcentrated system accessible to the whole population, is made up of several partners acting at different levels. At the provincial level, the MSSS funds this network and defines major orientations, policies, and programs, both curative and preventive. The 18 regional boards plan and coordinate services, allocate resources, monitor the budgets of the institutions in their region, and ensure that results are achieved for their region, whereas the institutions manage the care and services that they deliver. The regional boards also provide regional public health services through the mandate given to public health directors. The CLSCs provide curative and preventive services and are the local public health mandataries, whereas the medical clinics deliver care and some preventive services. Finally, several community organizations provide preventive community services.

Over the past 12 years, the MSSS has produced about 20 documents addressed to public health stakeholders and other resources of the health and social services network. They are, for example, the Policy on Health and Well-Being (1990), the Framework for the Development of the Public Health Program, and the Organization of the Public Health Network (1992), a report focusing on the development of children, literally translated as “Quebec wild about its kids” (Un Quebec fou de ses enfants) (1993), Quebec Priorities in Public Health (1997), the Tobacco Act (1998), followed by the National Tobacco Control Program (Programme national sur le tabac) and the Public Health Act (2001). The most recent document is the Quebec Public Health Program (2002). To sum up, it seems that several documents have been introduced one after the other into the network in a short period of time and had to be absorbed, but they were not all associated with a plan to integrate these into practice.

The Quebec Public Health Program hoped to be different from the documents that preceded it. While striving to achieve the same high-quality document as its predecessors, it is intended to serve as a platform for mobilizing public health stakeholders and partners around the full scope of public health actions that are common to all of Quebec. The program, just like the Public Health Act, which was developed at the same time, was seen as a structuring measure to consolidate the public health infrastructure. It was an element in a vast project to strengthen and enhance the credibility of public health. The Quebec health and social services network has just undergone a period of major change—that is, a shift to ambulatory services in the context of budgetary pressure. This indirectly caused some disinterest from the authorities toward public health actions as the attention of the media and politicians, in Quebec and elsewhere, was once more focused on the overcrowding of emergency departments and the length of waiting lists.

The aim of the MSSS was to share a common vision of public health and to provide the conditions so that public health actions would be coherent, with a strong science base and carried out by all partners—that is, the health and social services network (the regional boards’ public health departments and the CLSCs) as well as community organizations and partners in other sectors. It was hoped that the program would be the product of broad-based collaboration and participation of the entire network.

The key stakeholders who influenced this process were the Assistant Deputy Minister of Public Health and the Minister for Health and Social Services, who wished to strengthen the capacity of preventive health services; the National Public Health Director, who was particularly skillful at developing structuring measures, supported by a team of dynamic professionals; several public health directors; executive directors of CLSCs convinced of the advantages of working together; as well as the institute for public health (Institut de santé publique [INSPQ]), which could provide high-quality expertise.

Leadership Activities Linked to Policy Development

The following activities linked to policy development have served as an analytical framework for this case study:

• Developing support, particularly by building coalitions, empowering other stakeholders, recognizing community assets, and making representations on the health challenges targeted by the policy

• Clarifying values, creating a vision, linking that vision to the mission, and using partners to establish the priorities on which this policy is to be based

• Organizing goals and translating them into action

• Organizing and seeking new resources, and making organizational changes to better meet community needs

• Emphasizing innovation, delegating responsibilities for programming, and supervising programs resulting from the policy

Initial Challenges

In the autumn of 2000, at the very beginning of the process of developing the Quebec Public Health Program, a number of challenges to be met were identified through interviews conducted with public health authorities at different levels. At the time, it was expected that the program would provide a way to strengthen the capacity of all public health teams to act effectively in partnership and to be recognized as such in the health and social service system and by other sectors. These challenges are as follows:

• The desire of the MSSS to increase the coherence and a more uniform access to public health services and interventions in Quebec’s regions and local territories served by the CLSCs by defining the supply of public health services that are common to all regions and CLSC territories of Quebec

• The intention of the MSSS to use the program as a lever and a tool to mobilize all public health mandataries and support decisions on resource allocation

• The shared desire on the part of the MSSS, DSPs, and CLSCs for the program to give public health a greater role in the political space of the health and social services network and to confirm the importance of promotion and prevention, particularly in CLSCs

• The desire to conserve a degree of regional and local flexibility

• The recognition of CLSCs as public health mandataries in their own right, which is in keeping with the spirit of the public health bill being developed at the time and the need for them to assert themselves as such

• The fear on the part of a number of public health departments and CLSCs that a program would be too constraining and that it would stifle innovation and not take into account regional or local characteristics

• The choice of all public health mandataries to establish a participatory process to define the program, one in which all public health organizations would be involved under the leadership of the MSSS

Another major issue underlying the process was to reach an agreement on the content of the program, since the first attempt 10 years earlier had been transformed into seven “national priorities” in public health, because an agreement could not be reached on the content of an entire program.

On the whole, the idea of developing a national public health program, which was provided for under the act respecting health services and social services since 1993,1 but never written, originated from the MSSS. It mainly reflected the search for coherence in public health activities, which often varied from one region and one CLSC to the next, and did not address some major health challenges. This desire also reflected a recognition of the need to make more room for public health within the health and social services system.

Although several public health departments shared this vision, others feared that their regional flexibility would be reduced because the act respecting health services and social services defined their responsibilities but not the explicit link with the central level, except in the event of a health threat. For their part, the CLSCs appeared to be happy to participate in the process but had to assert themselves as a new stakeholder in the planning of public health activities. On the other hand, they had to figure out how to restore the importance of activities that deal with the cause of health and social problems, because they had to increase their ambulatory care activities during periods of budgetary pressure, therefore often at the expense of prevention.

While the program was being written, the Public Health Act,2 which was being developed at the same time, was used as another opportunity to provide the legal foundation on which to build the public health program and to confirm and specify the role and responsibility (and accountability) of the stakeholders in the program and its implementation.

Clarifying Its Foundations, Orientations, and Values

The task of specifying the foundations, clarifying the vision as well as the orientations and values to be conveyed by the program, was a challenge in itself because there was no consensus on vision and content. Although the values were, to a certain extent, shared and supported by professionals at all levels, several schools of thought had to be reconciled in terms of boundaries of the public health domain, philosophies, and intervention practices. The entire process of drafting the program, which took more than two years, was used in part to do this conciliation.

At the time, there was no program model from elsewhere that could simply be copied. The program was therefore written with a view to innovating and reconciling knowledge on practices that have been proven to be effective. Fairly early on in the process, the writing team, supported by the advisory committee, suggested that interventions be grouped under main areas or domains, which required that, as much as possible, actions be carried out with common partners and be based on common determinants. Although several times during the writing process doubts were raised about this “perspective,” it served as the basis throughout the construction of the program.

Organizing the Process

The work structure to be used in developing the program was defined in the spring of 2000, based on a central idea—that is, a participatory process in which all levels of the public health organization would be involved3 (MSSS, the INSPQ, DSPs, CLSCs) to ensure the highest quality product and support for the program by organizations with a public health mandate, even though the legal framework allowed the MSSS to establish the program on its own.

Partners from within4 the health and social services sector joined these representatives to form an advisory committee with the responsibility of providing an opinion on the content of the program. For its part, the main working committee was made up of managers and professionals from different levels of the public health organizations (the MSSS, the INSPQ, public health departments). The working groups responsible for developing the contents of the program were made up mainly of public health professionals and resources at the regional and national as well as the local levels. Finally, a team of MSSS professionals supported the process and led the working groups. Partners from other sectors and community organizations were invited to participate in developing the program on only a few occasions.

The choice of this structure demonstrates the wish of the public health mandataries to, on the one hand, assess the situation “among themselves” in order to plan public health activities and, on the other hand, to promote the maximum participation of the public health mandataries without weighing down the process by broadening it to other sectors. It was agreed that the trans-sectoral partners and community organizations would be asked to participate later, during consultations on the draft program. However, the choice of this work structure was not neutral; rather, it reflected the need of public health mandataries to plan public health activities together before turning to outside partners. The stage of recognizing community assets was carried out by professionals who made up the working groups, who brought with them the concerns of their communities (based on needs assessments previously conducted by the CLSCs and DSPs), and then validated by the CLSCs; the program’s authors took for granted that these assets existed without describing or examining them.

Agreeing on “What”

A crucial stage was defining the conceptual framework (see Figure 4-4 ), which represented the will to clearly define the scope of public health action by the functions exercised, to structure public health activities according to intervention areas or domains,5 and to guide these activities based on health and social objectives aimed at enhancing health and well-being as well as reducing the major health problems through interventions known to be effective. This was done in the autumn of 2000.

Moreover, the proposal of an ethical framework and the choice of action strategies, also in the autumn of 2000, helped to identify the set of fundamental values on which the program would be based. Through this process, it was possible to identify consensus on the values that would constitute guideposts to support the ethical consideration on the choice of interventions to be carried out and to guide the interventions themselves. The key values are the public interest; beneficence and nonmaleficence; respect for confidentiality and private life; responsibility; solidarity; recognition of the potential of individuals and communities and the necessary protection of individuals, groups, and communities that are at risk; and justice.

Another crucial stage was determining the program’s actions and activities, which mainly involved identifying main health and psychosocial problems as well as determining effective interventions to act on the problems and their determinants. This process was carried out in sub-groups by more than 200 public health professionals. It involved considerable work carried out intensively over four months (during the winter of 2001) and then continued for nearly a year, until January 2002. This process was supervised by the program’s main working committee and the professional team of the MSSS. The latter was also responsible for determining whether the material met the criteria of inclusion of activities in the program. During this stage, the professionals attempted to influence the program content through their work and expertise (but also through representations).

FIGURE 4-4 Components of the Quebec Public Health Program.

The sometimes poor adherence to the criteria of inclusion in the program, particularly regarding whether or not the activities belonged to the field of public health or were effective; the speed with which discussions took place between the professionals who had developed the content and the ministerial team (a speed that prevented the professionals from having the decisions validated by their working groups); the difficulty in uniformly applying the criteria of inclusion of activities; the lack of clarity about how the priorities could be determined; and the fear of seeing certain areas of expertise being left out of the program are all elements that gave rise to tensions during that period. It was at that turning point that a professional suggested conducting a strategic analysis of the issues in order to clarify the issues, expectations, fears, conditions for success, and pitfalls, and beginning to focus on “how” to manage change rather than focusing only on “what” the content of the program should be.

Which Priorities?

Furthermore, the program’s advisory committee and the public health authorities met a few times to validate the proposed contents and to establish priorities. The lack of consensus on the need to use duly established criteria to determine the priorities as well as on the relative importance of the proposed activities made this operation difficult. However, an exception should be noted—that is, a meeting held at the end of the development process, in which the criteria of feasibility and opportunity made it possible to determine, on the basis of consensus, the activities to be conducted during the first stage of the program.

In general, despite efforts and good will, some deficiencies were observed in the transmission of information throughout the process of development of contents and establishment of priorities. Indeed, information was perceived to have been insufficiently communicated or was communicated too late between the different groups (MSSS-DSPs-INSPQ-CLSCs, between the authorities and the professionals or other resources), and even within the same group. Apart from a newsletter that was disseminated by the MSSS a few times and on an irregular basis and the information transmitted to the national roundtables on public health (which include the regional and central public health organizations, except for CLSCs) and to the management committee of the MSSS’s General Department of Public Health (Direction générale de santé publique), few mechanisms had been specified and established to communicate information between members of the advisory committee and the organizations where they came from and between the authorities and professionals or other resources, except for a periodic and widely disseminated information letter and consultation meetings’ reports.

The speed of the process involved in this stage and the lack of time to disseminate information by the drafting team account, but only partly, for the unsteady flow of the information transmitted, and especially received, during the program’s development. The lack of information received only partly explains the tensions observed during this stage and the lack of synergy between the organizations and the different levels of the same organization during this stage of program development. Much of this perception of lack of information may have reflected the expectations of the professionals, in particular those who had been involved in the working groups, that they would participate in all stages of decision making and drafting the program.

The Writing and Consultation Stage

The writing of the program’s consultation draft (first full draft of the text) began in July 2002 following an advisory committee meeting in which the majority of members agreed with the comments made. This consultation, which had been postponed for a few months in relation to the initial schedule, was to last from 8 to 10 weeks. However, this process was upset by the ministers’ agenda. Although the consultation was to be launched during the Annual Public Health Days (Journées annuelles de santé publique) in November 2002, the ministers wished that the program be disseminated during this event instead. The consultation draft therefore had to be finished sooner than expected; and the consultation period was thus limited to around 12 days. It was intended for the public health organizations only, except for the principal intersectoral ministerial partners concerned by the program. Thus it was deemed unfeasible and inappropriate to consult the national groups of community organizations during such a short time, because the latter would not have enough time to consult their members.

Within this context, it was clear that the program could not be appropriated during such a brief consultation process, in particular by the CLSCs and the transsectoral partners, and an appropriation stage was to be planned for later. However, the matter of the minister missing the opportunity to launch the program was considered to be worse, given the risk of missing a key opportunity for appropriation by the minister and decision makers in the health and social service network. The assistant deputy minister thus decided to put his cards on the table during a teleconference with the regional and local public health partners.

Despite these difficult conditions, the responses to the consultation were most generous. Indeed, nearly all the organizations consulted sent their comments to the MSSS within the prescribed time. Moreover, the comments made were excellent and most were rapidly integrated. The regional and local public health leaders also seemed to agree that the opportunity provided by the ministers to rapidly disseminate the program should be grasped while the long-awaited synergy was present.

The Home Stretch …

The final draft of the program was thus written (including all the comments, many of which involved major rewriting), formatted, and printed in record time (four weeks).

The program was launched as planned on the Annual Public Health Days by the Minister for Health, Social Services, Youth Protection and Prevention; a rallying assistant deputy minister; and before representatives of all public health levels who seemed to enthusiastically welcome the first Quebec public health program.

What Comes Next …

The development of regional action plans followed by that of local action plans are crucial stages during which public health directors and executive directors of CLSCs will have to exercise strong leadership at their respective levels in order to formulate their action plans for implementing the program in their respective territories. Moreover, these stages are critical for program appropriation by professionals in the DSPs and workers in CLSCs as well as their partners. The development of regional and local action plans will also be a key moment to involve the community organizations and other trans-sectoral partners in the development of action plans and to seek their support for the program and the action plans.

The program’s implementation has begun. The Follow-up Committee of the Quebec Public Health Program, which includes representatives of all public health organizations (MSSS, INSPQ, DSPs, CLSCs), has held its first meeting. Its members accepted the mandate to jointly follow up the program’s implementation as well as its evolution based on the population’s health needs and the organizational and financial contexts. This committee will be required to play a key role in supporting the program’s implementation. Lastly, training activities and evaluation activities, which will make use of the services of all public health stakeholders, are essential to the successful implementation of the program.

Although the program’s publication is the end of a decisive stage, other issues in the implementation of the program are just as crucial:

• Changes in practice to be reconciled, supported, and facilitated

• Changes at the organizational level to facilitate changes in practice

• Professional and management leadership at all levels to promote implementation and a dynamic evolution

• Coherent actions of public health teams that are based on effective or promising interventions relying on community assets, and that foster innovation

• Mechanisms for reconciling different perspectives with partners as well as within and between public health teams

• Obtaining funding to support implementation

Conclusion

Building alliances. Special efforts were made to ensure the development of a program that fosters a broad consensus, both within the public health network and with key partners in its implementation. However, the appropriation exercise must continue, in particular in the development of regional and local action plans because the network’s people were not all closely involved in the process, particularly at the local level, but also in the regional and national organizations. Training and appropriation activities will be critical for the effective implementation of the program.

Clarifying values. The program clearly raises the ethical issues associated with public health action and makes a solid synthesis of evolving concepts and practices in public health, taking account of both the importance of public policies and the empowerment of communities, while proposing actions that are most likely to have an impact on avoidable morbidity, injuries, and mortality. In brief, this is a visionary program that will require time and sustained concerted efforts for appropriation and implementation.

Organizing goals. The prioritization of activities must nevertheless be continued in collaboration with the regional and local partners and will be reflected in the regional and local action plans, taking advantage of the strengths and minimizing the weaknesses due to the fact that the program is vast, not having reduced the proposed interventions enough through prioritization.

Additional effort will be needed to quantify certain goals and promote evaluation in order to measure and follow the degree of achievement, which could not be finalized before the release of the program. Evaluation is nevertheless a major issue of the program. The aim of improving the operation of the evaluation parameters will be to facilitate the follow-up of the program’s implementation as well as the capacity to report on the degree of achievement of goals. Lastly, the periodic evaluation can also be instrumental in supporting the program’s visibility and implementation.

Seeking new resources. The program’s adoption seems to have further contributed to the government’s intention to increase funding for prevention. A first commitment to increase existing funding for public health actions by 25% was made by the government in March 2003. Another major issue relates to the network’s capacity to promote the transition from intention to action and to invest in activities considered to be priority activities in terms of their potential impact on the health of the population.

Emphasizing innovation. By the very nature of its content and mission, the program leaves necessary room for innovative approaches while promoting its implementation. In brief, through the development of the program and the resulting activities, a context that is conducive to its implementation at the political level (associated with funding) seems to be emerging. Local, regional, and national organizations can take advantage of this context to intensify their collaboration, in particular by providing the conditions that are conducive to the program’s implementation (achievement of the action plan). This increased collaboration should be accompanied by the identification of other means to foster stronger public health leadership and infrastructure in this new context.

Notes

1. The act respecting health services and social services stipulated that the minister “establish the public health program, take the measures that are best suited to ensure the protection of public health, and ensure national and inter-regional coordination” (R.S.Q., c. S-4.2, s. 341.9).

2. Adopted in December 2001, the Public Health Act sets out four basic functions of public health: surveillance and monitoring, prevention, promotion, and health protection. It replaces the Public Health Protection Act, which dated back 25 years. It also defines the components of the program, the regional and local action plans, and the responsibilities of the mandataries.

3. The fact that people who were “committed” rather than “representatives” had been chosen to create a product that was based on the best expertise available rather than on the interests of the parties resulted in situations of quid pro quo, in terms of the information and the involvement of stakeholders from participating organizations at several stages of the process.

4. The advisory committee included a member of each of the following organizations: College of Physicians, Professional Association of Nurses, and several others.

5. The intervention areas are (a) development, adjustment, and social integration, (b) lifestyles and chronic diseases, (c) unintentional injuries, (d) infectious diseases, (e) environmental health, and (f) occupational health.

Note: Special thanks to Marthe Hamel, coordinator of program development, to the DSP, the MSSS, for the text’s history and basis.

Source: Courtesy of the Mid-America Regional Public Health Leadership Institute.

BRIEF DISCUSSION OF THE TOOLS

Advocates of systems thinking have developed a number of tools to graphically plot out understandings of how the systems work. The tools are also used to communicate to others how these potential solutions can affect the organization or community. The tools have been developed to simplify the explanation of very complex phenomenon. Although there are many different tools for systems work, the following discussion concentrates on systems archetypes. There are three other graphic systems tool measurements: causal loop diagrams, computer simulation software packages, and microworlds.38 Causal loop diagrams graphically show dynamic interrelationships in a system by tying such things as behavior of different variables over time to some systems factors.39 Computer simulation software includes such things as computer modeling and learning laboratories. Jackson discussed microworlds as management flight simulators that were constructed from data related to computer simulation models.40

Leaders who are systems thinkers view their world in terms of loops and links.41,42 In systems thinking, the leader believes that his or her tools will reflect a story.43 These stories can be seen in a series of archetypes that are graphic models that help to explain reality in a systems way. The archetypes tell us something else. Certain structural patterns seem to occur over and over again.44 These system archetypes thus become tools for learning and also analyzing the various social structures that seem to exist in our organizational and personal lives. Although each social situation is unique, there are still enough similarities in given cultures to allow the systems thinker as leader to classify these situations. Thus, these systems archetypes, which are few in number, can be useful tools. These system archetypes were defined and discussed by Senge and colleagues,45–47 and also extensively by Kim.48,49

It all seems to be about thinking in loops. All systems archetypes are based on two processes: the reinforcing process and the balancing process. These two processes are represented by a loop with feedback built into the loop. The reinforcing loop is based on a growth and collapse model.50,51 Using a simple public health scenario, Figure 4-5 shows how reinforcing loops work. If you are overweight, you tend to eat more than a person of normal weight. The more you eat, the greater your weight. Reinforcing loops also show that a change in one direction dynamically increases change in that same direction.52 Using the reinforcing loop process can give you other public health examples ( Figure 4-6 ). If you already realize that obesity and other nutritional disorders are not really as simple as portrayed in Figure 4-5, then you are ready to look at balancing loops.

Balancing loops refer to processes that limit growth and generate processes of resistance.53 Balancing loops attempt to stabilize a system or bring it into equilibrium.54 The balancing loops also show some other things. Look at Figure 4-7 . You are 50 pounds overweight relative to your height and age. The gap then is 50 pounds that you want to lose. As you eat more, the gap between your actual and acceptable weight will increase. So what can be done? You can exercise and go on a diet (corrective action). Your weight decreases, and the gap between your actual and acceptable weight also decreases. Some diagrams make a distinction between the gap and the desired level, as can be seen in Figure 4-7. Give public health examples utilizing Figure 4-8 . Now you can explore an archetype approach by putting together Figures 4-5 and 4-7.

FIGURE 4-5 Example of a Reinforcing Loop.

FIGURE 4-6 Reinforcing Loops.

Wouldn’t it be great if all situations were this easy to analyze? It is important to point out that every link in a system contains a delay. A delay can affect the operation of a system or other components in a system. There are four types of delay.55

FIGURE 4-7 Balancing Loops Seek Equilibrium–Some Desired Level of Performance.

FIGURE 4-8 Balancing Loops.

The first type of delay refers to delays that are physical in nature. Physical delays are time based and involve getting from here to there. For example, for some individuals, it may take three months to lose 10 pounds with exercise and diet. For other individuals, it may take six months. Thus, there is a physical delay in the time a corrective action is instituted and the desired state is actualized.

The second type of delay is transactional in that various procedural activities can slow down the change process. Using the above nutrition example, the buying of the diet products may be delayed due to delivery or production problems or even a change in price. The dieter may be affected by any of these transactional problems.

The third form of delay is informational in that there may be delays in communicating information about the physical changes that the diet and exercise may cause. The overweight person’s diet may be under the supervision of a physician who is monitoring the changes through various laboratory tests or communications from a nutritionist who works for an entity that has complex procedures related to sending reports back to the doctor who has to evaluate the report before giving information to the patient or modifying the diet in light of these new results.

The final delay is perceptual in that the dieting individual may misinterpret the messages which he or she has received.

When all the above pieces are put together, we have a systems archetype. There are basically eight major systems archetypes. Figure 4-9 shows a brief description of the eight archetypes and some guidelines for using them.56 Exercise 4-2 will allow you to try to apply the archetypes to scenarios in a team.

LEADERSHIP AND POWER

The issue of how a leader views work within an organization or system presents an interesting view of the world through the eyes of a manager and a leader. A manager is concerned with keeping the organization or agency moving in a forward fashion within the constraints imposed on that entity from the director or from a governing or advisory board. Although the organization is a system in principle, in practice the manager is usually more linear when moving from specific problems and challenges to specific conclusions. The leader needs to see the organization as a system that has roles and responsibilities in the context of the organization as a whole or its roles and responsibilities in the context of a community.

Systems and leadership can be viewed as power concerns.57 Power within a system is used to transform the system and to move it in a new direction. The goal of leaders is to use power to improve the system, and in public health, the goal is to improve the quality of life of all residents of the community. The prepared public health leader wants to help all members of the system gain self-awareness and see that systems thinking is beneficial to improved organizational and community health. Position by itself does not guarantee power, but rather the leader who understands the organization or community and how to move the system forward in a courageous way defines the real meaning of power. Power is the management of the energy in the system.58 The effective leader knows when to turn up the heat in a difficult situation and when to cool it down.59 Heating things up brings a creative tension to the situation.

In addition, there is the critical skill of relationship building needed to improve the functioning of the system.60 In addition, the whole process of systems change can be seen as a story, called an archetype in systems language. These archetypes help to monitor and better understand how systems work. As pointed out above, archetypes become critical analytical tools for the leader as a systems thinker. The problem for the average individual is that the parts are seen and the whole is lost. This has been labeled as spatial blindness.61 To this can be added the concept of temporal blindness to refer to the fact that all systems have a history or story to tell. The blindness refers to the fact that most people live in the present but ignore the past. The goal of a successful prepared public health leader must be to see the whole world systemically.

THE PARADOX OF INSIDE/OUTSIDE: A COMPLEXITY CONCERN

In traditional public health organizations and agencies, the walls of the building that house the public health entity serve as virtual boundaries from the outside community. Within the agency, programmatic silos also become isolated from the total mission and vision of the public health enterprise. When the administrator works with the community, the other staff of the agency often remain far removed from the administrative leader’s work with the community. With the increasing complexity of public health as a community system, the leader struggles with these issues. Traditional agencies and organizations are like machines. These entities tend to concentrate on the individual people, parts, programs, and silos rather than on the whole organization or agency. When a part breaks, it is necessary to fix it or the whole will suffer. These organizations tend to be hierarchical in structure, with generally a command and control type of leader. The status quo tends to be the governing principle. The mission of the organization often does not align well with the activities of the organization.62 You do not get aligned thinking or action until the vision of the leader drives the action.63

FIGURE 4-9 Systems Archetypes at a Glance.

This machine view tends to limit the effectiveness of the work of public health. This machine view creates a world that is delimited by boundaries.64 Wheatley believes that this machine model is extremely limiting and does not deal with organizations and communities as living systems. Systems often function in a chaotic manner and not according to the logic of the more linear mechanistic model. Systems are about chaos and change. Systems thinkers need to get away from the study of an organization or community as a machine and concentrate on the human relationships that drive the system. Wheatley and Kellner-Rogers pointed out that a system is holistic in that it is not really a sum of its parts.65 There are no separable parts. A system is basically about relationships between people. Exercise 4-3 will give you the opportunity to explore the differences between organizational and community collaborative skills.

The complexity model of systems is clearly an innovative approach that builds on the following premises:66

1. The universe is a living system that is creative in nature and exists at all levels from the microbe level to the cosmos.

2. Life’s energy is oriented toward organization. Life becomes more and more complex as it develops diversity and requirement for sustainability.

3. Life is oriented toward defining a self and is organized to create an identity.

4. Life self-organizes at all levels of complexity as networks, patterns, and structures emerge without external pressures.

5. People do not like to be controlled. If left alone, they will use their intelligence, talents, creativity, and ability to adapt, and they will search for meaning and organize themselves in appropriate ways.

6. Organizations are also living systems that follow all of the above premises.

In several books, Wheatley defines this new complexity paradigm in terms of the following dimensions:67–69

1. Focus on relationships and not facts, positions, and structure

2. Concentration on the importance of interconnectedness, which creates a web of relationships

3. Constant evolution

4. Concentration on process rather than only on outcomes

5. Different systems in different places

6. An agenda that is always on order out of chaos and a process that is always messy

7. The principle that life seeks organization and uses messes to get there

At the organization level, then, it is process and not structure that drives action. Structure needs to come out of the process. As soon as a group is brought together to address a public health issue—tobacco control, for example—a structure will evolve to address the issue. In Figure 4-10 , Rogers shows graphically that the phenomenon of organizations starts with the interrelationship between structures and systems organized around the processes needed to carry out action.

From organizations and their processes of change, the individual and especially the leader develop identity through the organizing process, from the information collected and from the relationships as they develop to how they affect action. Rogers adds the important level of meaning, action, and trust because these activities create the capacity for change and evolving organizations. To gain clarification on Rogers, who is an international consultant on complexity in organizations, a Public Health Quiz appears in Case Study 4-C. Exercise 4-4 shows how groups change as a result of new members entering the discussion.

LEADING AND COMPLEXITY

As the events of September 11, 2001, demonstrated, unanticipated events sometimes occur. Complexity science has emerged in recent years as a new methodology for dealing with the chaos and complexity of the modern world. Chaos theory is sometimes viewed as the next iteration of systems theory, with complexity science being the next point on the continuum.

Systems theory is based on nonlinearity.71 However, it does not seem to explore critically the process of small changes leading to large effects. This latter point was a critical aspect of chaos theory. It is chaos theory that argued that chaotic systems seem to develop according to verifiable rules or equations. Complexity science goes the next step. There are three system states: chaotic, stable, and a zone of adaptability somewhere between these two extremes.72 In addition, systems can change.

FIGURE 4-10 Complexity and Organizations. Source: Reprinted with the permission of Myron E. Rogers.

Another aspect of complexity thinkers is that they focus on the interactions between individual agents in the system and monitor their effects on the system as a whole. There is also a strong belief that order will arise out of chaotic times. However, it is not always possible to determine what that new order will be, but self-organization is the basic characteristic of the universe.73 Self-organizing groups come into being during periods of bounded instability when the outcomes of a crisis or event are infinite.74 Complexity theory should prove useful to those leaders who struggle with the changes that the terrorist events of 2001 have brought.

The new leaders and managers will have to learn the skills of managing the unknowable.75 When a system is undergoing dynamic change, it is not possible to study the system in terms of its parts. The dynamic system affects all the participants in it in ways that may not be predictable. It almost seems that the system is operating out of control. The traditional archetypes don’t seem to apply. The public health leader needs to think in terms of whole systems and interconnections between one system and another, and also view the patterns of behavior that the disorder creates in individuals. The leader has to observe the small changes that may change the whole system. Details within the system are often distracting. With the changes that complexity brings, new leadership strategies will be needed. Seven approaches can be taken:76

• The first approach relates to the change in the way a prepared public health leader gets the managers in an agency or the partners in a community collaboration to change their mental model concerning control. A traditional approach to trying to deal with an organizational or community challenge is to increase awareness that these unexpected challenges often require innovative and sometimes either organization-wide or community-wide involvement in a possible solution. Old rules and approaches may not work. How does the manager or leader control a situation that may not have traditional rules and regulations to guide the process?

• The second approach is tied to the first and relates to the issue of power. In working collaboratively on a problem solution, existing power relationships may need to be changed to allow for a sharing of power and leadership in the solution. Conflict may also be critical in order to explore all possible issues related to resolving the unexpected occurrence.

• The third approach requires that problem solving and decision making be done in self-organizing learning teams. Self-organization may well involve individuals’ opinions and judgments about who should be on the team relative to the skills and contributions that will be required to deal with the event.77 These teams will have to define their goals and objectives for the crisis and its possible resolution.

• The fourth approach adds the complex issue of multidisciplinary or multiple cultural group involvement. It is often difficult to create a common culture or a consensus solution when different groups are affected differently by the solutions proposed. If external experts are brought into the group as consultants or facilitators, the proposed solutions to these challenges will also be affected. Control, power, and decision making are all affected by the composition of the problem-solving body.

Case Study 4-C

A Public Health Practice Quiz for Myron Rogers

1. How do systems thinking and complexity thinking differ?

Complexity theory is a subset of systems theory. When thinking about organizational life, it’s most useful to consider living systems theory, as opposed to cybernetics, which is fundamentally about machines as systems. Systems thinking is a way of understanding the phenomenon of life as an interrelated, interconnected, dynamic whole. Life is a pattern of relationships, and more precisely a network of patterns of relationships. The old mechanistic view of the world was answering the question “What is a thing made of?” Systems thinking seeks to answer the question “How is a thing made?” This is a shift in thinking from things to processes; from parts to the whole; from linear, predictable steps to nonlinear, unpredictable outcomes; from analysis of substance to seeing patterns; from neat and nested hierarchies to messy and dynamic networks; from matter to relationships; from control to order.

If systems theory explores the process nature of wholes, complexity theory seeks to understand how patterns emerge from networks, and how order emerges in a system. Scientists have long noted that over time, the evolution of a living system and its environment produces more complex patterns, relationships, and networks. This creates the ability of a system to respond to complexity in its environment in a way that preserves the system, even as the system changes itself to preserve itself. The basic question in complexity theory is, “What are the simple rules that allow a system to continually self-organize into higher levels of complexity, capable of better response to an unpredictable environment over time?”

An understanding of complexity theory allows us to see how the dynamic patterns of a system come into being. I would say that complexity theory is actually a theory about simplicity. We seek to understand the simple rules that, when freely iterated over time, produce the ability to respond to complex environments and adapt successfully. The understanding of adaptation—how a system learns, grows, and thrives—is a central feature of complexity theory.

Consider for a moment the difference in applying either the mechanistic view of the world or the complexity view of the world. A mechanistic approach seeks to control the parts of the system. In organizational life, this translates into the imposition of rules, regulations, policies, procedures, micro-measurement, and micro-management. The outcome over time is complex bureaucracies with little ability to respond quickly to new information or new events in the environment. In the complexity view, the focus is on adaptation and learning, and therefore focuses on some simple rules or conditions that, iterated over time, create greater access and systemwide intelligence and enable coherent responses. In a mechanistic approach, you could look at the policy manual of an organization as the history of mistakes people have made, and each time a mistake was made, a rule was created to make sure no one else ever makes the same mistake. In a complex adaptive systems view, the essential need is to foster open networks of relationships, based on a shared sense of who we really are and what we are trying to do, and allow immediate response to whatever arises, then distributing the learning, as feedback, across the network, creating greater capacity for responsiveness in the future.

2. Why is relationship building so critical to organizational change?

It is the quality of the relationship within and across the system that determines the system’s access to information, its ability to respond coherently to the challenges it faces, and its ability to learn, grow, and develop.

I worked with the U.S. Army back in the 1990s. A challenge for the Army is how to create the capacity for rapid decision making and action in local units in response to immediate conditions, while still serving the objectives of the whole. The Army recognized that traditional command and control would not serve it in a time of confusion and complexity in the battle theater—it’s too slow and cumbersome and relies on limited intelligence (that of a small group of leaders). How do you create this capacity for rapid response from which emerges coordinated, systemwide action? The answer lies in the development of a coherent identity, built on a shared view of what is significant, what really matters, and how we should act. But this identity cannot be imposed. Meaning is constructed, not dictated. Individual soldiers have a local experience and make sense of it based on their own interpretation. So, we might have a shared experience in an event, but we don’t make sense of it in a way that will create shared meaning of its significance. This results in fragmented learning, and therefore fragmented, incoherent action over time, and ultimately, a fragmented identity, based on where you sit.

In any experience, each person holds a different and unique view of what transpired. And each person is wrong in the sense that his or her view is incomplete. We need to tap into the range of experience people have, and construct a shared view of the event, in order to tap into the intelligence that is everywhere in the system. Our ability to tap into this intelligence is a function of the quality of our relationships. If we believe that information has a hierarchy, that the captain’s experience is of greater value than the private’s, we’ll lose information that is critical to our learning, and therefore our ability to adapt to changing circumstances. Creating a quality of relationship that invites people’s experience without judgment, evaluation, or blame is essential to creating a learning organization. When evaluation is present, learning is absent.

It is the quality of our relationships across hierarchies, roles, and divisions that determines our access to information that is within the system. Access to the information and intelligence in the system determines our ability to learn and to create the freedom to act in response to what really matters. This is the key capacity of high-performing organizations.

3. What factors cause governmental agencies to change from traditional mechanistic organizations to systems-based organizations?

One clarification here: governmental agencies are systems and operate following the dynamics of life, whether we choose to acknowledge it or not. When we are operating mechanistically, we are working against these dynamics. The dynamics of life—self-organizing, self-generating, emergent networks of relationships, fed by information—are unstoppable. When we work mechanistically, we only predictably create unintended consequences. We then spend our energy trying to fix what showed up that we did not intend, and we become focused on the unintended, rather than on what we need and what to be.

So, what would cause a governmental agency to shift its view of how to get the results it wants from a mechanistic to a systems approach? I think there are many possible answers to this question, but the one I most frequently hear from my clients, who are leaders of complex organizations, is their awareness that more is possible. That no matter how well they’ve done, they haven’t really tapped into the potential of their people. They are seeking a better way, a simpler way, a way that results in greater service to all their stakeholders. They set off on a path of inquiry, willing to explore new possibilities and new ideas, and have a willingness to experiment.

Of course, sometimes what creates this shift is crisis or failure in the system. As the organization becomes more rule bound, over time it reaches a kind of inertia, unable to act reliably and rapidly to sudden shifts in the environment. People have two common reactions at this point—do what we’ve been doing with more force (use a bigger hammer), or consider what the source of problem is. Once you go beyond trying to manage and control the phenomena and ask the question “What is the source of this problem?” new options for organizing become possible.

4. Do leaders need special knowledge, talents, and skills to work in a complexity environment?

Well, yes and no. I would say leaders everywhere need to focus on certain talents and skills that they’ve neglected if they’ve been leading mechanistically, through command and control. And, they need to let go of some qualities they’ve been rewarded for inappropriately.

I believe most importantly that certain qualities of character are essential for leading in these times. One is humility. Another is compassion. A leader in public education once defined these for me in the most compelling way:

Compassion is when I realize you don’t have the whole picture.

Humility is when I realize I don’t either.

This sense that we need each other, that we each possess a piece of the picture, that none of us knows it all, creates a willingness to be curious and engage people everywhere in finding a shared understanding of what matters and why. I think great leaders possess these qualities in their DNA. They’ve shed the heroic ideals of leaders having all the answers and saving people. This heroic, mechanistic model leads to robbing people of their own competence. Many leaders trap themselves and limit their people by moving every problem up the hierarchy, to be solved above and far away from the problem, and then impose the solution in linear steps. Leaders who create true organizational capacity hold their people in the problem long enough and well enough for them to find their own solution, and regain their own competence. They see their role as nurturing relationships, connecting people to each other around questions and work that matters, and thereby connecting the system to more of itself.

Of course, this can require some special skills. Some knowledge of high-engagement, high-participation processes that bring the whole system into the room is useful. Some self-mastery that allows the leader to hold people in the space of exploration and chaos longer than they are comfortable being there, long enough for new ideas and insights to develop, is helpful. And finally, a willingness to hold the organization in new processes and ways of working together long enough for people to regain their sense of competence is essential.

I’d add to this a good dose of curiosity. Curiosity drives the desire to truly explore the source of a problem or challenge, and motivates the leader to seek answers everywhere in the system. This act alone is a powerful impetus for change.

5. Why are the three levels of change in your phenomena of organizational change so important?

This model of change helps people understand how change works and why it doesn’t. It is a powerful tool for understanding the source of an issue or problem.

At the phenomenal level, we’re dealing with the material form of organization—the stuff we can see and touch. Our mechanistic heritage says that this is where change should be made. For instance, if the organization isn’t working right, it must be because the structure is wrong. So, we move chairs, create new and more or less complicated arrangements, in an attempt to align the parts of the system. If we do this right, the parts will add up to a whole that is what we want.

But is this anyone’s experience? Structural, materialistic change has been the route for 50 years or more, and the pace of this kind of change is accelerating. Yet, when we examine what happens with structural change, the only predictable outcome is unintended consequences. What is the source of the unintended consequences we experience?

I suggest that the source of the unintended consequences is how a new structure is taken up by the “dynamics of organizing” in the next level of the model. When we change a structure, we are not just changing where people sit and who they report to—we are challenging their identity. What I’ve come to see as important, how I’ve learned to contribute, and what I’ve been valued for is now disrupted. The network of relationships I’ve built that helps me do work that matters is shattered, and now information that is essential is lost. This usually results in resistance. The source of the resistance is my sense of my identity being threatened or rejected. Now, I’m seen as a resistor, and additional pressure is applied to me. Leadership chants a mantra: “People resist change.” But this is not so. People resist being changed.

If we are working with the dynamics of organizing, then we are seeking to engage everyone in developing a shared view of what matters and why, what works, and what doesn’t. As our collective sense of what is truly significant grows, our ability to take right action in the moment expands. This shifts the work of leadership to connecting the system to more of itself. The work is about nurturing the network of relationships, accessing the intelligence and information in the system, and generating a shared sense of identity. It’s about deciding how we belong together. The ability to make meaning that is coherent across the system grows, liberating intelligent action everywhere in the system. Learning thrives; adaptation is possible without command and control.

This model provides a good map for understanding what is really happening in the organization, and why. It can be a path into the source of intelligence or the cause of stupidity in our collective actions. Just work with it from where you are. Start anywhere, but follow it everywhere.

• In the fifth approach, the prepared public health leader takes a sometimes calculated risk in sharing control and power with others. Creative solutions may lead to revolutionary change. It may not be possible to determine the creativity of a solution until after the event has been managed.78 The issue of how much risk the leader is taking is difficult to evaluate when an event and its outcome are unpredictable and when the future seems to be unknowable because the old ways of doing things have changed. The question becomes whether any sort of preparation is possible.

• The sixth strategy points to the need to improve group learning skills as a prerequisite to addressing the unknowable.79 If we apply the learning organization perspective, then we can extend the perspective to argue that each team can determine the training and other tools that will expedite its work. Training should not be a one-shot deal. Because of the complexity of the world and the unpredictability of events, learning must be ongoing.

• The final approach involves the critical leadership concern related to the time factor.80 It is impossible to predict how long it will take to address an unexpected event. Discussion and experimentation take time. It is necessary for a leader to give slack to the team so that it can carry out its work. The prepared public health leader has to determine how much slack time can realistically be allowed. The leader has to maintain stable equilibrium in times of complexity when the team needs learning time as well.81

Stacy summarized these reasons for a complexity approach to systemic problem solving as a way to better indicate how organizations and communities create conditions for spontaneous self-organization to generate emergent outcomes to crisis situations or other unpredictable events.

A SHORT NOTE ON THE FLATTENING WORLD

Collaborations are changing on a daily basis. Technology is changing the ways we expand our collective capabilities and creativity to create change, innovations, growth, and new measures of success. With the growing concern on the spread of infectious diseases around the world and the potential effect of the spread of these diseases in the United States, public health leaders have become concerned about the global nature of public health and its eventual effect on public health at the local level. It is thanks to technology and specifically the ability to collectively share information through the Internet that many of our discussions on systems and complexity are evolving to a new level of development. Friedman has discussed 10 forces that he believes are affecting our perspective on all the work done in the business and the governmental sector.81 The first force relates to two events in 1989 that changed the world as we know it: the fall of the Berlin Wall and the development of the personal computer and the Windows 3.0 operating system. Communication between the peoples of the world changed, and by 1995, the World Wide Web expanded the connections of people in ways previously unknown (flattener 2). The other flatteners included workflow and community-developed software, uploading, outsourcing, off-shoring, supply-chaining, insourcing, informing, and numerous other types of technological development. One of my colleagues has developed an online course. Students sign up for the course and do all the work of the course online. My colleague can respond to the students on a regular basis from anywhere in the world, including a French café.

As the world shrinks, public health professionals are beginning to track diseases around the world on the Internet and with public health colleagues worldwide. The term “Wikinomics” was coined to describe how mass collaborations are possible and how these new forms of collaboration in a complex world are affecting leadership in public health.82 In fact, the Internet now allows anyone to participate in the activities of the world in ways he or she never could before. In discussing Wikinomics, Tapscott and Williams use the term “peer production” to refer to the new possibilities for people joining together on the Web and addressing any issue of concern.83 The online encyclopedia Wikipedia allows anyone to add or delete information from a specific entry. YouTube can be used to share videos on various subjects. Second Life allows you to test new ideas in a second-life world where you can be whoever you want to be. Many other examples can be given to demonstrate that all our institutions and organizations will be affected by these changes in technology. Leadership in a complex world will be different.

SUMMARY

The world as we know it has changed significantly since 2001. This chapter has looked at traditional organizations and the shifts that are occurring in public health as we move to a community- and systems-based view of the work that we do. Our systems perspectives are also being affected by an increasing understanding of the role of chaos and complexity in our lives. This is clearly a period of development in the conceptualization of all the elements of importance in the understanding of complexity, self-organization, and emergence.84 Edward de Bono argues caution as these changes occur.85 The decisions we make need to be simple even in a complex world. People have trouble understanding complex and convoluted decisions. It is important that we strive for simple explanations without much jargon if we are to be successful leaders.

DISCUSSION QUESTIONS

1. Explain public health in the context of a complex adaptive system.

2. What is a learning organization, and what is the role of a leader in it?

3. What are the five disciplines of the learning organization?

4. What are “Presence” and “Theory U”?

5. Describe the differences between traditional linear organizations and systems-based organizations.

6. What is complexity thinking, and how does it relate to systems thinking?

7. Explain the four components of the systems-organizing model of vision, structure, learning, and action.

8. What are social entrepreneurs?

9. How are systems thinking, complexity thinking, and leadership affected by a flattening world?

EXERCISE 4-1: Childhood Obesity and Systems Thinking

Purpose: to examine the difference in solving a public health issue from a public health perspective and from a community systems perspective

Key concepts: traditional linear thinking, systems thinking, meta-leadership

Procedure: Childhood obesity is becoming an epidemic in the United States. Your county has seen a 20% increase in childhood obesity cases in the past five years. Your local health department decides to create a public health intervention to address the problem. Internal staff meet to come up with a program plan for the project. Professor McDavid from the local university feels that the proposed initiative of the local health department is too narrow and that childhood obesity needs to be seen as a systems problem that needs countywide attention with many different stakeholders involved.

1. Divide the class or training group into teams of 8 to 10. Half the teams will develop a program from only a public health agency perspective, and half the teams from a systems perspective working across agencies.

2. Spend an hour devising the strategy and plan for your team.

3. Present the plan to the group as a whole.

4. Discuss the differences in the two types of plans.

EXERCISE 4-2: Systems Archetypes

Purpose: to use systems archetypes for public health issues

Key concepts: systems archetypes, drifting goals, escalation, fixes that fail, growth and underinvestment, limits to success, shifting the burden, success to be successful, tragedy of the commons

Procedures: Divide the class or training group into groups of 8 to 10. Apply each scenario to the system archetype. You can make any assumptions necessary to better understand how archetypes work.

System Archetype	Scenario
Drifting Goals	You decide to go on a diet to lose 50 pounds. After a year, you lose 25 pounds. You lower your diet goal.
Escalation	A smoking coalition talks to a local theater owner about instituting a no-smoking policy in the theater bar. The local health department tobacco control department head is threatened.
Fixes That Fail	Teenage pregnancy rates in a community are increasing. A condom distribution plan is initiated in the local high school. Rates decline for six months and then increase again.
Growth and Underinvestment	A million dollars is given to your community to build capacity to address potential disasters. Six months into the process, your budget is cut by a third.
Limits to Growth or Success	The federal government allocates funds to local public health agencies to make them prepared to handle bioterrorism events. Training occurs. A bioterrorism event occurs.
Shifting the Burden	In the community with an increasing rate of teenage pregnancy, the short-term solution of condom distribution does not alleviate the problem. The high school develops a program to increase self-esteem.
Success to Be Successful	You have been promoted to director of your local health department. The promotion means you will be away from home four nights a week. How do you balance work and family responsibilities?
Tragedy of the Commons	There is a flu vaccine shortage. You hear that 100 shots will be given at the local high school on Saturday. You go on Saturday. Everyone else has the same idea.

EXERCISE 4-3: Organizational and Community Collaborative Skills

Purpose: to explore the different types of management and leadership skills to work inside a public health agency and the skills necessary to work collaboratively with external stakeholders

Key concepts: management, leadership, meta-leadership, collaboration, talents, linear thinking, systems thinking

Procedure: Divide the training group or class into small groups of six to eight people. Each group will get a large piece of flip chart paper and a colored marker. Half the groups will create a list of the talents and skills necessary to be a manager/leader inside a public health agency. Half the groups will create a similar list for leaders working collaboratively with external stakeholders. Groups will present their list to the group or class as a whole. Comparisons of the lists will then be made.

EXERCISE 4-4: Complexity Through Rotation

Purpose: to examine how the rotation of people in a group changes its internal dynamics

Key concepts: complexity, relationships, self-organizing systems

Procedure: All people need to be organized into groups of 8 to 10. Start your work on this exercise by discussing the following question: How are these times of stress affecting you personally? After 10 to 15 minutes, have one of the people in your group move to another group and someone from another group move into your group. The next question is, “How difficult is it to work across departments in this agency [students can answer this question by talking about difficulties in working in different groups in different classes], and what can we do about it?” After 10 to 15 minutes, the rotation is done again, and the next questions are, “Do we work in ways that support interconnectedness rather than separateness? How can we break down our silos?” After another 15 minutes, rotate again and answer the question, “If public health is a system, how does our agency reflect the systems needs of our state?” After 10 to 15 minutes, there is a final rotation, with the question, “How do we improve our relationships with our community partners?” Debrief the exercise after the 15-minute discussion.

REFERENCES

1. Institute of Medicine, The Future of Public Health (Washington, DC: National Academies Press, 1988).

2. G. H. Eoyang, “Public Health and Human Systems Dynamics: What Can We Learn from Each Other?” In Complexity Science in Practice: Understanding and Acting to Improve Health and Healthcare (Allentown, PA: Plexus Institute, 2003).

3. J. O’Connor and I. McDermott, The Art of Systems Thinking (London: Thorsons, 1997).

4. N. Weiner, Cybernetics (Cambridge, MA: MIT Press, 1948).

5. N. Weiner, The Human Use of Human Beings (Boston: Houghton Mifflin, 1950).

6. L. von Bertalanffy, General Systems Theory (New York: Braziller, 1968).

7. J. W. Forrester, Industrial Dynamics (London: Productivity Press [Taylor and Francis], 1961).

8. C. W. Churchman, The Systems Approach (New York: Laurel Books, 1970).

9. P. M. Senge, The Fifth Discipline (New York: Doubleday, 2006).

10. Senge, The Fifth Discipline.

11. D. H. Meadows, Thinking in Systems (White River Junction, VT: Chelsea Green, 2008).

12. L. Rowitz, Public Health in the 21st Century: The Prepared Leader (Sudbury, MA: Jones & Bartlett, 2006).

13. P. Senge, C. O. Scharmer, J. Jaworski, and B. S. Flowers, Presence (Cambridge, MA: Society for Organizational Learning, 2004).

14. Senge, The Fifth Discipline.

15. C. O. Scharmer, Theory U (Cambridge, MA: Society for Organizational Learning, 2007).

16. D. Cabrera, Knowledge Age Operating System: Four Principles of Project Design, Version 1.0 Workbook (Loveland, CO: Project N Press, 2001).

17. A. Best, P. I. Clark, S. J. Leischow, and W. M. K. Trochim, Greater Than the Sum: Systems Thinking in Tobacco Control (Washington, DC: National Cancer Institute, Tobacco Control Monograph Series, 18).

18. J. M. Kouzes and B. Z. Posner, The Leadership Challenge, 4th ed. (San Francisco: Jossey-Bass, 2007).

19. M. Lipton, Guided Growth (Boston: Harvard Business School Press, 2003).

20. A. F. Osborn, Your Creative Power: How to Use Imagination (New York: Charles Scribner, 1948).

21. E. de Bono, Six Thinking Hats (New York: Little, Brown and Co., 1999).

22. W. K. Kellogg Foundation, Logic Model Development Guide (Battle Creek, MI: W. K. Kellogg Foundation, 2004).

23. M. R. Weisbord and S. Janoff, Future Search (San Francisco: Barrett-Kohler, 1995).

24. M. Emery and R. E. Purser, The Search Conference (San Francisco: Jossey-Bass, 1996).

25. I. Bens, Facilitating with Ease (New York: John Wiley & Sons, 2000).

26. E. Wenger, R. McDermott, and W. M. Synder, Cultivating Communities of Practice (Boston: Harvard Business School Press, 2002).

27. Best et al., Greater Than the Sum: Systems Thinking in Tobacco Control.

28. Senge, The Fifth Discipline.

29. D. H. Kim and V. Anderson, Systems Archetype Basics (Watham, MA: Pegasus Communications, 2007).

30. Rowitz, Public Health in the 21st Century: The Prepared Leader.

31. M. J. Wheatley, Leadership and the New Science (San Francisco: Berrett-Kohler, 1999).

32. R. Wagner and J. K. Harter, 12: The Elements of Great Managing (New York: Gallup Press, 2006).

33. D. Bornstein, How to Change the World: Social Entrepreneurs and the Power of New Ideas (New York: Oxford University Press, 2007).

34. Best et al., Greater Than the Sum: Systems Thinking in Tobacco Control.

35. Best et al., Greater Than the Sum: Systems Thinking in Tobacco Control.

36. Centers for Disease Control and Prevention, “Framework for Program Evaluation in Public Health,” Morbidity and Mortality Weekly Report Recommendations and Reports, 48, RR11, 1–40.

37. The Commonwealth Fund Commission on a High Performance Health System, A High Performance Health System for the United States (Washington, DC: The Commonwealth Fund, November 2007).

38. M. C. Jackson, Systems Thinking (London: John Wiley and Sons, 2003).

39. D. H. Kim, Systems Archetypes I (Waltham, MA: Pegasus Communications, 1992).

40. Jackson, Systems Thinking.

41. D. H. Kim, Introduction to Systems Thinking (Waltham, MA: Pegasus Communications, 1999).

42. Senge, The Fifth Discipline.

43. Jackson, Systems Thinking.

44. Senge, The Fifth Discipline.

45. Senge, The Fifth Discipline.

46. P. Senge, C. Roberts, R. B. Ross, B. J. Smith, and A. Kleiner, The Fifth Discipline Fieldbook (New York: Doubleday, 1994).

47. P. Senge, A. Kleiner, C. Roberts, R. Ross, G. Roth, and B. Smith, The Dance of Change (New York: Doubleday, 1999).

48. Kim, Introduction to Systems Thinking.

49. D. H. Kim, Systems Thinking Tools (Waltham, MA: Pegasus Communications, 1994).

50. Senge, The Fifth Discipline.

51. Kim, Introduction to Systems Thinking.

52. Kim, Introduction to Systems Thinking.

53. Senge et al., The Dance of Change.

54. Kim, Introduction to Systems Thinking.

55. Kim, Introduction to Systems Thinking.

56. Kim, System Thinking Tools.

57. B. Oshry, Leading Systems (San Francisco: Berrett-Kohler, 1999).

58. Oshry, Leading Systems.

59. R. Heifetz, A. Grashow, and M. Linsky, The Practice of Adaptive Leadership (Boston: Harvard Business Press, 2009).

60. B. Oshry, Leading Systems.

61. S. Goldsmith and W. D. Eggers, Governing by Network (Washington, DC: Brookings Institution Press, 2004).

62. J. Steffen, Aligned Thinking (San Francisco: Berrett-Kohler, 2006).

63. Wheatley, Leadership and the New Science.

64. M. J. Wheatley and M. Kellner-Rogers, A Simpler Way (San Francisco: Berrett-Kohler, 1996).

65. Wheatley and Kellner-Rogers, A Simpler Way.

66. Wheatley, Leadership and the New Science.

67. Wheatley and Kellner-Rogers, A Simpler Way.

68. M. J. Wheatley, Turning to One Another (San Francisco: Berrett-Kohler, 2002).

69. M. J. Wheatley, Finding Our Way (San Francisco: Berrett-Kohler, 2005).

70. R. Lewin and B. Regine, Soul at Work (New York: Simon and Schuster, 2000).

71. Lewin and Regine, Soul at Work.

72. R. Lewin, R. S. Kelly, and M. A. Allison, The Complexity Advantage (New York: McGraw-Hill, 1999).

73. F. Westley, B. Zimmerman, and M. Q. Patton, Getting to Maybe (Toronto, ON: Vintage Canada, 2006).

74. R. D. Stacy, Managing the Unknowable (San Francisco: Berrett-Kohler, 1992).

75. Stacy, Managing the Unknowable.

76. Stacy, Managing the Unknowable.

77. R. D. Stacy, Complexity and Creativity in Organizations (San Francisco: Berrett-Kohler, 1992).

78. Stacy, Complexity and Creativity in Organizations.

79. Stacy, Complexity and Creativity in Organizations.

80. Stacy, Managing the Unknowable.

81. T. L. Friedman, The World Is Flat (New York: Farrar, Straus, and Giroux, 2006).

82. D. Tapscott and A. D. Williams, Wikinomics (New York: Portfolio, 2010).

83. Tapscott and Williams, Wikinomics.

84. M. Mitchell, Complexity: A Guided Tour (New York: Oxford University Press, 2009).

85. E. de Bono, Simplicity (London: Penguin Books, 1999).

CHAPTER 5

The Leadership Wheel and Organizational Change

Devote yourself to loving others, devote yourself to the community around you, and devote yourself to creating something that gives you purpose and meaning.

—Morris Schwartz, Morrie: In His Own Words

Good leadership depends on systems thinking and an understanding of the effect of complexity. This type of thinking focuses on ways to implement, in the short and long term, system components necessary for meeting identified needs. To ensure that systems thinking is effective, public health agency leaders must support the systems perspective and make sure staff understand what is involved in a systems approach to change. Communication must be frequent enough to allow the staff to help manage the implementation of strategic policies. The leader is responsible for guiding the implementation activities and presenting to the community the steps being taken by the agency in response to local public health issues.

Team building is a critical part of leading a public health agency. The leader creates teams inside the agency and coalitions, alliances, and partnerships outside to address the programmatic needs of the agency. Once the members are appointed, the teams need to clarify the values that will guide their activities. Community coalitions, alliances, and partnerships have basic similarities to teams, and their development resembles team development.

Public health leaders must:

• think systemically and act strategically

• create a learning organization

• coordinate knowledge and performance management activities

• promote and support the change process

• support the values of the agency and the community

• understand the relationship between system inputs, program interventions, and outputs

• monitor and evaluate the effects of change

The remainder of this chapter covers the main stages in the systems approach to organizational change as represented by a leadership wheel ( Figure 5-1 ). Strong leaders with a high level of commitment must serve as the conveners and inspirational voices for the process. These stages include values clarification, construction or revision of the agency’s mission and vision, identification of goals and objectives, development of an action plan, implementation of the action plan, and assessment of the effects of the implementation. As a systems-based working model, the leadership wheel sees the integration of planning, action, and evaluation. An important consideration in this whole process is the need to understand the assumptions that provide a foundation for all the activities that occur as part of the systems perspective for both internal and external stakeholders.1 In actuality, we often do not have all the knowledge necessary to the understanding of a public health or programmatic need before we start to work on it. The assumptions we make will depend on whether we take a linear perspective on an issue or we take a systems perspective. This assumption approach is tied to what Churchman has called an inquiry system.2 An inquiry system involves the process of creating a system of interrelated parts or components that provide a holistic perspective on the appropriate knowledge to address a problem or challenge.

FIGURE 5-1 Systems Approach to Organizational Change (Leadership Wheel).

The leadership wheel will lead to five specific products: a strategic plan, a business plan, an action plan, a work plan, and an evaluation plan. In the strategic planning phase, values, mission and vision, and goals and objectives are clarified. Moving from the formulation of goals and objectives, a business plan is developed in which the cost of programs that are developed to implement the goals and objectives becomes critical. The goals and business plan will lead to an action plan. With implementation imminent, a work plan is devised. The evaluation plan becomes the fifth document to drive the process. Quality improvement methods and techniques are often employed as a performance measurement set of priorities. In the following sections, we will examine the stages of the leadership wheel.

VALUES CLARIFICATION

Blanchard and O’Connor make a distinction between the Fortune 500 and the Fortunate 500.3 The latter are businesses in which management by values occurs. In the management-by-values process, which can take three years to complete, an agency goes through three stages. The first stage involves clarification of the agency’s mission, values, and vision. The second stage involves communicating the agency’s newly clarified mission, values, and vision to others. The final stage, which is the most complex, involves aligning the leadership and management practices of the agency with its stated values. In the case of public health leadership, the alignment of practices and values applies to the individual, team, agency, community, and professional levels.

An agency’s culture is made up, in part, of the values and beliefs that the members of the agency have in common.4 These values and beliefs guide the members’ individual and collective behavior. Also part of the agency’s culture are the rituals and myths that have grown out of the agency’s history. For example, a myth might be created about a former administrator, who, as an avid promoter of public health in the community, might be idealized as a public health hero. Treating the administrator as a hero has its benefits, because it reaffirms the importance of health promotion. Yet it can also have a downside. For one thing, it may lead to organizational stasis, for the myth suggests that everything the administrator did, every policy decision made, is above question, and thus the current members of the agency may be more reluctant to make necessary changes than if they viewed the administrator as praiseworthy but fallible.

Agency rituals might include a special public health award given to a community organization each year at an annual luncheon. If this award is named after the former administrator, the ritual supports the myth. A new public health administrator with new ideas and a new vision for the agency will need to work with the agency staff to redefine its values, and thus the current myths and rituals—and even the agency’s physical layout, which is a component of organizational culture—may need to be changed.

A value, according to Rokeach, is “an enduring belief that a specific mode of conduct or end-state of existence is personally or socially preferable to an opposite or converse mode of conduct or end-state of existence.”5(p.5) Each community has a unique configuration and a unique set of values, and the local public health agency is a reflection of these values. Societies that are geographically and politically separated from each other tend to develop different community approaches to dealing with their particular problems.6 For example, a county with a mostly rural population will have different public health priorities than a county with a mostly urban population. Rural health leaders often have to do more with less. They have less money, fewer staff than large urban health departments, sometimes geographic isolation, limited technical resources, lower salaries for staff, and often fewer external partners.7 Case Study 5-A examines some of these issues as well as leadership wheel issues in a local public health response to a potential smallpox outbreak in a rural county.

Some general truths about values are worth noting. First, certain values are universal, whereas others occur only in specific locales. There is a clear recognition that there are some values that are universally held. These universal values tend to be heterogeneous in content with some tied to our human nature and some tied to living in cultural groups. Brown has tied the study of universal value systems to both human biology and evolutionary psychology.8 Second, values tend to be organized into value systems. Third, people generally have the values they do because of the socialization they have undergone. Fourth, values are present in every social situation.

The increasing diversification in many communities has led to changes in value systems and in some cases to a confusing diversity of values. To ensure that a system of shared values evolves, a community must undertake a process of values clarification. This type of process respects diversity but is aimed at elucidating the dominant values of the community. A vision cannot be realized unless it is built on an infrastructure of shared core values.

Credible leaders use personal values to affect their organization or community.9 To make action activities work, leaders need to align personal values with organizational and community values. When this occurs, it is possible to push a shared values agenda. Shared values lead to finding a common ground for action. Jansen Kraemer pointed out that a values orientation enhances action.10 The prerequisites for strong leadership from a values perspective include self-reflection, the ability to see issues from many perspectives, life balance, confidence in personal abilities, and also real humility. Twenty-four leaders from around the world and from various professions were asked to address the issue of universal values.11 They reached a consensus that the following values were universal: love, truthfulness, fairness, freedom, unity, tolerance, responsibility, and respect for life. Some widely shared values were nonetheless not universally shared, but these were listed as well: courage, wisdom, hospitality, obedience, peace, stability, racial harmony, respect for women’s place in society, and protection of the environment. In the case of American culture, two other widely shared values should be added to the list: health protection and quality of life. Americans, among others, are concerned about the effect that disease can have on quality of life. Public health leaders promote a public health agenda oriented toward improving the quality of life of people in their service communities.

Americans are also concerned about having a choice.12 In the health reform debate in the early 1990s and again in the first decade of the 21st century, the potential for the loss of choice of medical provider (and loss of power over other aspects of medical care) was a critical factor in the defeat of the Clinton plan but lives again in the healthcare reform legislation of this new century. It almost became more important than the potential benefits of universal health care. To partially fill out the list of American cultural values, Americans are preoccupied with the biggest and newest consumer products, pursue dreams even when the chance of success is slight, are impatient, and tend to improvise in the making of changes. All these need to be taken into account in designing public health policies. It is interesting to examine the Commonwealth Fund report on the future of the American healthcare system because many of the issues discussed in the Clinton health plan were incorporated into the Patient Protection and Affordable Care Act passed by Congress during the Obama administration in 2010.

Case Study 5-A

Pustules Proliferate in Dairyair County—A Local Public Health Response to a Smallpox Outbreak: A Case Study in Assurance Mid-America Regional Public Health Leadership Institute, April 2003

Sue Becker, Kurt Eggebrecht, Sherry Gehl, Sue Kunferman, Jody Langfeldt, Cheryl Mazmanian, Lora Taylor

Opening/Introduction

The risk of smallpox being used by terrorists as a bio-weapon is becoming a viable threat to citizens of the United States. In the event of a smallpox outbreak, healthcare providers, emergency service personnel, and state and local governments are going to be working in a crisis mode not only to treat the victims, but to contain the outbreak and begin mass vaccination. Communities and especially individual neighborhoods may be initially left to fend for themselves during the onset of the crisis.

Ensuring that the health needs of the citizens of Dairyair County are met is the responsibility of Jo Jersey, the director/health officer of the Dairyair County Health Department. Jo is a member of Dairyair County’s community response team and has been trained in the Incident Command System.

Dairyair County is located in north central Wisconsin. It has a population of 100,000 people. Farming is the main industry of the county, with eight migrant farms supplying the majority of the workforce. A number of smaller factories are located in the county, the largest of which is the Cow Pie Factory, employing 3,000 workers. The median annual income in this county is $29,000. The largest municipality in this county is the small urban center, Lodge City (40,000 population), with other surrounding rural communities making up the rest of the population. A rural newspaper, the Dairyair Daily, is read by most of the residents of Lodge City, with limited circulation to the rest of Dairyair County. Two local radio stations, WSPOX and WPUS, are both linked to the county emergency broadcast system.

Case Body

The county executive, Wanda Windbag, has just been notified of a $400,000 Community Preparedness Grant that has been awarded to the county to be used for bioterrorism preparedness. She is soliciting input from community leaders on how these dollars should be spent to prepare the county to respond to a bioterrorist attack. The perception of a bioterrorism event occurring in Dairyair County is believed to be so remote that most residents and local officials gave little weight to the warnings and preparations going on about them. For example, Fire Chief Blaze Arson was skeptical of the likelihood of a biological attack. He is convinced, and is working to influence county supervisors to agree, that the county’s limited resources should be devoted to personal protective equipment and training for firefighters. Sheriff Sly Straightshooter believes, as a result of the training he received from the Federal Bureau of Investigation, that the likely scenario will be a car bomb at the Dairyair administration building. He is advocating for security badges for all county employees and that bomb reduction film be placed on the windows of the administration building. The executive of General Hospital, Mavis Moneypenny, has contacted the governor expressing concerns regarding the hospital’s lack of sufficient decontamination equipment and negative pressure rooms and is advocating for funding to improve the situation. Although the hospital is supportive of the local health department’s planning effort, the hospital’s lack of resources makes it incapable of fulfilling its role. Cricket Copyright, the aggressive reporter of the Dairyair Daily, is pressuring County Executive Windbag to disclose how these limited resources will be used.

Jo Jersey, aware of the real risk to the community in the event of a bioterrorism event, particularly a smallpox outbreak, had been working closely with the state and the Centers for Disease Control and Prevention (CDC) on educating and vaccinating her staff. Plans were being developed to educate the other members of the Incident Command Team and the political leaders regarding the unique issues the community would face in a biological emergency. Tommy Tabletop, the Dairyair county director of emergency management, has not embraced the recommendations of Jo Jersey to sponsor a biological incident exercise due to his limited knowledge and lack of understanding regarding bioterrorism issues.

As the discussion and political wrangling continued, on January 1, 2003, a woman from Lodge City walked into the local emergency department (ED) with a four-day history of fever, malaise, headache, and severe backache. She was exhibiting a pustule-type rash covering most of her extremities and face. As usual for a holiday, the ED was very busy, with at least 45 people present. Two days following the woman’s presentation in the ED, a family of four, mom, dad, and two children, walked into the local health clinic exhibiting the same symptoms. The clinic was busy, with 28 people in the waiting room and a staff of 10. After much testing and significantly more exposure, the tentative diagnosis was variola major, better known as smallpox. During the next 48 hours, 10 more people in Dairyair County were tentatively diagnosed with smallpox. The suspect smallpox patients were either quarantined at home, or for those requiring hospitalization, placed in an isolation area in the local hospital.

The unexpected had occurred. Local health officials began working on a plan to vaccinate all the citizens of Dairyair County. The CDC had released the vaccine. With more and more cases of smallpox presenting every day, it was imperative that the entire population be vaccinated. Never had the community faced this type of emergency, a biological one.

Within 48 hours and the diagnosis of 20 cases of smallpox, the community was in a panic. Clinic and hospital staff were afraid to go to work. The school superintendent, following a recommendation from Jo Jersey, closed all schools. Absenteeism in all workplaces was at an all-time high. People were isolating themselves and their families. The shelves in the stores were emptying fast. Following the advice of Jo Jersey, Tommy Tabletop activated the Incident Command Center and delegated the leadership role to Jo Jersey. Under Jo’s leadership, it became clear that this was a public health emergency that would require a nontraditional approach by the community emergency response team in Dairyair County.

Utilizing the state and the CDC mass vaccination protocols, clinics were established throughout Dairyair County. Jo assigned Tommy Tabletop the task of recruiting and organizing medical and nonmedical volunteers to assist with these clinics. Sheriff Straightshooter was assigned the role of public information officer. A community moratorium was ordered on public events. An emergency communications network was established. The CDC website was recommended as the source for information on smallpox. In addition, working with the media partners, municipal leaders assured the community that sufficient vaccine had been acquired to immunize all of the citizens of Dairyair County, and it would be made available to residents at multiple immunization clinics throughout the county. Chief Arson was assigned to work with the coroner’s office and the hospitals to ensure the appropriate handling of the deceased.

Seventy-two hours after the first case of smallpox was diagnosed, the first of many vaccination clinics occurred. Clinics were set up on a daily basis at numerous sites around the county. An exhaustive public awareness campaign on the need to be vaccinated was launched throughout the county. After a 10-day vaccination effort, with no additional residents presenting for vaccination, it was determined that only 75,000 smallpox vaccinations were provided, leaving 25,000 citizens unprotected and unreached by the vaccination efforts.

Source: Courtesy of the Mid-America Regional Public Health Leadership Institute.

Shared values play an important role in any reform of the public health system. Exercise 5-1 is intended to illuminate the relationships among personal, professional, organizational, and community values.

Public health leaders, as protectors of the values of the agency and the community, must emphasize the importance of maintaining high ethical standards inside the agency and in the community. One necessary task is to do an ethics check. Are the procedures used in the agency and the community legal? And even if they are legal, are they consistent with the values of the agency and the community? Leaders also need to examine the relationship between the science of public health, the facts that guide public health practice, and the explicit knowledge that comes from our formal learning.13 As can be seen in Figure 5-2 , which evolved from my discussion with Dr. Patrick Lenihan, the 2003 president of the National Association of County and City Health Officials, the science and explicit knowledge dimension of a public health system needs to be understood in relationship to the experiences, action activities, and tacit knowledge that grow out of practice and internal agency learning and operations. Tacit knowledge is difficult to communicate because it involves the internal understandings of people to the experiences they have filtered through their personal values and beliefs. The science and experience dimensions are quite interactive but derive meaning after being screened by our values positions. It is not knowledge, experience, or values alone that are important—it is the meaning that is attached to these activities. Leaders and managers have the critical role of translating tacit knowledge into explicit knowledge so that there is meaning in these events for internal and external stakeholders. This translation helps the organization address similar problems in the future.

FIGURE 5-2 Leadership and Meaning.

Public health leaders, besides identifying values, must consider how these values will affect the implementation of programs. They should be aware that the process of values clarification can simplify the solution of many local public health issues. Following is a list of strategies for leaders for clarifying values and promoting them in the agency and community:

• Learn which values are universal (or nearly universal) and promulgate them in the community.

• Learn which additional values prevail in the community and in the agency.

• In conjunction with agency members and community partners, integrate universal, community, and agency values.

• Evaluate prevailing values and revise those that need to be changed.

• Develop a shared values statement.

MISSION AND VISION

Leaders need to be oriented toward the future and help create the vision that guides the activities of the agency. They must also inspire their colleagues to share the vision and use it to guide their activities. Therefore, the next task after values clarification is to evaluate both the agency’s mission and the current vision for the agency (or create a new one).

An agency’s mission and the vision must reflect each other. A vision is a picture of what, according to its leaders, the agency’s future should be like. The agency’s mission is the role it sees itself playing in the community. If the vision and mission truly reflect each other, then the agency, in fulfilling its mission, will help realize its vision (i.e., help bring about the kind of future it desires).

In addition, public health, like other areas of society, is changing rapidly, and an agency’s vision and mission must change in concert. For example, disaster preparedness and response, public–private partnerships, emerging infections, drug resistance, mental health, community violence, and health reform are issues, some newer than others, that public health must address. A public health agency’s mission statement must be revised periodically to take into account new problems, changing priorities, or other developments that have occurred in the public health arena. Agencies are also affected by many different constituencies as well as a number of elected officials, which makes the development of an agency vision much more complicated than it would be in the business world.14 However, the agency mission may be defined by state or local statutes.

An organization’s mission defines its purpose—its reason for existing.15 A standard mission for a public health agency is the promotion of health and the prevention of disease. If an agency views itself as having this mission, then it should not be primarily involved in providing direct services with a strong medical orientation. During the past two decades, health departments have stopped doing most direct service activities. Community health centers, hospitals, drug stores, and a number of big box stores like Walmart and Target have begun delivering immunizations and other primary care services.

A mission statement can be short or long. It can be a statement of the agency’s general purpose, or it can detail the agency’s role in several areas. According to Wall and colleagues, a mission statement needs to answer four questions:16

1. What is the purpose of public health?

2. How does the public health agency intend to coordinate its values and actions?

3. Who makes up the constituencies of the agency?

4. How does the agency link the present with the future?

Pearce and David claimed that a mission statement should address such things as the customer market (community), service-related issues, geographic concerns (global, national, state, or local), the level of technology, the requirements of agency survival, the personal concerns of the agency’s leaders, the agency’s philosophy, and the image of the agency in the community.17 Albrecht recommended addressing the environment of competitors, economic concerns, political concerns, legal concerns, and social issues.18 Wilson cautioned that a mission statement may leave out critical organizational activities, which sometimes shrivel financially and programmatically if not included in the mission.19

A mission statement should be inspiring, for the public health agency’s workforce needs to embrace the mission.20 Getting the staff members to do this could be difficult, because many of them have a minimal background in public health. Many will have been hired to perform clinical functions rather than engage in community-oriented preventive activities.

The mission is an important determinant of the agency’s goals and objectives and should be closely tied to the agency’s action plan. Therefore, the agency leaders must communicate the mission to community partners and constituents as well as to the agency workforce.21 One strategy is to ask partners and constituents to read the mission statement in order to evaluate its clarity.

There is a question whether the mission or vision should be developed first. Typically, a public health agency has a clear idea of its mission but an undeveloped vision of its future. In a case like this, the mission is virtually given and the vision is what must be worked on. Sometimes an organization’s mission and vision are both treated in a single statement that covers the present and the future. For example, the public health mission enunciated in Healthy People in Healthy Communities can also be viewed as a vision of the future.22

As pointed out earlier, managers are focused on protecting the integrity of their organization, whereas leaders are visionary and committed to change. Therefore, leaders can often benefit from developing their visioning skills. A vision can be likened to a blank canvas on which the leader sketches a possible future. Although a vision statement is about the future, it is often written in the present tense, which is one method of expressing the strong connection between the “now” and the “then.” Lipton has developed a vision framework for leaders.23 The core for building the vision includes organizational and/or community values, the mission of the agency, and strategy tactics. The leader needs to carefully select an executive team for implementing the vision. There also need to be methods that will maintain a growth-oriented perspective for the agency and, finally, techniques for managing people and getting buy-in for the vision.

Two cautionary notes: First, leaders are responsible for more than creating a vision. They need to motivate others and to play a major role in the development of action plans. Second, leaders may need to give up power in order to bring the vision into reality.24 For example, they may be required to make changes to the organizational chart.

Following is a brief description of one method for developing a vision statement. First, the visioning team lays out the values and principles that will guide the visioning process. Second, the team develops a glossary of terms to go along with the shared mission statement. Third, it includes key constituents in the visioning process. Fourth, it describes the functions of a vision statement and how the vision statement to be created will be used. Fifth, the visioning team discusses the future and where it wants public health activities to go. (The team should consider scenarios likely to occur if the agency moves in certain directions. Scenario building is an important step in the visioning process.) Next, the team redefines terms and relates them to concepts in the glossary. Then it devises a vision statement based on the work it has done. The construction is followed by general editing, which occurs in smaller teams. The final step is to reach a consensus on the vision statement. Of course, once the vision statement is agreed upon, it is necessary to audit progress toward the implementation of the vision.

Following is a summary of the steps public health leaders need to take in order to develop a mission and vision for their agencies:

• Use a mission statement to guide the daily activities of the public health agency.

• Create a vision statement to guide the activities of the agency as it moves forward in time.

• Use visioning skills to create the vision.

• Involve colleagues and community partners in the development of a shared mission and vision.

• Develop a glossary of public health terms for colleagues and community partners.

• Review the mission and vision statements yearly.

Mission and vision are also affected by whether the leader is a traditional thinker who defines public health in a narrow sense as tied to the programmatic activities of the governmental public health agency or more systemically from the perspective of the community as a whole. Because leaders often work from the inside of their agency to the outside and also recognize the possibilities and concerns of external stakeholders as an outside-to-inside approach, the practice of action inquiry needs to occur.25 Action inquiry is a systems activity of transformational leaders that should lead to mutual approaches to addressing public health challenges. It is through action inquiry that knowledge and action will come together.

GOALS AND OBJECTIVES

The next task in the systems approach to organizational change is to translate the mission and the vision into measurable goals and objectives. The mission statement is framed in general terms and does not contain the details of how the mission is to be fulfilled. Nor does the vision statement lay out how the vision is to be realized. Goals are more specific than either the mission or vision, and objectives are more specific still. They are, so to speak, the individual steps on the way to fulfilling the mission and realizing the vision.

Goals can be classified in several ways. One distinction is between organizational goals, which the activities of the organization are intended to achieve, and order goals, which are pursued as a means of preventing certain events from happening.26 Organizational goals can be further divided into the stated goals of an organization and the actual, sometimes hidden, goals of the organization. Creating a fit between organizational goals and systems goals is an important leadership activity. Goals can also be classified in terms of the areas of human activity to which they pertain, as seen in the division between economic, cultural, social, and political goals.

Objectives are the quantitatively and qualitatively measurable steps needed to achieve the goals of the organization. Along with the goals, they are used to guide the managerial processes for which public health agency leaders are responsible. The goals and objectives also need to reflect the vision of the agency and community, or the vision or goals need to be revised. Specifically, the leader then has the responsibility for:

• translating the agency’s mission and vision into programmatic goals and objectives

• discovering any hidden goals that may sabotage activities (action inquiry)

• considering the budgetary requirements necessary to realize the goals and objectives

• examining goals to determine if they are translatable into action

Exercise 5-2 explores the relationship between an organization’s mission, vision, and goals and objectives, which are key components of a strategic plan.

THE ACTION PLAN

The next step is to develop an action plan for achieving the goals and objectives identified in the preceding stage. The action plan, which can include the key components of a business plan, consists of operational steps that, if performed, will lead to the attainment of the stated goals and objectives. In this step, the agency leaders are required to be especially creative, because the action plan will almost certainly demand innovative approaches to achieving the goals and objectives. Creativity is called for by the structural tension that exists between the vision and the current reality. A creative leader looks for ways of resolving the tension in order to move the organization forward.27

Brainstorming is frequently used at this stage because it is an effective way of discovering worthwhile ideas. In addition, the leaders, in creating an action plan, must take into account the environment (the agency and its community) and the resources needed to carry out the plan.28 Another set of techniques involves scenario planning, which is the development of stories to examine variations in eventual outcomes in bringing vision into reality. Scenario planning uses many tools, including forecasting, forces for change, tabletop exercises, computer simulations, environmental changes, politics, and systems tools and techniques.29

Leadership Tip

Public health is about adapting to change. There is really no status quo.

The creative process can be divided into three stages.30 First comes the germination phase, in which the leader uses personal excitement to address the problems that need to be dealt with. In the second stage, the organization and its employees begin to adapt to the leader’s agenda. In the third stage, the process is completed. At this time, the leader often starts the process over again.

Some management experts suggest that devising strategies for goal attainment is more effective than an action plan. Mintzberg, for example, argued that the action plan approach is too narrow.31 For one thing, it separates strategic thinking from the goal-attainment process, and the separation prevents leaders from responding creatively to the changing environment. In Mintzberg’s view, planning is an incremental process and is not something that can be done all at once. One way of proceeding is to create an action plan that addresses only a few important areas. If the plan is too complex, failure may result.32 Note that if the strategic approach is used, the strategies chosen may in fact replace goals in the minds of the various constituencies.

One way of looking at an action plan is as a process of learning through action. Constant feedback is a necessary part of the process. If progress toward the goals is not occurring, revisions in the plan will need to be made. The leaders may have to go back to previous stages and repeat them. Feedback in systems is in actuality quite complex, as can be seen in Figure 5-3 .33 This diagram demonstrates that a critical aspect of action is to close the gap between a designated goal or set of goals and a series of action steps. Part of the reason for this gap is that there may be hidden goals in the system that come to the forefront when specific action steps are implemented. As action steps are implemented, unexpected occurrences may also happen that change the system. This fits the Wheatley argument that change is messy and chaotic.34

One point to mention here is that government agencies tend to be highly bureaucratic because of the legislative need for oversight and accountability. As may be expected, civil service requirements often work against organizational change, and networks are often difficult to form in bureaucratic organizations. Yet an interesting phenomenon is occurring that may help in overcoming some of the barriers caused by bureaucratization. Prior to 2012, almost all states had an in-state or regional public health leadership institute, and such institutes facilitaed the development of leadership networks. Websites, forums, blogs, social media sites, chat rooms, and other forms of electronic communication are making networking easier.

The structure of any organization is multilayered, and those devising an action plan need to take account of the hidden parts of the organization’s structure.35 Furthermore, they need to keep in mind that any stage in the implementation of the plan will be affected by all the previous stages. They also must pay attention to authority issues and the effect that the implementation of the plan will have on the workforce, because major changes can alter a staff member’s sense of identity.

FIGURE 5-3 Feedback Loops in a System Dynamics Model. Source: Reproduced from A Best, PI Clark, SJ Leischow, and WM Trochim, Greater than the Sum: Systems Thinking in Tobacco Control. Washington, DC: National Cancer Institute Tobacco Control Monograph Series, 2007.

A number of strategies, including the following four, can be used to reduce the problems likely to arise from a major change. First, resulting changes in roles and relationships should be determined as the action plan is being created. Staff will worry about no longer having a job when the process is completed—and in fact, jobs may vanish as a result of the implementation. Second, the human resources office may have to be reorganized or its practices reformed in light of the proposed change. Third, an information system capable of monitoring the implementation process may have to be created. Finally, the financial management of the organization may have to be altered.

One way to measure the effectiveness of an action plan is to use the balanced scorecard model developed by Kaplan and Norton.36 This model evaluates the degree of success from the financial, internal organization process, customer, and learning and growth perspectives. What the balanced scorecard demonstrates is that action planning needs to be aware of the many different dimensions to action planning activities. We need to be careful to include all the dimensions in our action activities. Oversimplification can be as much of a problem as too much complexity. For an action plan to work, according to the authors, the leaders of the organization must communicate the mission and vision, the goals and objectives, and the action plan to all the relevant constituencies. Second, the leaders must understand and be able to explain to these constituencies the linkage between the action plan goals and the rewards associated with good performance—what might be called “encouraging the heart.”37 Third, the process of developing the plan must include target setting. Fourth, the action plan must include feedback and learning components.

An action plan can usher in a new era for the organization or be its death knell. It is more likely to benefit the organization if it is created by means of a well-thought-out method and is implemented using the strategies mentioned above. Following is a list of guidelines that public health leaders should follow when engaged in action planning:

• Develop an action plan tied to the agency’s mission, vision, and goals and objectives.

• Use strategic planning techniques for action planning.

• Formulate operational steps or strategies for each goal and objective.

• Know the resources that are needed and the resources that are available to implement the action plan.

• Explore existing barriers to successful action planning.

• Use the balanced scorecard model to measure the effectiveness of the action plan.

IMPLEMENTATION

The implementation of an action plan for the purpose of achieving goals and objectives and thereby realizing the agency’s vision is the practice of public health, or at least part of it. During implementation, the leaders of the agency have the task of communicating the mission, vision, and goals and objectives of the agency to the staff and community constituents and doing this within the governing paradigm of the public health core functions of assessment, policy development, and assurance. In short, the leaders must become a bridge between the agency and the community.

Very little has been written about the implementation of action plans in the field of public health, although quality improvement techniques will work to make this occur. Yet it is clear that implementation of an action plan can involve many of the same activities public health leaders normally engage in as part of their responsibilities. These include:

• identifying community leaders and other external stakeholders

• delegating tasks to staff members and community partners

• establishing relationships with constituents

• communicating health information to the community

• working with the legislature

• working with the county board or local board of health

In a survey of California public health officers and executives, the respondents stated that their work encompassed budgeting, programming, disease control, staffing, environmental issues, health issues related to foreign nationals, and issues arising from undocumented care.38 The researchers examined the lessons that the public health leaders had learned from their daily activities. These lessons included the importance of accuracy of information, flexibility, the total involvement of all stakeholders, action based on vision, patience, and providing information to the public.

EVALUATION

After an action plan and work plan are implemented, the results of the implementation need to be evaluated. The object of the evaluation is to determine to what degree the goals and objectives were achieved. Although the leaders of a public health agency will not be directly involved in gathering and analyzing the evaluation data, they will use the conclusions of the evaluation to determine what steps to take next to realize the agency’s vision.

Leaders of an agency need data to foster a culture of evidence-based practice within the agency and among community constituents. For one thing, public health leaders are seen as sources of knowledge about community public health issues, and ensuring that evaluation data are gathered and publicized in some form confirms the legitimacy of their role as knowledge providers. In addition, the data will show the effects of the agency’s activities on the residents of the community and, assuming they are mostly positive, will confirm the legitimacy of the agency’s role as a protector of the community’s health.

The evaluation process has been analyzed as consisting of six separate steps:39

1. posing questions about the program

2. setting effectiveness standards

3. designing the evaluation

4. collecting the data

5. analyzing the data

6. reporting the results

Not part of the evaluation process itself but an essential step nonetheless is the use of the results to determine further changes that need to be made.

Evaluation seems to frighten American health professionals, who tend to think evaluation data will jeopardize their jobs. In Great Britain, in contrast, public health leaders seem convinced that evaluation helps strengthen programs.

SUMMARY

This chapter describes the main stages in the systems approach to organizational change using the leadership wheel. The first step is for the organization to clarify its values and create a strategic plan. Once it does that, it can more easily construct a mission for itself and create a vision of its own future. The next task is to determine which goals and objectives, if achieved, will lead to the fulfilling of the organization’s mission and the realization of its vision (development of a business plan). The third task is development of an action plan designed to accomplish the goals and objectives. The action plan needs to be implemented during the fourth task (creation of a work plan). The fifth step, of course, is to do an evaluation to determine whether the goals and objectives were accomplished and whether their accomplishment led to the realization of the organization’s vision. Usually the evaluation uncovers changes that need to be made if the vision is to be realized. Feedback mechanisms need to be included if the integrity of the systems perspective is to be maintained.

DISCUSSION QUESTIONS

1. What are the similarities and differences between systems thinking and strategic thinking?

2. What are the values that characterize public health in the United States or in your home country?

3. How do an organization’s mission and its vision differ, and how are they similar?

4. What is the relationship between goals and objectives and vision?

5. What is an action plan, and what is the typical purpose of such a plan?

6. What are four strategies for reducing the seriousness of problems resulting from major changes?

7. What are the six steps in the evaluation process?

8. What is the role of leaders in the change system defined by the leadership wheel?

EXERCISE 5-1: Shared Values Team Assignment

Purpose: to elucidate the relationships among personal values, community values, organizational values, and professional values

Key concepts: community coalition, community values, organizational values, personal values, professional values, value alignment, meaning

Procedure: The class should divide into teams of four or five members each. Each team pretends to be a community coalition charged with creating a shared values position statement intended to guide the coalition as it addresses the community’s public health needs. The statement should integrate personal, organizational, community, and professional values—the values that guide our personal lives, the organization we work in, the community we live in, and the profession we are members of. Each team will perform the following steps:

1. Each team member writes down on a Post-it one of his or her personal values. The member acting as “mayor” (facilitator) collects the Post-its and sticks them on a poster board in a column. The team reviews the values to see if a pattern emerges.

2. Each team member writes on a different color Post-it (one of another color than the Post-its used in step 1) a community value (the team members should choose from among the values held by the community in which they live). The mayor collects the Post-its and puts them on the poster board in a column next to the personal value Post-its. The team reviews the community values and compares them with the personal values.

3. Each team member writes on a different color Post-it a professional value held by public health practitioners. The mayor collects the Post-its and puts them on the poster board in a third column. The team reviews these values and discusses the ways in which they are consistent or inconsistent with the values previously listed.

4. Each team member writes on a different color Post-it an organizational value held by the organization in which he or she works. The mayor collects the Post-its and puts them on the poster board in a fourth column. The team reviews the values listed and discusses their relationship to the other sets of values.

5. The team reviews all the values listed and creates a values list that reflects the shared interests of all the team members (remember, the team members are pretending to be representatives of the organizations in a community coalition).

6. Each team presents its list of values to the whole group.

EXERCISE 5-2: The Vision Thing

Purpose: to elucidate the initial steps in the systems approach to organizational change; the role of a public health agency’s mission, vision, and goals and objectives; and the connections between these

Key concepts: goals and objectives, mission, vision

Procedure: The class should divide into agency work teams of 5 to 10 members each. The first task is for each team to act as an ad hoc committee assigned the job of drafting a mission statement for a public health agency. If a glossary of terms is necessary, one should be drafted. After the mission statements are completed, the teams present them to the class as a whole, and the class then develops a shared mission statement.

In the second task, each team acts as a committee that has been assigned the job of developing a vision statement utilizing the shared mission statement created in the first task. Some team members should be designated as senior staff and others as front-line staff. After the vision statements are completed, the teams present them to the class as a whole, and the class then develops a shared vision statement.

In the third and final task, each team develops goals and objectives statements that indicate what actions must be achieved in order to implement the agency’s mission and vision.

REFERENCES

1. I. I. Mitroff and H. A. Linstone, The Unbounded Mind (New York: Oxford University Press, 1993).

2. C. W. Churchman, The Design of Inquiring Systems (New York: Basic Books, 1971).

3. K. Blanchard and M. O’Connor, Managing by Values (San Francisco: Berrett-Koehler, 1997).

4. P. Hersey et al., Management of Organizational Behavior, 9th ed. (Upper Saddle River, NJ: Prentice Hall, 2007).

5. M. Rokeach, The Nature of Human Values (New York: The Free Press, 1973).

6. R. M. Williams Jr., American Society: A Sociological Interpretation, 3rd ed. (New York: Knopf, 1970).

7. Center for Rural Public Health Practice, Bridging the Health Divide: The Rural Public Health Research Agenda (Pittsburgh: University of Pittsburgh, 2004).

8. D. E. Brown, Human Universals (Boston: McGraw-Hill, 1991).

9. J. M. Kouzes and B.Z. Posner, Credibility (San Francisco: Jossey-Bass, 2011).

10. H. M. Jansen Kraemer Jr., From Values to Action (San Francisco: Jossey-Bass, 2011).

11. R. M. Kidder, “Universal Human Values: Findings on Ethical Common Ground,” Futurist 28, no. 2 (1994): 8–13.

12. J. Hammond and J. Morrison, The Stuff Americans Are Made Of (New York: MacMillan, 1996).

13. H. Mintzberg, B. Ahlstrand, and J. Lampel, Strategy Safari (New York: Free Press, 1998).

14. B. Nanus, Visionary Leadership (San Francisco: Jossey-Bass, 1992).

15. S. P. Robbins and M. Coulter, Management, 11th ed. (Upper Saddle River, NJ: Prentice Hall, 2011).

16. B. Wall et al., The Visionary Leader (Rocklin, CA: Prima Publishing & Communication, 1992).

17. J. A. Pearce Jr. and P. R. David, “Corporate Mission Statements: The Bottom Line,” Academy of Management Executives (May 1992): 109–116.

18. K. Albrecht, The Northbound Train (New York: American Management Association, 1994).

19. J. Q. Wilson, Bureaucracy (New York: Basic Books, 1989).

20. N. M. Tichy, The Leadership Engine (New York: Harper Business, 1997).

21. E. Marzalek-Gaucher and R. J. Coffey, Transforming Healthcare Organizations (San Francisco: Jossey-Bass, 1990).

22. T. Norris and L. Howell, Healthy People in Healthy Communities: A Dialogue Guide (Chicago: Coalition for Healthy Cities and Communities, 1998).

23. M. Lipton, Guiding Growth (Boston: Harvard Business School Press, 2003).

24. Wall et al., The Visionary Leader.

25. B. Torbert and Associates, Action Inquiry (San Francisco: Berrett-Kohler, 2004).

26. A. Etzioni, A Comparative Analysis of Complex Organizations (New York: The Free Press, 1971).

27. R. Fritz, The Path of Least Resistance for Managers (San Francisco: Berrett-Kohler, 1999).

28. E. E. Bobrow, Ten Minute Guide to Planning (New York: Macmillan, Spectrum, and Alpha Books, 1998).

29. G. Ringland, Scenario Planning: Managing for the Future (New York: John Wiley and Sons, 1998).

30. R. Fritz, The Path of Least Resistance (New York: Fawcett, 1984).

31. H. Mintzberg, Mintzberg on Management (New York: The Free Press, 1989).

32. Albrecht, The Northbound Train.

33. A. Best, P. I. Clark, S. J. Leischow, and W. M. Trochim, Greater Than the Sum: Systems Thinking in Tobacco Control (Washington, DC: National Cancer Institute Tobacco Control Monograph Series, 2007).

34. M. J. Wheatley, Leadership and the New Science, 2nd ed. (San Francisco: Berrett-Kohler, 1999).

35. P. M. Senge et al., The Fifth Discipline Fieldbook (New York: Bantam, 1994).

36. R. S. Kaplan and D. P. Norton, The Balanced Scorecard (Boston: Harvard Business School Press, 1996).

37. J. M. Kouzes and B. Z. Posner, The Leadership Challenge, 4th ed. (San Francisco: Jossey-Bass, 2007).

38. J. C. Lammers and V. Pandita, “Applying Systems Thinking to Public Health Leadership,”Journal of Public Health Management and Practice 3, no. 4 (1997): 39–49.

39. A. Fink, Evaluation Fundamentals (Newbury Park, CA: Sage, 1993).

CHAPTER 6

The Five Levels of Leadership

Effective leaders are capable of reframing the thinking of those whom they guide.

—D. R. Conner, Managing at the Speed of Change

A leader is a person who inspires others to action and guides their undertakings. These others can be members of a team, employees of an agency, or heads of groups that have formed a coalition, an alliance, or a partnership, for example. In other words, leaders in public health, as in other arenas, operate on different levels. The major difficulty in conceptualizing what leadership is relates to the fact that we live in an ever-changing world that demands that leaders adapt to these changes in a continuous way. Each day leaders face new technical challenges for which solutions need to be found. These challenges require more than the usual solutions tied to an authoritative position or to the standard operating procedures of an organization or community. All we need to do is look at the events of September 11, 2001, to see that the world has changed. Heifetz and Linsky pointed out that these adaptive challenges require solutions that are innovative, perhaps experimental, and create new forms of adjustment.1 Adaptive change may require a change in attitude, values, and behavior, or a new interpretation of events.

Sometimes this new perspective may involve trying to see the situation from the perspective of others. I have suggested to students that simply changing their seats from one class session to another will give them a new perspective of me as professor. I recently saw this effect in a management training program. The trainees were asked to develop a new public health program during the first six months of the training. During the second six months, the trainees’ task was to develop a business plan for their new program. They reported that the business plan project gave them a whole new perspective on their project and the feasibility of making the project work. Heifetz and Linsky have added a variation on this technique, which they named the balcony exercise.2 If you are at a dance, you tend to concentrate on dancing with your partner. If you go to the balcony between dances, you can see the whole dance floor. You can see the band, and you can see all the dancers. In other words, you get the big-picture view. You can see all the interacting parts. You can see the dancers who stumble and have difficulty with the dance steps. You are a systems thinker on the balcony. The systems thinker not only sees how his or her organization is functioning, but can also see how the organization functions in the context of the community in which the organization is embedded.

Let us assume that there is a second balcony. From this balcony, events and activities appear less structured. As you add new information to the dance floor and all the activities outside the building, you begin to change information into knowledge synergistically. Your synergistic leadership approach allows you to see the mess beyond the structure. Thus, you need to expand your leadership in this complex environment beyond the dance floor or your organization. You begin to cultivate new relationships as your activities become more complex and less predictable. Lewis warns of self-organized criticality (SOC), which is the point at which the system partially or totally collapses.3 Structures become less permanent, new structures come into being, and they seem to grow into these new cultivated relationships. Social networks expand and contract due to increasing real time and virtual social network relationships. You will notice more chaotic situations that create interventions to resolve. Wheatley has pointed out that human beings seek organization in their lives, and it takes messes to get us to organization.4 Organization is clearly about developing new relationships and new structures that are co-evolving. Change is the organizing force. Order is about our ability to influence our organization and community to organize, reorganize, and continue to grow more complex. The second balcony can clearly be an exciting place that increases our understanding of the activities on the dance floor and the first balcony.

It is also important to understand what entices people into leadership roles. Over the past 20 years, there has been a strong belief that leadership can be taught. Many public health leadership programs have come into being with the goal of training public health professionals to be better leaders with the belief that leadership is one of the key dimensions in building a stronger public health system. Parks has stated that there are important explanations of why people want to be leaders.5 She calls these explanations “hungers” and discusses five of them as follows:

1. hunger to contribute and make society better

2. hunger to be in an authority position

3. hunger to implement and explore systems issues

4. hunger to show others how to adapt to change

5. hunger to demonstrate moral courage on behalf of the “common good”

This chapter first discusses the abilities that public health leaders need at any level, including the personal level (i.e., when dealing with another individual one on one), then goes on to consider the particular abilities and strategies they put to use in heading a team, heading an agency, working on a community collaboration activity, or guiding their profession toward improvement. As we proceed, it is important to remember that each of the five levels of leadership provides a foundation for the next level of leadership. It is almost like going up a flight of stairs on which we need to go up the first stair before going to the second stair. Skipping a stair might trip us up.

PERSONAL LEADERSHIP DEVELOPMENT

This section considers some of the prerequisites for being an effective public health leader at any level. These prerequisites include a commitment to social justice, an understanding of democracy, an understanding of the political process, communication skills, mentoring skills, decision-making skills, and the ability to balance work and life outside work. There are at least eight learning strategies that will enhance personal leadership development activities:

1. Lifelong multidisciplinary learning

2. Systems thinking and complexity

3. Reading

4. Exploring the arts

5. Creativity

6. Family–work balance

7. Retreats and reflection

8. Experiential learning

Values

Public health leaders, to be fully effective, must be committed to the values that characterize public health, especially social justice. However, they need to be careful not to let the social justice agenda prevent them from doing the tasks that need to be done. Furthermore, social justice is a broad concept and encompasses a range of different issues. The predominant social justice issue of concern to almost all public health leaders is equity in access to care. However, no consensus exists that, for instance, there should be a radical redistribution of wealth in the society at large.

A commitment to a value such as equity in access to care entails a willingness to challenge the political status quo and act as an advocate for the public health agenda. Leaders are supporters of organizational and community values and should be on the front lines in attempts to make public health practices and policies conform to these values. Leaders also need to be at the front of the line if values need to be changed, modified, or reinterpreted.

Politics and Governance

Public health leaders need to understand the political system of the location in which their activities take place. In this country, they need to understand how the American version of democracy works at the local, state, and national levels and how to influence the political process. As an example, the author, on a visit to the office of a public health professional in a state health department, noticed The Federalist Papers and de Tocqueville’s Democracy in America on the shelf. The public health leader said that he often referred to these books for guidance in making decisions.

One question that arises is whether there is a difference between government (or governance, the activity of governing) and politics. Governance, in large part, consists of administering programs and adjusting them to fit policies developed as part of the political process.6 Unfortunately, these policies are sometimes not founded on the best available evidence but instead reflect the personal concerns (including the desire to get reelected) of the politicians who vote them into existence. Several years ago, I talked to a state legislator about having a school of public health supply data on specific health issues and social determinants of health of interest to the legislator. He refused the offer, because, according to him, he did not need data to make his decisions. (As someone has pointed out, politicians have “spin doctors,” whereas government agencies have “spokespeople.”7 That says something about the difference between politics and government.)

Public health agencies are government agencies, and public health leaders are implementers of policies set by politicians. This creates interesting possibilities for a partnership between the political and governmental sectors. Leadership theories often focus exclusively on organizational tasks, such as setting organizational policies and motivating the workforce, but public health leaders need to develop the skills necessary for working with elected officials. Their role is to use the values, mission, vision, and goals and objectives of their agency to clarify public health issues and ensure that the policies created to deal with these issues will have a good chance of being effective.

Communication and Empowerment

The AIM Leadership Model is based on the idea that leaders have to learn to take action, learn how to influence the field, and be motivated by the process.8 According to the model, the five building blocks of effective personal leadership are communication, the empowerment of followers, a focus on key issues, linkage to others, and life balance. Each of these building blocks is affected by leadership style and practices as well as the systems approach to organizational change.

Good communication skills are critical. Effective communication has several aspects, including slowing the thought processes, increasing understanding, testing conclusions, listening constructively, getting to the essence of things, and exploring areas of disagreement.9 In addition, gender differences, racial or ethnic differences, and age differences can affect whether messages are received as intended.10 Leaders need to understand all the factors that influence communication so they can synthesize public health information into effective messages.

Leaders, in trying to empower work and community associates, often act as their mentors. Interaction between leaders and constituents is critical,11 and leaders need to empower “followers” in ways that give them the chance to be more effective as well as to develop their own leadership skills. Followers are themselves people with exceptional talents, and according to one study, 80% of the effectiveness of a project is due to the followers and only 20% to the leadership (80–20 rule).12

Leading and Following

Also, followers in one situation become leaders in another, and many public health practitioners see themselves in both leadership and follower roles. Public health practitioners who work for public health agencies see themselves as professionals first and even leaders in their profession, but those who are part of a traditional public bureaucracy are frequently expected to be less leaders than followers, which can create a contentious work environment.

Members of a board of health often see themselves as powerful individuals and therefore as natural leaders. Health administrators also see themselves as leaders rather than followers. This may lead to conflict. For example, a health administrator addressing a group of public health professionals in a leadership program said that it was his job to protect board members from gossip and controversies. A local board of health president who was in the training program said that if the health administrator kept information hidden from board members, someone in the community would give them the information instead. Board members need information and lose trust in health administrators who hold back information.

Another board of health president pointed out that the administrator of the health department was his employee, because he could fire the administrator and recommend cutting the local health department budget. This shows how important it is for the board of health members and the public health administrator to develop an understanding that they are partners. In this regard, governance has an important role to play.13 A governance public health framework should include mechanisms for organizing values, carrying out the public health mission, formulating goals and objectives, developing realistic action plans, resolving conflicting agendas, determining the need for structural change, improving the relationship between the board and the health department, and developing mechanisms to share governance with the appropriate governmental body. As one public health leader stated:

To create effective governing boards, we must examine our values and determine why our boards need to exist. Once we discover our common purpose, we can develop skills and processes to improve our effectiveness. Boards and administrators need a shared vision, commitment, and leadership to make goals a reality. As public health leaders, it is our job to develop boards that are a part of our leadership teams and join us in creating healthy communities.14(p.11)

Agenda Setting

Public health leaders should learn about and use the systems approach to organizational change and the public health core functions model to ensure that their agencies’ agendas are tied to the core functions of public health. In addition, they need to master the art and science of public health. Leaders are the grand integrators of science and practice, and part of their job is to explain public health issues to health professional associates and community partners.

Leaders should acquire agenda-setting skills. An organization needs to prioritize the problems that it is facing and create action plans that deal with the largest problems first.15 Figure 6-1 presents a model for agenda setting that includes the creation of a media agenda, a public agenda, and a policy agenda. The fact that public health leadership practice takes place in a government setting means that community and political realities affect the agenda-setting process. Also influencing the process are gatekeepers, the media, and spectacular news stories (e.g., a story about children becoming ill after eating in a fast-food restaurant).

FIGURE 6-1 Three Main Components of the Agenda-Setting Process: The Media Agenda, Public Agenda, and Policy Agenda. Source: Reproduced from Rogers and Dearing, Agency-Setting Research: Where Has It Been? Where Is It Going? In Communication Yearbook, Vol. 11, J. A. Anderson, ed., p. 5, © 1988 by Sage Publications, Inc. Reprinted by permission of Sage Publications, Inc.

Barriers to Effectiveness

In 1988, the Institute of Medicine issued a report stating that the public health system in the United States was in disarray.16 The report listed a number of barriers that reduce the ability of public health leaders to be effective, including the following:

• a lack of a consensus on the content of the public health mission

• inadequate capacity to carry out the essential public health functions of assessment, policy development, and assurance of services

• disjointed decision making uninformed by the necessary data and knowledge

• inequities in the distribution of services and the benefits of public health

• disharmony between the technical and political aspects of decisions

• rapid turnover of leaders

• an inadequate relationship between public health and the medical profession

• organizational fragmentation

• problems in relationships between layers of government

• an inadequate development of necessary knowledge across the full array of public health needs

• a poor public image of public health, inhibiting necessary support

• special problems that unduly limit the financial resources available to public health

Without question, the public health system in the United States needs to become more effective, and public health leaders will be at the forefront of attempts at reform.17 One problem is that public health agencies are dealing with more complex problems today than previously, and the complexity of problems in the areas of infectious diseases and chronic diseases will probably continue to increase. Therefore, organizational stability may not be possible to achieve. In addition, public health professionals come from different disciplines with different approaches to problem solving, which leads to professional disagreements.18 It will be only through collaboration that effective problem solving and decision making will occur.

In a speech before the Illinois Public Health Leadership Institute in 1992, George Pickett said that public health leaders need to increase their skills transorganizationally; that is, they need to be able to understand and communicate with others in community sectors with values and priorities different from theirs. Public health leaders are often deficient in collaboration skills,19 and consequently they are sometimes prevented from cooperating effectively with leaders from important sectors, such as the business community and the religious community. Fortunately, obstacles to cooperation are becoming less frequent.

It should be noted that, in general, leaders who are extremely effective tend to be key players in rather than reactors to the change going on around them.20 Effective leaders, when confronted with a problem, typically consider a wide range of options and seem to know how to select the important factors first. They also think in terms of win–win and try to arrange it so all parties are winners in a dispute. They are good listeners who try to understand others and their perspectives before trying to make themselves understood. They are excellent synthesizers who try to foster cooperation and collaboration. Finally, they constantly renew themselves through training, education, exercise, values clarification, and so on.

Leadership Style

Public health leaders need to develop an appropriate leadership style. Autocratic and directive styles work best when the leader structures the tasks and the workers are willing to do what the leader asks. In public health, the democratic style seems to work better.21 Participative forms of leadership, in which staff members are involved in the problem-solving process, facilitate the building of a consensus and the acceptance by the staff of the decisions arrived at. Collaboration should be viewed as a creative process whose goal is to discover new approaches and new solutions for old problems.22

Dealing with Diversity

Professional diversity in public health brings its own set of problems.23 Practitioners from different professions view public health differently. Public health leaders need to look at public health in its totality and develop strategies for integrating the different approaches. Exercise 6-1 provides an opportunity to consider the issue of professional diversity and its effect on public health strategies.

Public health leaders need to confront not only professional diversity but gender, race, ethnic, and age diversity. For example, the so-called glass ceiling for women still exists,24 and therefore public health leaders must conscientiously promote gender equality. The first step is to gather the data necessary to determine whether gender inequalities exist and, if so, where they exist. The next step is to hire a consultant to evaluate the agency’s environment and its receptiveness to gender equality. The third step is to use a benchmarking process (comparing the agency with the best agencies, not the average ones) to identify best practices for achieving gender equality and taking full advantage of the skills that women bring into the workplace. The final step, so to speak, is to prepare oneself for a backlash. Case Study 6-A is an interview with Dr. Joyce Lashof, who has held a number of public health leadership posts over the past 50 years. The interview explores some of the gender issues that public health leaders typically confront.

Diversity encompasses gender, age, race, ethnicity, sexual orientation, work and family issues, education, work experiences, tenure within the agency or organization, personality, risk tolerance, geographic region, and religion.25 A unified diversity enhancement program for public health professionals and clients may be difficult to construct because of the different issues that are prominent in each diversity category.

Case Study 6-A

A Leadership Interview with Joyce C. Lashof, MD

Shirley F. Randolph

Joyce C. Lashof, MD, is dean emeritus, School of Public Health, University of California at Berkeley. Her most recent previous positions include president of the American Public Health Association; Dean, School of Public Health, University of California at Berkeley; president, Association of Schools of Public Health; Assistant Director, Office of Technology Assessment, U.S. Congress; Senior Scholar in Residence, Institute of Medicine, National Academy of Sciences; Deputy Assistant Secretary for Health Programs and Deputy Assistant Secretary for Population Affairs, U.S. Department of Health, Education, and Welfare; and Director, Illinois Department of Public Health.

The first name that comes to mind when one thinks of women leaders in the field of public health is Joyce C. Lashof, MD. Dr. Lashof has done it all. After five decades in public health leadership positions, she is, quite simply, the quintessential public health leader.

And she did it all while successfully integrating her workplace duties with her responsibilities as the wife of a university professor (her husband, Richard, is a well-known mathematician) and the mother of one son and two daughters—two of whom have made Joyce and Richard grandparents, and all of whom are growing as young professionals in their chosen fields. Her insights into leadership issues, particularly as they apply to women, are perceptive and fascinating.

One of the first areas Dr. Lashof and I explored during an interview several years ago dealt with the challenge women often experience when faced with men as “gatekeepers” to upward mobility.

What have been your greatest challenges when confronting the male monopoly on power and men as gatekeepers on the upward path to leadership?

There was definitely a problem early in my career. Moving up depended a good deal on having a mentor who paved the way. At the beginning of my career, after I received my MD from Woman’s Medical College of Pennsylvania and completed my residency in medicine at Montefiore Hospital in New York, I went to the University of Chicago first as a physician at the Student Health Services and then as an assistant professor in the Department of Medicine.

I served year to year on a one-year appointment for three years and then asked for a regular three-year appointment. I was told by the chairman of the Department of Medicine that he would never give a married woman a tenured track appointment because she would leave and go where her husband’s career took him. Needless to say, I was unhappy about the situation and told him “thanks, but no thanks” to another one-year appointment. That was in 1960. At that time, of course, there were no laws about discrimination and affirmative action.

Luckily, colleagues referred me to Dr. Mark Lepper at the University of Illinois, College of Medicine, and Presbyterian–St. Luke’s Hospital, Chicago. Mark offered me a faculty appointment in the Department of Preventive Medicine at the University of Illinois and arranged an appointment as assistant attending physician at Presbyterian–St. Luke’s Hospital. This led to a series of succeeding appointments and long-term collaboration.

In many ways, Mark was a mentor who opened doors for me. Most specifically, he appointed me research director of a study of health needs of poverty populations funded by the Office of Equal Opportunity (OEO). It was this study that led to recommendations that health centers to serve the disadvantaged be opened in Chicago. The study was well received by the OEO and resulted in the further development of a proposal to open a health center on Chicago’s West Side. The West Side’s Mile Square organization approached Presbyterian–St. Luke’s about developing such a health center. We put together a proposal for an OEO-funded Mile Square health center. The proposal was successful, and Mile Square Health Center was the second OEO-funded health center in the country. I served as its director for five years.

During this same period of time, I was promoted to attending physician and director, Section of Community Medicine, at Presbyterian–St. Luke’s Hospital. As the only woman to head up a section, during staff meetings I was the lone woman sitting around the table with all the men. They were more or less accepting of me, but I could sense that in their eyes I was not quite an equal. I walked a thin line between asserting myself and not being too assertive.

When Dan Walker became Illinois’s governor in 1973, he said he was going to appoint women to his cabinet. He did, and I became the first woman to be named the director of a state public health department. I think I ought to thank the women’s movement!

What changes in the male monopoly are occurring as we move into a new era with a new vision about women as leaders and managers?

Things are certainly changing. Obviously there are now laws against overt discrimination against women. But just as important as the legal ramifications of discriminating against women (or anyone else), the fact is that women have proved themselves capable and are accepted as leaders and managers. In addition, women are networking more. Not being the only woman sitting around a table with a group of men makes a real difference in relationships with colleagues. And the younger generation of men is much more accepting of women in peer relationships. Men who are not comfortable with women as leaders and managers and who do not accept them as colleagues are a dying breed.

How did you counteract the obstacle of discrimination in the workplace because you are a woman? Was discrimination more or less a problem as you moved from mid-level management to top leadership roles?

Of course the way I counteracted the first obstacle at the University of Chicago was by leaving. Beyond that, I think I just did the best job I knew how to do. I worked hard to be sure that I met every expectation and did not give anyone any excuses to criticize me because of my gender.

Then again, sometimes I just ignored the problems, and sometimes I took a little action. For example, at Presbyterian–St. Luke’s, we would sit around the table and select interns and residents. We would come to a woman applicant and the men would make comments like, “Let’s take her … she is really attractive.” I would wait until we came to a likely male applicant and then I would say, “Yes, I think we should take him … he’s quite a handsome fellow.”

Problems related to discrimination because of my gender became less and less as I moved up. It was easier working with younger men and women. But some of the “old timers,” both in terms of age and length of service in an agency, were still a problem that had to be faced.

Is it your sense that leadership opportunities are increasing or decreasing for top leadership positions for women?

In many ways, top leadership opportunities for women are increasing. For instance, more women are serving as directors of state health departments, as deans of schools of public health, and in high-level leadership positions at all levels of government. On the other hand, I look at medical school professorships and I’m not sure that the number of women professors has increased. I think people are looking for women to fill leadership roles, but it is still a problem when you look at the top jobs.

Are the opportunities for women to fill leadership positions greater or lesser in the field of public health?

There are greater opportunities for women in public health. I think one reason for this is the more liberal nature of the public health field, the result being more opportunities and less discrimination. Public health professionals have a commitment to equality, social justice, women’s rights, minority rights, etc. In addition, a career in public health often gives a woman the opportunity to be a leader in politics and in government by virtue of the position she holds.

Are the attributes and characteristics of successful women leaders different than they are for successful men leaders?

Women’s leadership styles tend to be different from men’s to some degree. Whether those differences are the things that account for success is the question. Are women more successful as leaders because they have different values and styles? This is a research question and an issue that is currently being studied. In my experience, especially earlier on in my career, I found women to be more sympathetic, compassionate, much less aggressive, less domineering, and more inclusive … all very valuable traits when one looks at leadership. We know now that research studies regarding capable leadership indicate that those who have an inclusive leadership style are more effective. Obviously, there are always exceptions to this rule. Taken as a whole, the inclusive leadership approach is lower key; it is more sharing and more “motherly.” One of the best compliments I received as assistant director of the Office of Technology Assessment was that I was good at “mothering” them, but I could also kick their rears when I needed to!

In addition to being a successful public health leader in a variety of forums, you are also a wife, mother, and grandmother. How did you integrate the workplace with your private life responsibilities and “juggle” the complexities that resulted from your various roles?

It has been a real juggling act! Of course, things got easier as my three children grew up, but at times it was wild! One of the very conscious decisions I made early on in my career was to move toward public health and research in the medical care area because it was less competitive and would result in a less intensive demand on my time, which gave me more time to be with my family. Before I made this decision, I had been working in infectious diseases. I observed how competitive this field was and felt that with three young children at home it wasn’t what I wanted to do. I wanted to be home with my husband and children at night and on the weekends, holidays, etc. When the children were all in school and busy with their individual activities, the balancing act became easier. Also, I was very fortunate in having the same full-time housekeeper for over 20 years.

My need to spend time with my family was one of the main reasons why I decided to go into public health and medical care research. It was really serendipity … opportunity knocked through Mark Lepper’s mentoring, and I was there.

The present job market is very competitive for public health practitioners regardless of gender. What leadership skills are most important for women to cultivate who are currently at the lower and middle levels of a public health organization?

First and foremost, one needs to know one’s field. One has to be looked at as one who is a good problem solver. My advice is to learn how to be objective and analytical and how to be fair. Other important leadership skills include developing an inclusive leadership style, learning how to be a good listener and to reflect on what you hear. One leadership skill that is absolutely essential is knowing how to relate well to other people and to be honest in those relationships.

As public health redefines its role within a new healthcare delivery system that is likely to emerge as the result of some form of healthcare reform, will there be different or “new” opportunities for women in public health leadership positions?

If the whole healthcare system becomes more and more competitive through a corporate approach, some women will be able to fit into that structure as leaders. If we move into a system that is accountable for populations (core functions included), opportunities for women to attain top leadership positions certainly should increase. As public health grows and strengthens its positions as an integral part of the healthcare delivery system, there will be increasing leadership opportunities for both women and men.

One way for public health leaders to deal with diversity issues is to empower staff so that they become advocates for themselves. It is important to understand how human beings in our society act and what needs they have. In his classic work Motivation and Personality, Maslow defined a hierarchy of needs.26 At the most basic level, individuals want their physiological needs met. Second in order of importance are their safety needs. In other words, issues of job security and amount of income are critical for most people. Next come social needs, including the need for recognition by colleagues. One level up, people want to experience a sense of self-esteem. They want to take pride in their work and hence want to be empowered to do a good job. A professional who works well and without the need of much direction will usually be allowed the freedom to design his or her own activities, an almost sure way of increasing self-esteem. Finally, people have a need for self-actualization—the ability to make personal dreams become reality.

Balancing Work and Play

Work has a tendency to take up most of a leader’s waking hours, and family life can suffer as a result. O’Neil called this dilemma the paradox of success.27 In his view, the myth of success is that success offers complete fulfillment, that success is tied to how much money is made, and that success increases freedom. In fact, success causes a constant craving for more success and hence can lead to a kind of bondage. Factors that can help a leader keep a balance between work life and private life include self-knowledge, managing conflicting pressures, and maintaining a concern for how others feel.28

Women seem to be proficient at balancing personal and professional interests. For working women with a family, work and home are full-time jobs that they typically seem to handle equally well. At work, women, by redesigning their positions and demanding employee training and development, are helping to break traditional organizational molds.29 They are also helping to break down the barriers between home and work by pushing for flex time, child care, and family leave.

This section raised and discussed many issues related to personal leadership development. Following is a list of leadership strategies that can be used to increase one’s leadership skills and abilities:

• Be a value role model. Live the values that the community espouses.

• Understand the democratic process and how it affects the public health system.

• Translate political policy into action.

• Improve communication skills.

• Be a mentor to others.

• Learn to follow when appropriate.

• Be partners with the agency’s governing board.

• Learn agenda-setting skills.

• Address barriers to effective public health practice.

• Explore community partnerships.

• Be creative in finding new funding sources.

• Balance work and family.

• Increase leadership opportunities for others.

LEADERSHIP AT THE TEAM LEVEL

Public health leaders do not work alone. Public health practice is a group activity. Therefore, among the most important skills a leader can possess are those that are necessary for building and maintaining teams and increasing their effectiveness. It almost seems that somebody always wants to take charge when even two people are in a room.

A team is a group of people who come together to pursue a common purpose.30 The results of the team’s activities are often greater than the sum total of the results that would have occurred had each team member been acting alone.

Each team member should be viewed as leader although one person will generally become the official leader. The team leader will share information in an equitable manner with other team members.31 The leader will build trust in the team process and share authority and power with other members. The leader will also intervene when necessary to move the team forward. The expectation is that all members will be involved in the performance of the team tasks.

Team members who are also members of the public health agency may need to act as a link between the team and the agency and community constituents. These team members, in particular, will need to learn the skills of conflict resolution and negotiation. When a skilled leader guides the team process, creativity and innovation are the result.

Reasons for Creating Teams

The reasons for creating teams include the following: First, a team allows an organization to use the leadership skills and talents and the multidisciplinary and multicultural backgrounds of its staff. For example, a multidisciplinary team that includes nurses, social workers, and environmental health specialists, among others, might be assembled to address the low level of prenatal care in the community. If we add on multicultural team members, potential conflicts may arise due to different cultural orientations related to prenatal care. Second, creating a team allows the members time to get to know one another and to develop a sense of togetherness in the context of shared leadership. In general, team members find they can communicate with each other better even once they have left the team or the team has been disbanded. In addition, they learn how to cooperate and collaborate, and cooperation and collaboration increase productivity.32 Finally, team decision making produces decisions that are supported by the majority of the team’s members.

Teams that are created to lighten a supervisor’s workload are often doomed to failure.33 Teams are not a replacement for training and not a way for leaders to observe the opinions and working style of the staff. Teams do not necessarily increase the personal productivity of their members. They need leaders to clarify issues and set the parameters of their activities.34 One of the strengths of teams is that they are flexible and can reorient themselves as roadblocks occur. Yet the freedom teams are given can be a weakness as well. Teams sometimes fail because they lack discipline and a sense of responsibility for achieving the desired outcomes. When team members realize they will be completely in charge of their activities and will have the power to make decisions, they sometimes abuse this power, with negative results for the agency. This risk can be reduced if the agency leaders make clear to each team how they expect it to proceed and what results they expect it to achieve.

Leadership teams work differently than management teams. Management teams carry out the instructions of a supervisor. Their tasks are circumscribed, and there is very little room for creativity or innovation. Leadership teams share leadership with the public health administrator, who openly delegates decision-making power to them. In some leadership teams, the health administrator becomes a team member. If given the trust of the agency administrator, leadership team members become committed to the agency and lose their fear of reprisal. They feel that they are respected for their expertise and ability to innovate. They also know that their recommendations will be seriously considered.

Facts about Teams

Katzenbach and Smith studied teams in 30 organizations, including businesses, schools, and social agencies.35 They found that teams were critical for building quality organizations and improving customer service. The authors came up with 10 findings about teams in general.

The first finding is that teams are created to address a performance challenge, and indeed a leadership team must have a purpose (mission) if it is to succeed. The second finding is that the team’s composition and its purpose need to be thought through. Not every leadership team should be of the same size or professional composition. Third, leaders need to promote team performance opportunities. As the leaders view the organization, they will find these opportunities exist throughout. Fourth, many teams composed primarily of people at the top fail because of the other demands made on these individuals’ time and energy. Fifth, organizations and their leaders find it easier to work with individuals than with teams. Everything, including the hiring of people, the determination of salary, the construction of career paths, and the monitoring of performance, is oriented toward the individual. Teamwork seems to go against the structure of individual responsibility.

The sixth finding is that organizations committed to high performance standards are more likely to use teams than organizations with lower performance standards. Seventh, very few high-performance teams exist. High-performance teams can be either leadership or management teams. However, leadership teams are generally clearer on the purpose for which they were created. They take control of their activities and promote the development of relationships between their members. They build team activities on good communication. The leaders maintain their flexibility, work productively together, and recognize the accomplishments of their leader colleagues. Leadership teams also seem to have high morale. (High-performance teams can be created using the PERFORM model, propounded by Blanchard and colleagues.36 The acronym stands for Purpose, Empowerment, Relationships and communication, Flexibility, Optimal productivity, Recognition and appreciation, and Morale.)

The eighth finding is that teams do not replace organizational hierarchies. Instead, teams enhance these hierarchies, partly because they are able to cross over structural boundaries. Because of the strong community orientation of public health agencies, leadership teams can be used to address community concerns. These teams may include community partners among their membership.

The ninth finding is that teams are small learning organizations that integrate performance and learning. Typically a team will do research on a subject related to its purpose. Team members also learn team-building and leadership skills. They often learn that each member is a leader or potential leader. The conjoining of performance and learning in teams is generally a plus, because their conjunction throughout an organization is often a prerequisite for the organization to increase its effectiveness. This applies to public health agencies as well.

The final finding is that teams are effective in addressing new issues as well as old issues. In the case of old issues or problems, they often discover new solutions. One reason teams are good at discovering solutions to problems is that they view the problems from a systems perspective rather than using the traditional cause-and-effect approach.37 They are also experts at sharing information and coordinating actions, and members of one team frequently tie their activities to the activities of other teams working on different though related issues.

The important question is why so many teams fail when their importance to the work of public health is so important. Lencioni pointed to five major dysfunctions that affect the success of team-based activities.38 First, teams fail when there is a lack of trust either in their organization or in their leadership. This includes the implicit leadership of the team as well. Second, team members fear conflict and contesting the decisions of other team members. Conflict is not necessarily a personal issue, but rather is often an issue related to the challenge that the group must address. The third dysfunction relates to the level or lack of commitment of team members to the process. The Leadership Wheel pointed to the important dimension of values clarification and the need to get all team members to commit to the team activities or project. If there is a lack of commitment, then the fourth dysfunction occurs. The lack of accountability will often affect the effectiveness of team activities. The fifth dysfunction relates to the problem of ignoring the results of the teamwork regardless of the reasons. If the boss had the team do busywork or did not allow the team any involvement in the decision-making process, all the dysfunctions come into play. There will be no trust, no conflict on the surface, no commitment to the process, no accountability, and obviously no attention to the results.

Teams build social capital, which brings people together in a way that individuals alone cannot do. Building social capital helps to develop trust, allows for shared leadership and creativity, expands social networks for the team members, develops shared purpose in team activities, levels the playing field for the members in terms of equity, increases collaboration and commitment, enhances knowledge sharing, and fits different talents of individuals into a comprehensive whole.39 At the individual level, teamwork provides many benefits to the individual as well and creates satisfaction and sometimes personal rewards in the accomplishments of the team.

Team Classification

Many writers have attempted to classify teams. One helpful classification is as follows:40 Natural work teams are made up primarily of individuals who work together as part of their regular activities. These teams, which can be either management or leadership teams, are usually given a set of designated activities to perform. Cross-functional teams, the second type, include members who have different functions within the organization. They are primarily leadership teams. Corrective action teams are management teams assigned to work on the solutions to problems that are already determined. Finally, hybrid teams address issues not addressed elsewhere in the organization. They may be either management or leadership teams, and they utilize the techniques associated with all the other types. Local public health departments use all four types of teams.

The Importance of Empowerment

Teams and their members need to be empowered by administrators to take active decision-making roles.41 Empowerment, which gives team members the freedom to use their knowledge, experience, and skills to address important issues,42 tends to increase their commitment to the agency and the level of their performance as well. Empowerment must come from the agency leader, and there appears to be a direct relationship between the amount of responsibility staff are given and the degree of their empowerment.43

The transfer of power to a team must be real and not merely nominal. A public health leadership team from a state public health leadership institute worked with a local health department to develop a lead-screening program for children. The administrator allowed the team to work on the creation of this new program because she had been told by the state to develop the program. However, the administrator viewed the team members as outsiders, and though she told them that she had respect for them and would seriously review any recommendations they made, she used the team merely to show the state that she was complying with its request and in reality had no intention of implementing the team’s recommendations. This is an example of team activity subverted by a hidden agenda. The power to have an effect on the development of a program through recommendations was implied but was in fact an illusion.

As Figure 6-2 shows, empowerment is related to organizational values, leadership activities, human resource systems, and the structure and activities of the organization. Empowerment is often used as a tool for the improvement of programs and services.

FIGURE 6-2 Empowerment in Contemporary Organizations. Source: Reprinted with permission from R. S. Wellins, W. C. Byham, and J. M. Wilson, Empowered Teams: Creating Self-Directed Work Groups that Improve Quality, Productivity, and Participation. p. 23, © 1991, Jossey-Bass Inc., Publishers.

Teams and Leadership Style

The situational leadership model identifies four leadership styles: directing, coaching, supporting, and delegating. This same classification can be applied to team-based activities.44 When a team is first created, the leader is involved in formulating the team’s purpose and determining the activities to be performed. The leader, in other words, is using a directive style. During the next phase, the leader, acting as a coach, clarifies the team’s activities. The leader then begins to involve team members in decision making, a process that falls into the category of providing support. In the final phase, the leader empowers the team members, and empowerment, as pointed out above, is closely related to the delegation of responsibility.

It is also important to concentrate on the leadership activities associated with working on teams. LaFasto and Larson discussed the six tasks of team leadership.45 First, leaders clearly need to focus and pay attention to the goals of the project that will occur during the teamwork. Second, the critical nature of collaboration within the team to get the work done is an important leadership activity. Third, team members like to think and feel that the team process builds their confidence in the way the work is progressing. Team members want to see short-term and long-term results in the work. Team leaders need to help build this confidence and need to be willing to keep team members knowledgeable about external events that affect the work of the team. Secrets defeat teamwork. The fourth leadership activity involves leaders demonstrating technical knowledge and abilities. This activity also means the leader will ask for help or technical assistance when necessary. The fifth leadership activity involves keeping the team on track by setting priorities. It is important to keep the team on task and prevent distractions if possible. When priorities change, leaders must make note of this to the team. The sixth and final task relates to the necessity of managing performance, giving feedback through the group process, and rewarding results.

Team Preparedness

Of course, teams are at different places in their involvement in and commitment to the tasks they have been assigned, and leaders need to monitor team readiness, which ranges from unable and unwilling to carry out the team assignment to able, willing, and confident. In some cases, leaders may have to utilize planning strategies for key team members as well as for the team as a whole.

One useful team technique, based on the so-called skunkworks model, is to send a team to a neutral place away from the organization to work on issues related to the team’s activities.46 The “skunkworks” is a subteam composed of experts on the topic that is the focus of the team activities. These team members tend to be transformational leaders who will move the organization forward.

Team Members

Mallory studied the characteristics of various types of team members.47 Some members tried to take control of the activities of the team, and these he labeled dominant members. These individuals do well in structured situations with a well-defined purpose. The influencers tend to be creative and extremely talented in interpersonal relationships. They also tend to be optimistic and try to keep the team together. The balancers look at the big picture in an objective manner and try to reconcile the differences among the team members. The loyalists are committed to the status quo. Each actual team member, although mainly of one type, has at least a little of every personality characteristic associated with any of the four types. Exercise 6-2 is based on this personality typology. It is intended to get you to reflect on the type of team member you are likely to be.

Team members benefit in several ways from working on a team. First, they gain experience in working together with colleagues on a project.48 They also learn problem-solving skills, interpersonal relationship skills, and new technological information. In addition, they learn about accountability from a personal perspective as well as a team perspective and become more committed to the team’s goals and objectives.

The Life Cycle of Teams

Teams have a life cycle that is similar to the life cycle of human beings.49 A team starts out as an infant and disbands as it ages and finishes its tasks. Organizational leaders must develop the ability to function as team leaders at each stage of the team life cycle. This is especially true in the public health field, where so many leadership activities occur in a team setting.

Following are guidelines that organizational leaders should use when creating and working with teams:

• Develop teams to address agency or community public health problems.

• Choose multidisciplinary team members for their expertise and leadership qualities.

• Allow teams to make decisions and recommendations for change. Share power and control.

• Share information.

• Intervene in the team process when necessary.

• Do not create teams to alleviate your workload.

• Use the skunkworks technique for dealing with team issues.

• Tie team development to performance standards.

• Put a time limit on the activities of the team.

LEADERSHIP AT THE AGENCY LEVEL

In a 2011 book on management in the health field, the authors claimed that managers nowadays have to integrate clinical practice skills and management skills.50 The view propounded here is that public health leaders have to integrate public health practitioner skills, management, and leadership skills.

Currently, public health agencies typically have a management orientation. In the 21st century, they will need to become consumer and community driven.51 The leadership expertise of agency staff will need to be increased if the agencies are to keep up with the speed of change. Figure 6-3 shows the relationships among management theories, the healthcare environment, clinical expertise, and consumer healthcare expectations. Most of the items listed are relevant to public health as well as medical care. Two missing items that pertain particularly to public health are building community coalitions and health promotion and disease prevention.

Public health agencies, along with other types of organizations, are undergoing many reforms but need to change further. For one thing, they have not fully incorporated the lessons of business. They are still run as traditional bureaucracies, although community groups are trying to take a role in the making of decisions about public health issues.

In a bureaucracy, the managers and leaders are often far removed from the daily activities of the staff,52 yet they feel the need to control these activities. Perhaps this is one reason that Peters and Austin urged the importance of “managing by wandering around.”53 Of course, it is true that leaders need to monitor operations, but they also need to delegate authority to managers and staff members.54 By doing this, they can help make the professionals in their organization excited about coming to work in the morning. Leaders need to remember that associates are customers too.

FIGURE 6-3 Characteristics of the Healthcare Management Role. Source: Reproduced from J. G. Liebler and C. R. McConnell, Management Principles for Health Professionals, 4th ed. Sudbury, MA: Jones & Bartlett, 2004.

In the late 1950s, Drucker noted that traditional bureaucratic organizations were gradually becoming knowledge-based organizations.55 Public health agencies have always been knowledge based, and in fact the business community can learn much from public health leaders about knowledge-based organizations and how they work. However, the models for knowledge management are more developed on the business side. For example, Tiwana has examined the four phases of knowledge management strategies for knowledge-based organizations.56 First, it is necessary to evaluate the current structure for dealing with knowledge in an agency (an infrastructure issue). Second, it is important to develop the system related to knowledge in terms of the analysis dimension, the design of the system, and how it is developed. Third, the issue of deployment and how to use the results of the system becomes critical. Finally, it is necessary to determine the return on investment for the system, the performance evaluation of the system, and making refinement as necessary. Public health leaders have an important role in knowledge management. It will be important for leaders to apply these phases to public health and to modify the models to better reflect the knowledge management aspects of public health practice.

Public health leaders, in order to thrive in the ever-changing environment, need to make a commitment to change and to focus on increasing customer satisfaction, fostering innovation, empowering staff, and instituting appropriate structural reforms.57 Leadership is not just a matter of charisma; it is hard work.58

Nanus identified four main leadership roles ( Figure 6-4 ).59 First, public health leaders (to keep to the focus of this discussion) are spokespeople who present the contemporary public health issues to the community. Second, they are “direction setters” and involve community leaders in prevention activities and in the search for ways to increase the level of health in the community. Third, they act as coaches or mentors for agency associates as a means of improving the agency’s effectiveness. Finally, they act as organizational change agents.

Looking into the Future

If public health leaders are oriented to change and want to become catalysts for change, they need to develop program scenarios for possible futures. This means that they should look for societal trends to guide agenda setting for the agency. They need to be students of change, in other words, and look closely at the predictions of futurists.

The social scientist Alvin Toffler tried to make sense of the changes that are occurring now by looking at past periods of vast social change.60,61 Toffler identified three waves of societal and organizational change. The first wave was the agricultural revolution, the second was the industrial revolution, and the third, which is occurring now, is the information revolution.

Toffler developed what he called social wavefront analysis, by means of which a scientist can supposedly analyze the leading edge of a wave to predict its future. In Creating a New Civilization, he and Heidi Toffler examined the effects of the shift from the second wave to the third wave.62 Political tensions have arisen between those whose thinking was formed during the industrial period and the new leaders of the information age. An interesting question can be framed regarding the current structure of government in this country. If government reflects its era, does this mean that the old governmental organizational structures, created prior to the industrial age but refashioned during that era, are now obsolete and need to be reworked to fit the information age?

If Alvin Toffler is correct, then public health will undergo major reforms in the 21st century. Even if he isn’t, it is unimaginable that public health will remain perfectly static. The developments and trends likely to drive changes in public health agencies in the 21st century include the following:

New models of public health. The direct service activities of local public health departments will continue to decline in the next 20 years.63 New program and service models will emerge, and community-based public health activities will increase.

Team-based problem solving. More multidisciplinary teams, both ad hoc and permanent, will be created to address public health concerns. Use of the team approach will lead to the structural leveling of organizations. Team success will empower the public health workforce and increase the self-esteem of individual health professionals.

Community health coalitions based on partnership. Public health activities take place in a community setting. Consequently, community partners as well as staff members need to be empowered. Also, partners need to have their expectations met and even exceeded.64 If their expectations are exceeded, they will become “raving fans” of the agency.

Privatization of assurance activities. Privatization of service provision and program development will become a reality in the future. One local health department struggled with running a mental health program in its county. It also owned the building where mental health services were provided. The program was being operated at a loss, and the health department decided to contract out the delivery of mental health services. A contract was signed (although the department kept oversight responsibility), the building was sold, and the deficit vanished.

Decentralization of responsibilities. Community partners can do some of the work. If they become involved in public health, all sorts of activities will occur. Empowered communities address community issues.65 Financial issues become less important because community volunteers will find a way to get things done even when the money is not there. Power must be shared to be effective.

Community-wide governance. Governance will need to be incorporated into the activities of the agency and the activities of the community partnerships.

Revision of values. Public health leaders not only will be protectors of the community’s values but will help create new or revised value statements that reflect societal and cultural changes. It is interesting to note that politicians defend the status quo, whereas organizational leaders support the generation of new values. Nonetheless, there seems to be a lag between the development of new values in the society and their adoption at the agency level.

New political structures. There appears to be a trend on the horizon that may affect the future activities of agencies in the public sector. A number of states and local jurisdictions have combined public health departments and human services departments into superagencies. These mergers have caused some public health professionals to wonder whether public health has a future. However, my study of public health leaders indicated that these leaders are generally very hopeful about public health. Public health problems will not go away and will still have to be addressed by agencies headed by public health leaders.

Third-wave leaders. The leaders of the new age are breaking down barriers to collaboration. These leaders know how to build their agencies using self-directed teams with high performance standards. Third-wave leaders also are expert at community building and empowerment. The goals of the agency become integrated with community goals. Third-wave leaders are innovative, creative, flexible, and adaptable to change.

Integration of individual and community goals. Public health leaders must articulate the relevance of public health initiatives to the personal life of individual citizens. In an interview, one public health leader talked about an initiative designed to respond to the nationwide increase in tuberculosis cases. The leader, who worked for a congressional representative, pointed out that tuberculosis would need to be present in the representative’s jurisdiction for him to be concerned about the problem. The unfortunate fact is that the societal perspective of public health practitioners—the attitude that protection of the public’s health is a matter of social justice—has yet to be accepted by our elected officials.

Complete community empowerment. Citizens as well as public health professionals need to be empowered to carry out public health activities. Empowerment leads to shared responsibility for addressing the public health needs of the local jurisdiction.

Universal access to services. The service system of the future will be comprehensive. Programs will be integrated across agencies, and community coalitions will work together to address health needs. Leadership will be shared. The passage of health reform legislation in 2010 appears to be changing the healthcare system in the United States in spite of criticisms of this legislation.

Because of the terrorist events of September 11, 2001, preparedness will take center stage in the activities of public health with new skills required of public health leaders in this new environment. Although public health will still be local in practice, it will be global in perspective and orientation.66 The future of American society will be affected by globalization, the expanding of information technology, our chronic financial deficits, and our high energy consumption.67 Friedman and Mandlebaum argue that it is possible to address these issues and come to positive outcomes, although these outcomes need much work to become reality. These concerns will affect what public health and its infrastructure will be like in the future.

Public Health Functions

From the 1840s to the 1940s, six basic local health agency functions evolved: the collection and interpretation of vital statistics, sanitation, communicable disease control, the provision of maternal and child health programs, health education, and the provision of laboratory services.68 Between 1940 and 1980, other functions were added, including the provision of environmental health services, the development and provision of personal health services, the coordination of community health services, the operation of medical care and public health facilities, area-wide planning, and the assessment of the adequacy of health services. The year 1988 saw the release of the Institute of Medicine report on public health. This report promoted the use of core functions to organize the activities of public health at the community level.69

Public health leaders have changed as public health has changed. They have adapted to new developments and devised innovative approaches to performing the standard public health functions. Although somewhat dated, Table 6-1 presents a comparison of the activities of a local health department in 1947 and 1995.70 Since 1995, local health departments have continued to change. Many direct service activities have been outsourced. Local health departments have reoriented some of their activities to emergency preparedness and response activities.71 I discussed this table with Dr. Bernard Turnock, who pointed out that the determination of which performance measures predominate at a particular point in time is somewhat subjective. Different organizations, performance management committees, and public health professional writers will often come up with different lists of measures. Thus, it is important to determine the credibility of the source.

TABLE 6-1 Comparison of Public Health Practice Performance Measures Used in 1947 and 1995

Examples of Performance Measures from Evaluation Schedule (1947)

Hospital beds: percentage in approved hospitals

Practicing physicians: population per physician

Practicing dentists: population per dentist

Water: percentage of population in communities over 2,500 served with approved water

Sewerage: percentage of population in communities over 2,500 served with approved sewerage systems

Water: percentage of rural school children served with approved water supplies

Excreta disposal: percentage of rural school children served with approved means of excreta disposal

Food: percentage of food handlers reached by group instruction program

Food: percentage of restaurants and lunch counters with satisfactory facilities

Milk: percentage of bottled milk pasteurized

Diphtheria: percentage of children under 2 years given immunizing agent

Smallpox: percentage of children under 2 years given immunizing agent

Whooping cough: percentage of children under 2 years given immunizing agent

Tuberculosis: newly reported cases per death, 5-year period

Tuberculosis: deaths per 100,000 population, 5-year period

Consolidated Panel of Core Function-Related Performance Measures (1995)

Assessment

For the jurisdiction served by your local health department, is there a community needs assessment process that systematically describes the prevailing health status in the community?

In the past three years in your jurisdiction, has the local public health agency surveyed the population for behavioral risk factors?

For the jurisdiction served by your local health agency, are timely investigations of adverse health events, including communicable disease outbreaks and environmental health hazards, conducted on an ongoing basis?

Are the necessary laboratory services available to the local public health agency to support investigations of adverse health events and meet routine diagnostic and surveillance needs?

For the jurisdiction served by your local public health agency, has an analysis been completed of the determinants and contributing factors of priority health needs, adequacy of existing health resources, and the population groups most affected?

In the past three years in your jurisdiction, has the local public health agency conducted an analysis of age-specific participation in preventive and screening services?

Policy Development

For the jurisdiction served by your local public health agency, is there a network of support and communication relationships that includes health-related organizations, the media, and the general public?

In the past year in your jurisdiction, has there been a formal attempt by the local public health agency at informing elected officials about the potential public health impact of decisions under their consideration?

For the jurisdiction served by your local public health agency, has there been a prioritization of the community health needs that have been identified from a community needs assessment?

In the past three years in your jurisdiction, has the local public health agency implemented community health initiatives consistent with established priorities?

For the jurisdiction served by your local public health agency, has a community health action plan been developed with community participation to address priority community health needs?

Examples of Performance Measures from Evaluation Schedule (1947)

Tuberculosis: percentage of cases reported by death certificate

Syphilis: percentage of cases reported in primary, secondary, and early latent stage

Syphilis: percentage of reported contacts examined

Maternal: puerperal deaths per 1,000 total births, 5-year rate

Maternal: percentage of antepartum cases under medical supervision seen before sixth month

Maternal: percentage of women delivered at home under postpartum nursing supervision

Maternal: percentage of births in hospital

Infant: deaths under 1 year of age per 1,000 live births, 5-year rate

Infant: deaths from diarrhea and enteritis under 1 year per 1,000 live births, 2-year rate

Infant: percentage of infants under nursing supervision before 1 month

School: percentage of elementary children with dental work neglected

Accidents: deaths from motor accidents per 100,000 population, 5-year rate

Health department budget: cents per capita spent by health department

Consolidated Panel of Core Function-Related Performance Measures (1995)

During the past three years in your jurisdiction, has the local public health agency developed plans to allocate resources in a manner consistent with the community health action plan?

Assurance

For the jurisdiction served by your local public health agency, have resources been deployed as necessary to address the priority health needs identified in the community health needs assessment?

In the past three years in your jurisdiction, has the local public health agency conducted an organizational self-assessment?

For the jurisdiction served by your local public health agency, are age-specific priority health needs effectively addressed through the provision of or linkage to appropriate services?

In the past three years in your jurisdiction, has there been an instance in which the local public health agency has failed to implement a mandated program or service?

For the jurisdiction served by your local public health agency, have there been regular evaluations of the effect that public health services have on community health status?

In the past three years in your jurisdiction, has the local public health agency used professionally recognized process and outcome measures to monitor programs and to redirect resources as appropriate?

For the jurisdiction served by your local public health agency, is the public regularly provided with information about current health status, healthcare needs, positive health behaviors, and healthcare policy issues?

In the past year in your jurisdiction, has the local public health agency provided reports to the media on a regular basis?

Not all states have local public health agencies. In states that do not, the state health department operates like a local agency. In states with local agencies, the activities of the state health department leaders are separate from the activities of the agency leaders. For example, state health departments have tended to stay away from the provision of direct services, especially in the case of services being provided by local public health agencies.72 A state health department may provide special services that the local agencies do not offer. It is also likely to be engaged in overseeing and coordinating public health activities in the state.

State health department functions include communicable disease control, tuberculosis control, venereal disease control, acquired immune deficiency syndrome monitoring, sanitation, industrial hygiene, dental health, laboratory services provision, public health nursing, case management, maternal and child health program provision, public health education, technical assistance, public health workforce training, development of new local health departments, epidemiologic surveillance, regulation of healthcare facilities, licensure, inspection, cancer screening, and many more. The state health department also serves as the repository for state health data. Since 2001, the activities related to emergency preparedness and response have been added to the list. There clearly is still a need for inclusion of emergency mitigation and recovery dimensions for public health work as well.

State health department leaders are responsible for organizing the state public health system to reflect its mission, vision, and goals and objectives. They need courage to carry out their action plans in the face of community opposition and must know how to reform the state public health system without overstepping the boundaries of the state political system, for, among other reasons, the state is the conduit for funding for local public health agency programs.

In order to see where our performance measurement thinking is today, Table 6-2 shows the measures determined by the United States Department of Health and Human Services in 2011. There are five major goals for public health and a number of objectives tied to each goal. The measures do provide a framework for state and local health agencies and their leaders to guide public health programs in the future.

TABLE 6-2 HHS Performance Measures, 2011

1 Target provided from Douglas W. Elmendorf, Director, Congressional Budget Office, to the Honorable Nancy Pelosi, Speaker, U.S. House of Representatives, In letter dated March 20, 2010.

2 Cannot project beyond 2013 because young adults may prefer to get their own policies in the Exchanges once they are available.

3 Data from first quarter 2010. Baseline will be updated with full year 2010 data when available.

4 Includes Medicaid incentive payments for adopting, implementing, and upgrading certified EHR technology in the first year.

5 EID (pandemic influenza) products would be eligible for use in a public health emergency under EUA in advance.

6 During FY 2011, in coordination with CMS, the Medicare Administrative Contractors (MACs) and Zone Program Integrity Contractors (ZPICs) will develop a methodology for computing Risk Indicators for Part A and B providers and suppliers similar to the National Supplier Clearinghouse’s (NSC’s) Fraud Level Indicators for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) suppliers and utilize them to identify “high risk” providers. For this measure, Risk Indicators will be defined per the proposed regulations at 42 CFR Parts 424, 431, 438, 455, and 457 Medicare, Medicaid, and Children’s Health Insurance Programs; Additional Screening, Application Fees, Temporary Enrollment Moratoria, Payment Suspensions and Compliance Plans for Providers and Suppliers; CMS-6028-P. Medicare contractors will utilize CMS-developed reporting requirements to compile the data on the numbers of targeted “high risk” enrollment site visits conducted and the percentage which resulted in an administrative action and to track and report the results of the administrative actions (e.g., dollars denied as a result of prepayment review). While the goal is national, based on the aggregate number of “high risk” site enrollment site visits conducted, individual contractors will be strongly encouraged to meet and exceed the national goal to the extent appropriate for the provider population in their jurisdiction.

Source: Reproduced from U.S. Department of Health and Human Services (2011). About the Secretary: Appendix B: HHS Performance Measures. http://www.hhs.gov/secretary/about/appendixb.html. Accessed May 2, 2012.

Responsibilities of Public Health Leaders

Leaders of local public health agencies have the responsibility to promote their agencies. They make sure the agencies are viewed as repositories of public health information as well as providers of high-quality programs and services. They develop relationships with the leaders of public health agencies throughout their state and also develop partnerships with community health providers.

Funding, of course, is critical for strengthening the public health system, and there is currently intense competition in the entire health industry for additional money.73 Public health leaders need to be involved both in the allocation of public health funds and in the funding for related health service programs. They will need to make strong arguments for public revenues. Public health leaders have become more entrepreneurial since the 1990s. They received grants from and developed contracts with public and private funding organizations to supplement their base budgets. Fund-raising needs to be tied to the mission and vision of the public health agency.

Public health leaders are concerned with excellence in public health. They act as role models for emerging public health leaders. They develop benchmarks for best practices. In their oversight role, they motivate community providers to improve their performance. They work with the leaders of other organizations to develop a comprehensive, integrative approach to improving public health in the community. Public health agencies do not want to duplicate programs or services adequately provided by others, although they might offer competing services if the quality of a community provider’s services is open to question.

Public health agency leaders have important responsibilities toward agency staff. They must honestly monitor and evaluate job performance and job satisfaction.74 If job evaluations are done fairly and regularly, staff will be able to learn their full job responsibilities and meet them more effectively. In addition, public health leaders must be enthusiastic about the task of protecting public health and be able to motivate their colleagues to be enthusiastic as well, by fostering collaboration and sharing power with them, for example.75 They also should cheer colleagues and their progress. Einstein’s formula e = mc2 has been reinterpreted as enthusiasm equals mission times cash and congratulations. People have to be cheered, and they also have to be paid for their efforts.

As noted already, leaders need to empower agency staff. Empowerment must occur at the team level, the agency level, and the community level. Table 6-3 presents a list of principles of empowerment.76

In summation, at the agency level public health leaders have the responsibility to:

• understand how the agency functions

• delegate authority whenever possible

• monitor client satisfaction

• develop performance measurement metrics

• make structural changes in the agency to accommodate new or emerging public health issues

• encourage knowledge management systems development

• explore alternate futures for the agency

• apply the core functions model to agency activities

• empower the agency staff and the community residents

TABLE 6-3 Ten Principles of Empowerment

1. Tell people what their responsibilities are.

2. Give them authority equal to the responsibilities assigned to them.

3. Set standards for excellence.

4. Provide them with training that will enable them to meet the standards.

5. Give them knowledge and information.

6. Provide them with feedback on their performance.

7. Recognize them for their achievements.

8. Trust them.

9. Give them permission to fail.

10. Treat them with dignity and respect.

LEADERSHIP AT THE COMMUNITY LEVEL

Leadership at the community level requires more systems-based skills than are utilized at the team and agency levels. At this level, public health leaders work to increase the visibility of the public health agency. In interviews with 100 American public health leaders, the author found consistent agreement that the public lacked in-depth knowledge about public health. Thus, public health leaders have a duty to provide public health information to the business community, the medical and health industry community, social agencies, and the general public. Public health leaders need to develop skills in community building in order to work with community groups to create an environment for positive social change.

Figure 6-5 shows the dimensions of public health leadership. Public health leaders build on the core functions model, regardless of the level of leadership, while taking into account the political and social realities that affect the agency and the community. Public health agencies must take into consideration social and political issues if they are to survive. For one thing, they are mandated by funding sources to provide certain basic services and programs. (This raises the issue of the proper balance between mandated services and community-based services and programs not included in the mandated services protocol.)

The Nature of Community

Over the past couple of decades, business discovered community.77 Business leaders now see that community involvement needs to be part of the practice of business. Public health agencies, by their nature, serve communities, but serving a group of citizens who live in a specified geographic area does not mean community issues are being addressed. My study of public health leaders found that their efforts at developing community coalitions have been uneven at best. Almost all of the respondents stated that public health agencies have not been successful in getting the public to understand public health.

FIGURE 6-5 Dimensions of Public Health Leadership.

Community is more than bricks and mortar. It is more than a place to live. It is the place in which our dreams and aspirations are or are not fulfilled. When we talk about improvement in our quality of life, community is part of the improvement process. Community is the place where values are put into action. Community is a complex system made up of individuals, families, politicians, health organizations, human services agencies, churches, schools, businesses, business organizations, and so on ( Figure 6-6 ). It is a system that accepts challenges, and to develop the resources to deal with them it needs to be built on the strengths of its constituent parts, not on their weaknesses.78

One view currently prevalent is that we need to rediscover civility.79 Civility requires that community leaders be open to the opinions of other people and other organizations. It also means that it is important to not degrade others. If civility training needs to be done, it should include a discussion of civility and its components, the relationship of civility to leadership, problem solving and decision making, conflict resolution and negotiation, levels of collaboration at the vertical and horizontal levels, systems thinking, values and ethics, and the relationship of civility to trusteeship. Furthermore, public health leaders must transfer the leadership skills they use at the team and organizational levels to the community level. Leaders build communities in all their leadership activities.

It should be noted that public health concerns are part of almost every crisis that confronts a community. Exercise 6-3 is intended to explore what is likely to occur when a community experiences a natural disaster.

Advocacy through the Media

Media advocacy is an important way to promote public health programs and services.80 The use of social media like Facebook and Twitter is another approach. Public health leaders should learn how to use the media to create support for agency goals. For example, they should consider sending letters on a regular basis to newspapers and other sources to increase the visibility of public health.

FIGURE 6-6 Community Constituents.

Think of the importance of using the media in the following situation: a public health leader in a conservative, middle-class community discovers that five cases of human immunodeficiency virus infection have recently been discovered. A statistic like this can hit the nerve center of a community. It is the public health leader who will have the skills to defuse the crisis and get community constituents to become partners in dealing with the problem.

One of the most important responsibilities of public health leaders is to promote prevention at the community level.81 Our knowledge of health and disease is constantly growing, and new technologies and community-based prevention strategies are continually being developed to address public health concerns. The public needs to be convinced of the importance of using these technologies and strategies. It is the job of public health leaders to make the case.

Linking Programs

There is a good argument that public health programs should be linked together where possible.82 The Centers for Disease Control and Prevention created Prevention Research Centers in a number of universities. Many, if not all, of these centers rely on community support to carry out their activities. Public health leaders, who see the future of their agencies as tied to primary prevention rather than direct services, know that linkage to academic programs will strengthen the infrastructure of public health in their communities.

Community Building

Community building is a complex process that does not occur overnight. Peck analyzed it into four stages.83 In the first stage, various community representatives who have formed a coalition pretend to have the community’s interests at heart in order to gain acceptance for their own agendas. Peck called this the pseudocommunity stage. The second stage, which begins when the coalition realizes that community concerns are not being addressed, is one of chaos. Next comes the stage of emptiness, in which the leaders have to empty themselves of all their preconceived notions about the community and its concerns. It is extremely difficult for the leaders to leave their agendas at the door. The fourth stage is when true community comes into being.

Organizations involved in building a community need leaders.84 These leaders must be students of the community and its culture and be able to involve individuals with different power bases in community change. Because each community resident has an agenda to which he or she is committed, leaders have to find ways to reconcile the differing agendas.

Community coalitions ideally should be learning organizations.85 The members of a coalition need to examine their predispositions and how these predispositions affect the community-building process. In addition, the scientific perspective needs to be incorporated into the group’s deliberations.

Community building is best achieved through the use of collaborative leadership.86 Following are 10 factors that can contribute to the success of collaboration and community building:

1. good timing and a clear need

2. strong stakeholder groups

3. broad-based involvement

4. credibility and openness of process

5. commitment and/or involvement of high-level leaders

6. support or acquiescence of “established” authorities or powers

7. overcoming mistrust and skepticism

8. strong leadership of the process

9. interim successes

10. a shift to broader concerns87

Coalition Building

Coalition building is an important part of empowering communities. Public health agencies can no longer work in isolation. Community leaders need to be involved in addressing public health issues. The major advantage of a coalition is that all voices are heard and programs can be developed that better reflect the health needs of the community. The major disadvantage is that being part of a coalition is time consuming.

Cohen and colleagues developed an eight-step model for developing community coalitions ( Table 6-4 ).88 The model is based on the experience of the Contra Costa County (California) Health Services Department Prevention Programs. The authors define a coalition as a group of interested parties (individuals and organizations) that want to influence the attempt to solve a critical problem. The coalition members need to develop strategies for each of the eight steps and know when to move to the next step.

A coalition can have many advantages. It can help to save resources. It can influence a large number of people in a community through its diversified membership. It can create an agenda that is more comprehensive than the agenda of any single community organization. It can create a network for the sharing of information, a network that could be used beneficially by the local public health agency for purposes of marketing and fostering change in the community. In addition, coalition members gain satisfaction when they see positive things happen, and a coalition can influence emerging grassroots organizations as they explore their roles in the community.

Building community through coalitions that are responsible and credible is an important goal of public health leaders. A report from the Centers for Disease Control and Prevention stated that public health should use a process called community engagement.89 Community engagement involves collaboration between people who are in the same geographic area, share special interests, or are in similar situations. A mixture of social science and art, community engagement integrates the ideas of culture, community, coalition building, and collaboration. The report reviewed the literature for examples of successful engagement and presented a list of the principles of community engagement ( Table 6-5 ).

Partnerships are collaborative relationships that involve more than minimal cooperation. They tend to evolve through the same steps outlined in the systems model of organizational change. Partnerships have a vision and a mission, they have goals and objectives, and they develop and implement action plans and evaluate their degree of success. The late Reverend Everett Hageman, who was one of the founders of the National Association of Local Boards of Health (NALBOH), was a major supporter of leadership development in public health, and I spent many hours talking to him about the importance of partnership. After Hageman’s death, I put together a list of principles based on discussions with him. The principles that pertain to partnerships follow:

TABLE 6-4 Eight Steps to Building an Effective Coalition

Step 1: Analyze the program’s objectives and determine whether to form a coalition.

Step 2: Recruit the right people.

Step 3: Devise a set of preliminary objectives and activities.

Step 4: Convene the coalition.

Step 5: Anticipate the necessary resources.

Step 6: Define elements of a successful coalition structure.

Step 7: Maintain coalition vitality.

Step 8: Make improvements through evaluation.

TABLE 6-5 Characteristics of Successful Community Engagement

• Community engagement efforts should address multiple levels of the social environment, rather than only individual behaviors, to bring about desired changes.

• Health behaviors are influenced by culture. To ensure that engagement efforts are culturally and linguistically appropriate, they must be developed from a knowledge and respect for the targeted community’s culture.

• People participate when they feel a sense of community, see their involvement and the issues as relevant and worth their time, and view the process and organizational climate of participation as open and supportive of their right to have a voice in the process.

• Although it cannot be externally imposed on a community, a sense of empowerment—the ability to take action, influence, and make decisions on critical issues—is crucial to successful engagement efforts.

• Community mobilization and self-determination frequently need nurturing. Before individuals and organizations can gain control and influence and become players and partners in community health decision making and action, they may need additional knowledge, skills, and resources.

• Coalitions, when adequately supported, can be useful vehicles for mobilizing and using community assets for health decision making and action.

• Participation is influenced by whether community members believe that the benefits of participation outweigh the costs. Community leaders can use their understanding of perceived costs to develop appropriate incentives for participation.

Source: Reproduced from Centers for Disease Control and Prevention (1997). Public Health Practice Program Office, Principles of Community Engagement, Agency for Toxic Substances and Disease Registry.

• Leave time to get to know your community partners on a personal level.

• Partnership is part of the human condition.

• Working together is better than fighting.

• Learn by listening to your partners.

• True partnership is the gourmet approach to organization.

Each community coalition needs to be revitalized on a regular basis. A community coalition often seems to work better when a community crisis is occurring.90 When the crisis is over, people tend to move away from the coalition back to their own personal agendas. Thus, public health leaders need to be aware of this fact and make an extra effort to keep community coalitions alive after crises are resolved.

National and International Communities

Thus far the discussion has been on leadership in local communities, but there are also national and international communities that offer an arena for action by public health leaders. National leaders, like local leaders, act as advocates for public health. They keep the public informed about health issues. They work on the construction of a national mission and vision as well as public health goals for the future. They collaborate with leaders at the state level on the creation of a coordinated nationwide approach to public health. They collaborate with national elected officials to address key public health concerns, including the training of the public health workforce.

Leadership Tip

When you are given another committee assignment:

(a) Ask, why me?

(b) State that you are willing to be on this committee for the next three months, then you will come back and discuss whether you should continue on this committee.

(c) Tell the committee chair that you do not want to be on another committee for life. You want the group to decide on how long the committee will remain in existence. If more time is needed, you want to determine whether you will continue to serve.

On the international level, public health leaders implement public health programs in countries where public health is not a priority. These leaders need to develop skills to enhance their ability to improve the quality of life of people in these countries. Rather than reinvent public health, these leaders develop networks with public health leaders throughout the world to share model program methods for addressing specific public health problems. As already stated, public health leaders need to think globally about public health concerns while acting locally (to protect community residents from potential health crises). Building healthy communities is partially a matter of applying knowledge gained from all parts of the world to local conditions. The importance of the 2005 International Health Regulations (IHR) cannot be overestimated. These rules and regulations were agreed upon by 193 countries. These countries believe that these international rules and procedures will help to make the world safe from potential threats to global health. The IHR were approved by the World Health Organization in the summer of 2005.91 These rules will affect every community in the world.

Most of the strategies and techniques discussed in this chapter have universal application. Following is a list of guidelines of special pertinence for public health leaders working at the community level:

• Build trust.

• Form coalitions.

• Develop partnerships.

• Teach community groups about the core public health functions.

• Do community building with partners.

• See the community as a system.

• Encourage coalitions or partnerships to continue after a public health crisis has been resolved.

• Use the media to promote best practices in public health.

• Push a prevention agenda.

• Understand the connections between public health at a global level and public health at a local community level and their connections.

LEADERSHIP AT THE PROFESSIONAL LEVEL

Despite the multidisciplinary nature of public health, its leaders need to speak with a unified voice. Public health as a profession takes precedence over the particular educational backgrounds of the public health workforce. The following situation occurs much too often. A physician with almost no background in public health was appointed the administrator of a large county health department. He made decisions from a medical viewpoint and felt that physicians were the only ones who were qualified to do the department’s work. He ran the department using a direct medical service approach and totally ignored the population-based approach to public health.

Public health practitioners tend not to travel to professional meetings or for professional development. Many local health departments have a small staff and are reluctant to let employees go to meetings. Funds for professional development are generally minimal, and paying for professional development is typically considered by taxpayers to be a waste of money. Yet public health leaders know that it is important to communicate with other public health professionals. Some of these leaders go to the annual meetings held by the various public health associations and even take a leadership role in these associations. They help to create public health policy that will trickle down to the local public health programs. Leadership development training seems to be a factor here. For example, most of the presidents over the past 15 years of the Illinois Public Health Association were either faculty members or fellows of the Mid-America Regional Public Health Leadership Institute (Illinois, Indiana, Wisconsin, and Michigan).

Public health leaders need to become active participants of the American Public Health Association (APHA). This association represents all segments of the professional public health workforce. It is at the annual meetings of the APHA that national public health policy tends to be made. The National Association of County and City Health Officials (NACCHO) is a key national organization for local health leaders. The Association of State and Territorial Health Officials (ASTHO) is a similar national organization for state health leaders. Leaders should also consider taking key roles in the various associations for state and county public health directors. Board of health leaders can also become involved in a national organization for boards (NALBOH). Following is a list of guidelines for leaders who wish to make a mark in the profession of public health:

• Promote public health as a profession.

• Encourage staff to become involved in state and national public health associations.

• Be active in state and national public health associations by serving on committees or agreeing to run for an association office.

• Run for office in these associations.

SUMMARY

Leaders need to operate on five different levels. On the most basic level, they need to know how to exert their influence as leaders on other individuals person to person. To do this, they need a whole range of skills and abilities, from communication skills to the ability to balance work and private life. Regardless of the level at which the leader works, commitment and passion for the work are critical. Leaders strongly believe in what they do. Bolman and Deal believe that there is a spiritual quality to leadership that is difficult to explain or study.92 However, it can be seen in the work and the dedication of leaders. Thus, leadership is not only about money; it is also about all the things that make us wake up in the morning with anticipation for the job we have to do today. Leadership at the personal level is about our passion in action.

Leaders also must be capable of functioning in teams, either as team leaders or as ordinary team members. Some of the leadership skills needed for teamwork are also needed on the personal level, but some are different. It is on teams that we see the mission of our work in action.93 It is at the team level that we also see the emotional aspects of working together and creating networks of collaboration and friendship.

Public health leaders are often the heads of public health departments or agencies and thus need agency-level leadership skills as well. Their duties as agency heads include such things as mission and vision statement development, fund-raising, job performance evaluation, and role modeling. At the agency level, leaders also see systems thinking in action. It is the big picture that guides our work.

Public health is obviously community oriented, and so public health leaders need to be able to play a major role in the community by acting as advocates on public health issues and building coalitions to deal with such issues. They thus need advocacy skills and coalition-building skills, among others. At the community level, we can see the passion and commitment of our partners.

Finally, public health leaders, like other public health practitioners, have an obligation to try to improve the field of public health, by becoming involved, for instance, in professional organizations such as the APHA, NACCHO, ASTHO, and NALBOH. Many leaders have told me that the networking that occurs at the national level is important and helps leaders to sustain their strong belief that public health can make a difference. Fighting our battles legislatively becomes easier when we work with our public health colleagues. Professional friendships often become lifelong.

DISCUSSION QUESTIONS

1. What is the difference between politics and governance?

2. What is the relationship between communication and empowerment?

3. What are several of the main barriers preventing public health leaders from being as effective as they could be?

4. What is one way public health leaders can deal with the increasing cultural diversity in the public health workforce?

5. What are some of the main reasons for creating and using teams?

6. What are the main agency-related responsibilities of public health leaders?

7. What are the main community-related responsibilities of public health leaders?

8. How do partnerships differ from other types of collaborative relationships?

9. How can public health leaders further the interests of the public health profession?

EXERCISE 6-1: The Drawbacks and Benefits of Professional Diversity

Purpose: to explore how professional diversity affects public health decision making

Key concepts: decision making, diversity, professionalism

Procedure: There has been an increase in teen gang violence in Midcity over the past 10 years. The mayor and the city council have asked the Midcity Department of Health to develop a plan to address this public health problem. The class should divide into teams to discuss the problem. Each team will have a designated leader from a different profession (e.g., physician, nurse, social scientist, environmental health specialist, or business expert). In addition to discussing the issue at hand, which should be done for half an hour, each team should reserve 5 to 10 minutes to examine how the professional background of the leader influenced the process and the outcome of the discussion. Each team will then report its conclusions and observations to the class as a whole.

EXERCISE 6-2: Leadership and Team Building

Purpose: to explore leadership behavior in team situations

Key concepts: team building, leadership in teams, leadership style

Procedure: Using the Mallory personality typology, each group member, using the worksheet ( Table 6-6 ), should classify him-or herself as one personality type or as a combination of types and analyze the degree to which he or she possesses the characteristics associated with all four types. The group should then break into teams and discuss the results of the self-evaluations, focusing on issues that are critical to team development, such as team communication, discussion facilitation, consensus development, priority setting, and conflict resolution.

TABLE 6-6 Personal Worksheet for Team-Building Activities

1. Name ______________________________________________________________________

2. Leadership Personality Type For each personality type, determine the percent of time you spend demonstrating each type

3. How many years have you spent in activities related to teams?

4. Would you rather work alone or in teams?

5. How often have you chaired the team?

6. Describe any major successes on teams on which you have worked.

7. Describe your experiences on teams that have not been successful.

8. How have teams affected your job performance positively or negatively?

9. Have you felt stress while working on teams?

10. Do you find working on teams to be structured or unstructured?

11. How would you describe your people skills?

EXERCISE 6-3: A Community in Crisis

Purpose: to explore the role public health leaders play in dealing with a natural disaster

Key concepts: collaboration, community crisis, strategic planning

Procedure: In February, California is hit by storm after storm. The town of Crisona is flooded for a two-week period, the entire town is evacuated, and mudslides eventually begin to occur in the surrounding hills.

The class should divide into teams of 6 to 10 members. In each team, half the members are assigned to play the role of Crisona City Council members, including the role of the mayor and of the head of the Crisona Department of Public Health. The remaining team members are to act as community leaders. These leaders and the head of the Department of Public Health testify about the disaster and offer suggestions for addressing it. The city council listens to the testimony and then works with the community leaders to develop a strategy for dealing with the crisis. The whole team should develop a one-page consensus statement outlining a strategy for responding to the crisis.

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CHAPTER 7

Building Infrastructure

Form follows function—that has been misunderstood. Form and function should be one, formed in a spiritual union.

—Frank Lloyd Wright, 1908

Over the past two and a half decades, public health leaders and by extension human service leaders have struggled with the need to build the infrastructure of the public health and the human services systems. Since the publication in 1988 by the Institute of Medicine of The Future of Public Health, the issue of the human services system and its infrastructure has been on the table.1 This chapter will address some of the building block issues related to strengthening the infrastructure of public health and other health and human services systems, which requires effective leadership to make the changes necessary to build the public health system. First, the most important building block relates to people. Workforce development is a key building block. The education that each public health professional has before entering the human services arena is not sufficient over the long run. Lifelong learning and the ability to adapt to changing realities are critical to the future adaptability of professionals in the human services fields. Second, public health leaders have spent the past twenty-five years promoting the core functions and essential public health services paradigm and have developed its programs on the basis of these core service dimensions. Strengthening the infrastructure of public health will require support for this service paradigm and the data systems necessary to support this paradigm. This paradigm is applicable to most human services systems as well as to the emerging concerns related to emergency preparedness and response. A common language, governing paradigm, community planning systems, and organizational capacity are also critical components for building infrastructure. Figure 7-1 shows a public health services pyramid that the Centers for Disease Control and Prevention (CDC) has named the Pyramid of Preparedness. All public health is about preparedness and hopefully prevention.

There are a number of other components that need to be considered in better understanding how to build infrastructure. First, it is important for leaders to assess the health of the people in their service areas on a regular basis so that their human services systems are more responsive to emerging health and mental health needs of the public. It is for this reason that the development of model service standards and assessment tools becomes important to a nimble public health and human services system. Public health leaders have pointed out over the years that assessment methods and strategies have been a real strength of the public health system. Assessment as well as other epidemiologic techniques are also strong components of the human services system and its infrastructure. The second enhancement to infrastructure building is an increasing awareness that a performance management approach to organizational effectiveness and the various tools that measure performance are also important aids in strengthening our health service systems. Closely allied to performance measurement as a third factor is the incorporation of quality improvement methodologies into the culture of our human services and public health infrastructure. Leaders need to support this cultural shift. Other techniques that are emerging as important for the improvement in quality of agency programs and services are the community balanced scorecard methodology2 and the results-based governance approaches.3

FIGURE 7-1 Pyramid of Preparedness. Source: Reproduced from Centers for Disease Control and Prevention (2002). Public Health Preparedness: A Status Report. Public Health Practice Program Office.

Development of an accreditation system for local public health agencies creates a level of excellence as well as trust and credibility for public health. Recognition of the good work of public health raises public awareness as well. These standards of excellence for agencies also build infrastructure. A voluntary accreditation program for local health departments was implemented in 2011.4 The fifth building block is closely tied to accreditation, and that is certification.5 Certification refers to the individual and standards of excellence for the work of the public health professional. Certification can be tied to the field of practice of the individual as well as to evidence of management or leadership skills in practice. Health administrator and board of health member certification would be beneficial to the successful direction of local public health and human services agencies. Accreditation informs us of the quality of the work of the agency, and certification tells us how effective these professionals are in these quality organizations.

It is impossible to build infrastructure without well-trained leaders. Most of our professional education programs do not include much, if any, management and leadership training. There are now a number of public health leadership programs to train health professionals in management and leadership. These programs explore the practice of leadership in governmental and not-for-profit agencies in contrast to that in business organizations. Leadership is a critical building block in infrastructure capacity building. Finally, all of the above concerns need to be addressed if we want to reach more positive health outcomes. The effectiveness and efficiency of the work of our organizations need to be measured against the successes of our work on health outcomes.

WORKFORCE DEVELOPMENT AND LEADERSHIP

Workforce development in public health and other human services fields is clearly important if our health professionals are to remain current, be proactive, and improve community health outcomes over the long run. Collaboration is necessary if we are to address the critical concerns of training health professionals. Workforce development does not belong to any one organization. Expertise does not exist in only one organization, in one consulting firm, or in one professional organization. Training needs to be seen as an evolving system, like building an onion layer by layer. Each set of trainers adds a layer to the onion that leads to a more comprehensive approach to training with its important practice orientation. Thus, training and workforce development specifically must be viewed as a collaborative activity. Personal organizational agendas must not predominate in these workforce discussions. I have personally seen some governmental agencies, consulting firms, and organizations claim that they are the workforce development organization. Professional development can occur in many venues. At the federal level, each agency clearly has a role to play in adding another layer and training orientation to the onion. At the professional organization level, an agency must work with multiple partners to make workforce development comprehensive and collaborative.

Leadership development is clearly a critical component in workforce development. As health professionals, we are educated at the technical level to be expert in our chosen health professions. We are not trained to be managers or even leaders. We look for programs to teach us these skills when we move into higher administrative positions. I cannot understand how some of my professional colleagues do not see the connection between training managers and leaders as being a workforce development issue. All training is about being better at what we do. Not only do we need to support Public Health 101 training and learning, we need to add training on Management 101 and Public Health Leadership 101. As mentioned above, training of our professional colleagues is also a collaborative activity; we all learn from each other. Our training partners teach us new skills and approaches to leadership development. They teach us about new tools and resources. They offer us insights into new books with innovative approaches. How can we be effective trainers if we do not collaborate or learn from others? The secret is in the collaboration, if training programs are to be effective in training our colleagues. Personal agendas need to be pushed to the back burner. We need to build the workforce development onion together.

THE LEADERSHIP PYRAMID

Effective leaders are lifelong learners. To put this lifelong learning approach into perspective, it is useful to look at education and learning in a sequential manner. The following discussion is based on a new approach to leadership development conceptualized by Lichtveld, Rowitz, and Cioffi.6

Over the past 20 years, there has been increasing interest in developing a framework for training public health professionals in management and leadership under the assumption that leaders help build a stronger public health system. Yet there is controversy about whether leaders differ in the realms of business and the governmental human services fields. Although it is true that leadership is a universal phenomenon, it takes different forms depending on the cultural and ecological context in which it takes place. There is clearly a difference between the profit motive in business and the social justice motive that drives much of the public health enterprise. As we view the public health system during the second decade of the new century with all the new challenges that public health now faces, it is necessary that the issue of leaders in public health be looked at from a new perspective. This model presents a perspective for a better understanding of leadership from the vantage points of leadership competencies, performance, capacity building, and best practices.

Public health leaders act within the core functions of public health and the essential services that drive the public health enterprise. In addition, the public health leader is prepared for any natural or abnormal crisis that might occur in the community. The leader is committed to lifelong learning and the need to develop competencies required to protect the health of the public.

Figure 7-2 presents the leadership pyramid as an inverted triangle. Each level of the pyramid requires a determination of the specific competencies necessary to master that level of the pyramid. The triangle is inverted to show that the breadth of the set of core public health skills that public health professionals need to have act as the foundation for all that follows. There are numerous approaches these days to the learning competencies needed to practice certain professional and administrative skills. The pyramid requires that we reorganize these competencies to fit each level of the leadership pyramid. As each public health workforce member masters each level of the pyramid, performance should improve and the infrastructure of public health should strengthen. Performance management systems and performance standards guided by a set of principles (e.g., essential public health services) would monitor this process.

FIGURE 7-2 New Leadership Pyramid. Source: Reproduced from M. Lichtveld, L. Rowitz, and J. Cioffi, “The Leadership Pyramid.” Leadership in Public Health 6(4), 3–8.

Training is the key to mastering these skills, which are necessary to build infrastructure. If public health professionals improve their skills and become more effective as a result, they have increased their personal skills, which can then be translated into team-based and other collaborative processes. All of this would eventually improve the capacity of the total public health system. The bottom of the pyramid emphasizes the importance of best practices. The business community is not shy about discussing its best. Public health must begin to do the same. Quality assurance can then be newly defined by the following formula:

Quality improvement + leadership competency as evidenced by best practices + high-performance expectations + strategic capacity building

We can look for clues to the understanding of this quality improvement approach in the body of the pyramid. The first layer emphasizes the importance of an understanding and mastery of a set of core public health skills. Public health must have a public health workforce that is trained in public health principles and practice. Too many of the people in our existing governmental public health workforce have no formal public health training. Recent discussions on credentialing have raised some of these issues, and proponents have argued that the public health system cannot be strengthened without this training. The set of competencies required for this level of the pyramid has been developed by a number of different organizations. All of this means that these skills will be required of all public health workers in the governmental public health sector.

Public health is a profession with a workforce from many different disciplines. Doctors, nurses, dentists, lawyers, business administrators, behavioral scientists, epidemiologists, biostatisticians, and many other discipline-specific experts are required if public health is to carry out its major responsibilities. The major message in level two of the pyramid is that the successful public health practitioner must blend the competencies of public health with discipline-specific competencies if public health is to function in an effective manner. Business learned these lessons long ago and has been able to build profit enterprises through the combination of sound business practices with discipline-specific expertise in many different areas.

The skills necessary to achieve competence at the first two levels of the pyramid are somewhat technical in nature. When the public health professional moves to level three of the pyramid, the tasks to be performed relate to making an agency run effectively and efficiently. Thus, a shift occurs when an individual decides to move into a management role. New sets of skills are needed. In addition, many public health professionals find that during their professional education they were not trained to be managers. Although business schools have been involved in the development of competencies for work in commerce, adaptation of these skills to the public sector needs to become more formalized. Management competencies are quite complex and require training in such diverse topics as time management, performance appraisal, strategic planning, office management, budgeting, and so on. A few certification programs now exist for public health management that do begin to build a public health competency-based management model. Illinois, Missouri, and Iowa have tested such systems.

The move from management to leadership is not as easy as it first appears. First, there is a shift from an agency focus to a systems and community focus affected by the complexity of modern life. The manager looks inside the organization to make sure it is functioning efficiently and effectively. The leader looks outward and is concerned with how public health functions at the community and national levels. In addition, the technical skills required at levels one and two and the administrative task-oriented skills of level three become secondary to people and relational skill competencies. The core skills required to be an effective leader are also not taught in most traditional health science curricula. The national, regional, and state-based public health leadership institutes have been trying to fill this gap since the early 1990s. The National Public Health Leadership Network, in collaboration with the Centers for Disease Control and Prevention, developed a framework of core public health leadership competencies that have been integral to the training of public health leaders. Public health leaders throughout the country have gone through these training programs. The philosophy of these training programs has been that leaders exist throughout the public health system and that leadership can be taught.

Training without implementing the content of the training is nothing more than an academic exercise. Leadership development needs to be available for the practicing public health professional who can use these new leadership skills in the work and community context of their professional work. Leadership needs to be implemented to be effective. This may not be an easy task in environments that are resistant to change. Leaders need to be students of the cultural settings in which they work. Each new skill will undergo some transformation as it is applied in the work and community setting. These new challenges may require skills beyond those that occur in most leadership development programs. It is at this level that such skills as collaboration, team building, community building, assets planning and mapping, emotional intelligence, and others come to play a key role in effective leadership.

The events of September 11, 2001, changed the field of public health. Program priorities have changed. Bioterrorism and emergency preparedness specialists have become a critical component of the public health professional workforce. With these shifting priorities, it is clear that new leadership skills are needed to guide health departments. Public health preparedness and response have become a major priority for public health. Public health leaders have discovered that new skills are needed for the types of collaboration required to deal with crisis events in communities. Public health leaders need skills not only in risk management but also in health crisis communications. Forensic epidemiology has become a new specialty. Public health informatics is a new approach to the creation and use of data. Strategies are needed for working with families of the victims of a crisis event. New partnerships are required with the Federal Bureau of Investigation, police departments, fire departments, hospitals and other health facilities, crisis agencies, community partners, and elected officials. Communicating with people who use different jargon has also become a major leadership challenge. Higher levels of emotional intelligence skills have become more critical. Bioterrorism leadership competencies are different from traditional leadership skills. It is a new type of leadership with more complex skills needed for working in environments of constant change. Exercise 7-1 will put some of these issues in perspective by helping you examine public health before September 11, 2001, and today.

The leadership pyramid presents a start on the development of a complex, new approach to the training of public health leaders. Leaders themselves will need to move from level to level in the development of their personal, team, agency, community, and professional skills. Whereas technical skills are usually required to get a person a job in an agency, people skills become more critical to job performance over the long run. Leadership development becomes a lifelong learning activity that leaders must commit to if best practices are to occur and if the infrastructure of public health is to be strengthened.

PUBLIC HEALTH INFRASTRUCTURE

Underlying all discussions of public health training and education programs (much of this section of the chapter is based on the 2002 CDC report Public Health’s Infrastructure: A Status Report) is the rationale for why these programs are important. Public health professionals perform better when they have not only the skills and competencies necessary to make an agency run effectively, but also the vision and understanding of techniques to improve the health of people who live in their jurisdiction. Public health leaders provide the vision and direction for making these things happen. On one hand, we have the people who power the public health system. On the other hand, we have the structural components that make the system run. Public health infrastructure is embedded in the community and its organizational systems, the competencies for successful performance, and the relationships that are needed to carry out the mission of public health to improve the health of the public. Finally, public health is affected by the resources that aid public health professionals to perform well in their communities.

Above, the discussion involved the first key component of infrastructure: the public health workforce. The second component of basic infrastructure relates to information and data systems. This component addresses the key issue of the need for information to guide the public health enterprise. Uniformity in the way data are collected as well as agreed-upon definitions for data elements are required. Training the public health workforce in data collection techniques as well as in the important skills related to the use of information is necessary. Up-to-date data guidelines are needed. These guidelines include recommendations, health alerts, and standards-based information and communications systems to monitor disease and enable efficient and effective communication among public and private health organizations, the media, and the public. It is clear that the more traditional approaches to data provided by epidemiological methods are no longer sufficient. It is for this reason that the new science of public health informatics is making such advances. Public health leaders must know how to use information as well as have the ability to judge the quality of the data to be used; these skills are more important than the data collection procedures. However, the prepared public health leader needs to know how to ask the appropriate questions about data. A basic background in epidemiology is thus required.

The third component of basic infrastructure relates to organizational capacity. Organizational capacity relates to the ability of public health to collaborate with others in coalitions, alliances, and partnerships to guarantee that the three core functions of assessment, policy development, and assurance, as well as all 10 essential services, are being met in every jurisdiction ( Table 7-1 ). Public health leaders need to work with other professionals in public as well as private healthcare organizations to accomplish this. Organizational capability is enhanced by these relationships. Public health is a community issue, not just an agency-based one. As was pointed out above in the discussion of the leadership pyramid, public health leaders need many types of leadership skills if they are to be effective and prepared to address any health challenges in their communities.

The three components of basic infrastructure are clearly interrelated. A deficiency in one affects the other two. CDC has argued that the goal of strengthening the basic public health infrastructure means the achievement of improvements in all three. In addition, leadership is required to bring about these improvements. The public health leader is one who will see the systemic relationship between the three components of basic infrastructure and their relationship to the other two levels of the pyramid. The second level of the public health pyramid relates to the ability of the public health system to provide essential capabilities to respond more effectively to public health crises. These essential capabilities involve the knowledge, skills, and abilities related to surveillance (see Figure 7-1). Public health needs 360° vision so that its leadership can be on the watch for all potential threats to the health status of people in its jurisdictions. An occurrence of a new threat in another part of the world can affect the local community in the future. These techniques of surveillance involve quantitative as well as qualitative factors. Surveillance means listening to the stories of our colleagues at a national or local meeting. It involves an awareness of the fears and concerns of people who live in our neighborhoods. It involves news reports from other parts of the world about an outbreak of SARS; a major earthquake and tsunami that kills hundreds of thousands of people in southeast Asia; a major tornado in Joplin, Missouri; or some emerging infectious agent.

TABLE 7-1 The 10 Essential Public Health Services

Assessment

1. Monitor health status to identify community health problems.

2. Diagnose and investigate health problems and health hazards in the community.

Policy Development

3. Inform, educate, and empower people about health issues.

4. Mobilize community partnerships to identify and solve health problems.

5. Develop policies and plans that support individual and community health efforts.

Assurance

6. Enforce laws and regulations that protect health and ensure safety.

7. Link people to needed personal health services, and ensure the provision of health care when otherwise unavailable.

8. Ensure a competent public health and personal healthcare workforce.

9. Evaluate effectiveness, accessibility, and quality of personal and population-based health services.

Serving All Functions

10. Research new insights and innovative solutions to health problems.

Our public health laboratories and the work they do to discover threats and potential threats are essential to public health. In recent years, there has been a need for public health laboratories to work with crime laboratories on potential bioterrorism activities. Communication as well as an understanding of chain-of-evidence techniques become critical. The whole new field of forensic epidemiology has developed to address these new concerns. The third essential capability involves the important role of epidemiology in public health’s day-to-day activities. It is not that we don’t know the importance of epidemiology in our work; it is the limited number of epidemiologists to do the necessary work. Small health departments cannot afford an epidemiologist on staff. Models for sharing this expertise are becoming important in our environment of preparedness. Part of our workforce development strategy should be to train the public health workforce in basic epidemiologic skills.

The tip of the pyramid involves the new vision of public health. Today, most of public health’s work relates to responding to bioterrorism, emerging infections, and other health threats. This preparedness model needs to be expanded to include all those other concerns that public health has been addressing over the past decades. Water and air quality are still important. Restaurant inspections are still important. Teenage pregnancy is still an issue. Many other local issues continue to need to be addressed.

There are many issues that drive our agenda relative to strengthening public health infrastructure. There never seems to be enough money to do our jobs well. Public health still seems to lack importance among the public and the policy makers. Accountability for spending taxpayers’ money is always an issue. When financial deficits occur at the federal, state, and local levels, public programs are often the first things to be cut. Although public health has made many advances in the past, it is almost impossible to predict when another public health breakthrough will occur. Policy makers are often complacent about funding public health programs unless a crisis or threat appears imminent. The fear of potential terrorist acts on American soil has led to an influx of money into the public health sector. More traditional public health programs continue to be underfunded. Public health professionals need to learn the valuable lesson that our business leaders learned long ago: all money builds infrastructure regardless of source. Whining does not serve us well. There will never be enough money. It is important to do the best we can with the resources we have.

Public health is becoming an increasingly complex field. The scope and variability of the skills required to keep the public health system functional are quite extensive. Public health involves the investigation of outbreaks to questionnaire design, interviewing techniques, population-based program development, lab specimen collection techniques, standards for effective community prevention services, and many other emerging techniques. When you add all the skills necessary to be a successful manager and leader, the public health toolbox gets full. Despite the specialized competencies that are needed, many elected officials continue to believe that training programs are a frivolous expense.

Many global factors also affect infrastructure, including such things as the global movement of goods and people, antimicrobial resistance, global infrastructure gaps that prevent the containment of potentially lethal diseases, environmental and ecological changes such as deforestation and pesticide use, and the potential for bioterrorism. Public health leaders need to think globally even though they act within a local jurisdiction. The prepared public health leader is one who monitors the health issues of the world and is able to see the effect of these worldwide trends on local health conditions. Prepared leaders are visionary and always think of the future in developing local public health priorities.

Other issues of concern to public health leaders relative to building infrastructure include the necessity of building public health and emergency preparedness capacity at both the local and state levels. It is critical that any enmity between state and local public health professionals be removed. Collaboration is necessary. In addition, a strong relationship between a local or state health administrator and the board of health (if one exists) and elected officials is also a critical partnership if communities are to become prepared for all potential health threats. Another important infrastructure issue is the defining role of the public health agency in the community setting. Public health agencies need to be seen as responsive to the health needs of the entire population. If these agencies are to serve as coordinating centers for all public health concerns, then they must develop collaborations with all other health providers in the community. Although it is often a social justice philosophy that drives many public health professionals into the field, it is sound management and leadership competencies that will strengthen the public health system.

Many infrastructure discussions involve the issue of service access and the elimination of health disparities. It is important to move beyond access issues to strategies to change the existing situation. The public health leader knows that solutions need to be found in places other than the financial area. Arguments have accumulated that universal health coverage is the answer. It may be, but leaders know that universal health coverage is still a long way off. So the strategies that must be developed will require innovative approaches to health promotion and disease prevention as well as new collaborations to increase the health service coverage for the people in our communities.

New types of information are needed. Better data on the public health workforce are needed, ranging from the composition of the workforce to the movement of public health professionals through the system. Performance appraisals based on individual assessment need to be changed to team performance appraisals, as so much of public health’s work occurs in the community with community partners. The views of expenditures with the concern of methods of determining costs for community-based activities also needs to be part of the public health infrastructure discussion. Public health leaders need to work with their business partners to develop new measures for this nontraditional form of activity.

A final issue of importance is tied to the program mismatch between mandated public health services and the 10 essential public health services. First, the public and the policy makers often do not understand the essential services mode. It is clearly an approach that makes sense to the public health leader in the context of the public health system. The essential services are the driving force behind much of what is done in the public health system at a community level. The local public health agency may not carry out all 10 essential services, but all the community agencies involved in public health should carry them out collaboratively. Second, public health leaders know that it is specific mandated programs that are understandable to the public. The public understands the need for clean water and inspected restaurants. The essential services provide a framework for action for public health infrastructure. The prepared public health leader knows that he or she must communicate the results of these actions in a understandable way. The leader must stop being shy about marketing public health’s good deeds and best practices. In Case Study 7-A, Dr. Bernard Turnock, director of the Illinois Department of Public Health in the 1980s and now professor of community health sciences at the University of Illinois at Chicago School of Public Health, answers a public health practice quiz related to the issues raised in this chapter regarding the changes in the public health system in the past several years.

Case Study 7-A

A Public Health Practice Quiz for Bernard Turnock

1. How has public health practice changed since 2000?

Public health practice has always been about identifying and addressing threats to health. Since 2000, there has been much more attention focused on health threats attributed to terrorism, but preparing for and responding to emergencies have long been major roles for public health practitioners. Public health practice has not really changed; however, there have been significant changes in the environment in which public health practice takes place, in terms of greater public visibility, expectations, and accountability.

2. Does the essential public health service paradigm make a difference in the way public health professionals practice public health?

The essential public health services provide a framework for public health practice, allowing standards to be established for individual and collective practice. Having a more formalized set of practice standards does indeed change what individuals and organizations do. After all, what gets measured gets done.

3. Why does the discussion of public health infrastructure development dominate the emergency preparedness and response dialogues?

Preparedness and response are attributes of public health systems. Improving public health systems involves making positive changes in the structures and processes (i.e., the infrastructure) of those systems. You can’t improve preparedness and response without focusing on public health infrastructure.

4. Do leadership development programs make a difference in the practice of public health?

Leadership is essential to configure and guide the resources and relationships available for public health ends. Leadership development programs bring enhanced skills and attitudes to public health professionals even before they assume leadership positions. The net result is an ever-expanding corps of current and future leaders sharing common values and skills and greater consistency in and better results from modern public health practice.

5. Are leadership skills different in emergency preparedness and response than in traditional public health practice activities?

Not really. Emergency preparedness and response are, and always have been, traditional public health practice activities. This role may not have been widely understood or appreciated prior to the events of 2001, but it is one that public health agencies have carried out since their inception.

HEALTHY PEQPLE 2020

The new Healthy People report demonstrates that infrastructure development is critical to all the health topic areas in the report.7 The key goals of the new report involve objectives related to health improvement, the development of environments that promote good health, and teaching people ways to promote their good health and improve their health behaviors. The job of the public health leader is to build infrastructure to provide a framework to address the social determinants of health. The World Health Organization defined social determination of health as follows:8

The complex, integrated, and overlapping social structures and economic systems responsible for most health inequities. These social structures and economic systems include the social environment, physical environment, health services, and structural and societal factors. Social determinants of health are shaped by the distribution of money, power, and resources throughout local communities, nations, and the world.

A concern about building public health infrastructure for the year 2020 has led to the development of several emerging issues, including tribal public health infrastructure, public health workforce disparities, public health agency accreditation, public health systems research, and public health law.9 Exhibit 7-1 presents the recommended objectives related to public health infrastructure in the Healthy People 2020 document.10 These infrastructure objectives provide guidance to public health leaders for some of their work and collaborative activities.

EXHIBIT 7-1 Healthy People 2020 Summary of Public Health Infrastructure Objectives

Public Health Infrastructure

Number	Objective Short Title
Workforce
PHI-1	Competencies for public health professionals
PHI-2	Continuing education of public health personnel
PHI-3	Integration of core competencies in public health into curricula
PHI-4	Public health majors and minors
PHI-5	Public health majors and minors consistent with core competencies
PHI-6	Associate degrees and certificate programs in public health

Data and Information Systems

PHI-7	National data for Healthy People 2020 objectives
PHI-8	National tracking of Healthy People 2020 objectives
PHI-9	Timely release of national data for Healthy People 2020 objectives
PHI-10	State vital event reporting

Public Health Organizations

PHI-11	Public health agencies laboratory services
PHI-12	Public health laboratory systems performance of essential services
PHI-13	Epidemiology services
PHI-14	Public health system assessment
PHI-15	Health improvement plans
PHI-16	Public health agency quality improvement program
PHI-17	Accredited public health agencies

Topic Area: Public Health Infrastructure

Workforce

PHI-1: Increase the proportion of Federal, Tribal, State, and local public health agencies that incorporate Core Competencies for Public Health Professionals into job descriptions and performance evaluations.

PHI-1.1 (Developmental) Federal agencies.

Potential data source: Office of Personnel Management.

PHI-1.2 (Developmental) Tribal agencies.

Potential data source: Indian Health Service.

PHI-1.3 (Developmental) State public health agencies.

Potential data source: State and Territorial Public Health Survey, Association of State and Territorial Health Officials (ASTHO).

PHI-1.4 Local public health agencies.*

Target: 25 percent.

Baseline: 15 percent of local public health agencies incorporated Core Competencies for Public Health Professionals into job descriptions in 2008.

Target setting method: 10 percentage point improvement.

Data source: National Profile of Local Health Departments, National Association of County and City Health Officials (NACCHO). (*Data for local public health agencies include only data on job descriptions.)

PHI-2: (Developmental) Increase the proportion of Tribal, State, and local public health personnel who receive continuing education consistent with Core Competencies for Public Health Professionals.

Potential data sources: Indian Health Service, the Public Health Foundation TRAIN database, and HRSA’s Public Health Training Centers.

PHI-3: Increase the proportion of Council on Education for Public Health (CEPH) accredited schools of public health, CEPH accredited academic programs, and schools of nursing (with a public health or community health component) that integrate Core Competencies for Public Health Professionals into curricula.

Target: 94 percent.

Baseline: 91 percent of Council on Education for Public Health (CEPH) accredited schools of public health, CEPH accredited academic programs, and schools of nursing (with a public health or community health component) integrated Core Competencies for Public Health Professionals into curricula for public health professionals in 2006.

Target setting method: 3 percent improvement.

Data source: Council on Linkages Study, Council on Linkages Between Academic and Public Health Practice.

PHI-4: Increase the proportion of 4-year colleges and universities that offer public health or related majors and/or minors.

PHI-4.1 Majors.

Target: 10 percent.

Baseline: 7 percent of 4-year colleges and universities offered public health or related majors in 2008.

Target setting method: Modeling/projection.

Data source: Catalog Scan of Undergraduate Public Health Programs, the Association of American Colleges and Universities (AAC&U).

PHI-4.2 Minors.

Target: 15 percent.

Baseline: 11 percent of 4-year colleges and universities offered public health or related minors in 2008. Target setting method: Modeling/projection.

Data source: Catalog Scan of Undergraduate Public Health Programs, the Association of American Colleges and Universities (AAC&U).

PHI-5: (Developmental) Increase the proportion of 4-year colleges and universities that offer public health or related majors and/or minors which are consistent with the core competencies of undergraduate public health education.

Potential data source: Association of Schools of Public Health (ASPH) in collaboration with the American Association of Colleges and Universities (AAC&U).

PHI-6: Increase the proportion of 2-year colleges that offer public health or related associate degrees and/or certificate programs.

PHI-6.1 Associate degrees. Target: 3 percent.

Baseline: 2 percent of 2-year colleges offered public health or related associate degrees in 2009.

Target setting method: Modeling/projection.

Data source: American Association of Colleges and Universities (AAC&U); American Association of Community Colleges (AACC).

PHI-6.2 Certificate programs. Target: 1 percent.

Baseline: 0 percent of 2-year colleges offered public health or related associate certificate programs in 2009.

Target setting method: Modeling/projection.

Data source: American Association of Colleges and Universities (AAC&U); American Association of Community Colleges (AACC).

Data and Information Systems

PHI-7: (Developmental) Increase the proportion of population-based Healthy People 2020 objectives for which national data are available for all major population groups.

Potential data source: Assessment of Objective Data Availability (AODA), CDC, NCHS.

PHI-8: Increase the proportion of Healthy People 2020 objectives that are tracked regularly at the national level.

PHI-8.1 (Developmental) Increase the proportion of objectives that originally did not have baseline data but now have at least baseline data.

Potential data source: Assessment of Objective Data Availability (AODA), CDC, NCHS.

PHI-8.2 (Developmental) Increase the proportion of objectives that have at least a baseline and one additional data point.

Potential data source: Assessment of Objective Data Availability (AODA), CDC, NCHS.

PHI-8.3 (Developmental) Increase the proportion of objectives that are tracked at least every 3 years.

Potential data source: Assessment of Objective Data Availability (AODA), CDC, NCHS.

PHI-9: (Developmental) Increase the proportion of Healthy People 2020 objectives for which national data are released within 1 year of the end of data collection.

Potential data source: Assessment of Objective Data Availability (AODA), CDC, NCHS.

PHI-10: Increase the number of States that record vital events using the latest U.S. standard certificates and report.

PHI-10.1 States using the standard certificate of birth.

Target: 52 (50 States, the District of Columbia, and New York City).

Baseline: 28 States used the 2003 U.S. standard birth certificate in 2008.

Target setting method: Total coverage.

Data source: National Vital Statistics System-Natality (NVSS-N), CDC, NCHS.

PHI-10.2 States using the standard certificate of death.

Target: 52 (50 States, the District of Columbia, and New York City).

Baseline: 30 States used the 2003 U.S. standard death certificate in 2008.

Target setting method: Total coverage.

Data source: National Vital Statistics System-Mortality (NVSS-M), CDC, NCHS.

PHI-10.3 States using the standard report of fetal death.

Target: 52 (50 States, the District of Columbia, and New York City).

Baseline: 22 States used the 2003 U.S. standard report of fetal death in 2008.

Target setting method: Total coverage.

Data source: National Vital Statistics System-Fetal Death (NVSS-Fetal Death), CDC, NCHS.

Public Health Organizations

PHI-11: Increase the proportion of Tribal and State public health agencies that provide or ensure comprehensive laboratory services to support essential public health services.

PHI-11.1 Disease prevention, control, and surveillance.

Target: 97 percent.

Baseline: 88 percent of State public health agencies provided or ensured comprehensive laboratory services to support disease prevention, control, and surveillance in 2008.