Leading Public Health : A Competency Framework [1 ed.] 9780826199072, 9780826199065

Citation preview

A Competency Framework James W. Begun, PhD Jan K. Malcolm

Based on the premise that public health as a field is undervalued in health policy and practice, the book addresses the need for more informed and proactive public health leadership and describes the values, traits, and knowledge that undergird such leadership. At its heart are detailed examinations of 25 specific competencies required for effective public health leadership. Written in accessible and engaging language, the book includes 19 case studies and multiple examples from public health practice to demonstrate the successful application of leadership competencies. With an eye to the future, the book also includes content on emerging public health challenges, complexity science, innovation, resilience, quality improvement, and leading during unexpected events.

Key Features: • Empowers public health students and practitioners with leadership knowledge and competencies • Examines 25 specific competencies required for effective public health leadership • Combines the expertise of an academic and a practicing health care leader • Provides abundant case examples from public health practice • Presents leadership development as a lifelong process

ISBN 978-0-8261-9906-5

11 W. 42nd Street New York, NY 10036-8002 www.springerpub.com

9 780826 199065

Leading Public Health

L

eading Public Health is intended to equip current and aspiring public health leaders with the knowledge and competencies they need to mobilize people, organizations, and communities to successfully tackle tough public health challenges. Designed specifically for graduate students and practitioners of public health, the book highlights the aspects of leadership unique to this field. Building on several existing competency-based models, the book focuses on preparing public health professionals to invigorate bold(er) pursuit of population health, engage diverse others in public health initiatives, effectively wield power, prepare for surprise in public health work, and drive for execution and continuous improvement in public health programs and organizations. It is based on research from leadership theory and practice and combines the viewpoint of a prominent scholar with that of a seasoned practitioner.

Begun · Malcolm

Leading Public Health

James W. Begun Jan K. Malcolm

Leading Public Health A Competency Framework

Leading Public Health

James W. Begun, PhD, is James A. Hamilton Professor of Healthcare Management in the Division of Health Policy and Management, School of Public Health, University of Minnesota. He teaches management and leadership at the graduate level in the School of Public Health, where he received the Leonard M. Schuman Award for Excellence in Teaching in 2009. Dr. Begun’s 100-plus publications include the books Understanding Teamwork in Health Care (with G. Mosser) and Managing Health Organizations for Quality and Performance (with L.F. Fallon and W. Riley). Dr. Begun has been active nationally in promoting competency-based education serving as Chair of the Accrediting Commission on Education in Health Services Administration. He was awarded the Gary L. Filerman Prize for Innovation in Healthcare Management Education in 2008 by the Association of University Programs in Health Administration. Dr.  Begun currently serves on the science advisory board, Plexus Institute; editorial advisory board of Health Care Management Review; and Higher Education Committee, American College of Healthcare Executives. He holds a PhD in sociology from the University of North Carolina at Chapel Hill. Jan K. Malcolm is vice president, Public Affairs, for Allina Health, a network of 12 hospitals and more than 90 clinics in Minnesota and western Wisconsin. Ms. Malcolm served as commissioner of health for the State of Minnesota from 1999 to 2003 under Governor Jesse Ventura. She has served as president of the Minnesota Public Health Association, and her former work positions include chief executive officer of Courage Center, a Minnesota-based rehabilitation and resource center; senior program officer for the Robert Wood Johnson Foundation, where she helped develop funding initiatives to strengthen the nation’s public health system; and senior vice president of Government Programs and Public Policy at HealthPartners, Bloomington, Minnesota. She currently serves as a board member of BlueCross BlueShield of Minnesota (BCBSMN) and the BCBSMN Foundation, Stratis Health, and the Bush Foundation. Ms. Malcolm is a graduate of Dartmouth College.

Leading Public Health A Competency Framework

James W. Begun, PhD Jan K. Malcolm

Copyright © 2014 Springer Publishing Company, LLC All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of Springer Publishing Company, LLC, or authorization through payment of the appropriate fees to the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400, fax 978-646-8600, [email protected] or on the Web at www.copyright.com. Springer Publishing Company, LLC 11 West 42nd Street New York, NY 10036 www.springerpub.com Acquisitions Editor: Sheri W. Sussman Production Editor: Shelby Peak Composition: Integra Software Services Pvt. Ltd. ISBN: 978-0-8261-9906-5 e-book ISBN: 978-0-8261-9907-2 14 15 16 17/5 4 3 2 1 The author and the publisher of this Work have made every effort to use sources believed to be reliable to provide information that is accurate and compatible with the standards generally accepted at the time of publication. The author and publisher shall not be liable for any special, consequential, or exemplary damages resulting, in whole or in part, from the readers’ use of, or reliance on, the information contained in this book. The publisher has no responsibility for the persistence or accuracy of URLs for external or third-party Internet websites referred to in this publication and does not guarantee that any content on such websites is, or will remain, accurate or appropriate. Library of Congress Cataloging-in-Publication Data Begun, James W., author.   Leading public health: a competency framework/James W. Begun, Jan K. Malcolm.    p. ; cm.   Includes bibliographical references.   ISBN 978-0-8261-9906-5 — ISBN 978-0-8261-9907-2 (eBook)   I.  Malcolm, Jan, author.  II.  Title.   [DNLM: 1.  Public Health Administration.  2.  Leadership.  WA 525]  RA971  362.1068’4—dc23 2014003516 Special discounts on bulk quantities of our books are available to corporations, professional associations, pharmaceutical companies, health care organizations, and other qualifying groups. If you are interested in a custom book, including chapters from more than one of our titles, we can provide that service as well. For details, please contact: Special Sales Department, Springer Publishing Company, LLC 11 West 42nd Street, 15th Floor, New York, NY 10036-8002 Phone: 877-687-7476 or 212-431-4370; Fax: 212-941-7842 E-mail: [email protected] Printed in the United States of America by Gasch Printing.

JB: To the bold change makers and progress makers in public health—thank you for your leadership. JM: To the wonderful professionals, past and present, at the Minnesota Department of Health and in local health departments all over Minnesota. Your skill and dedication to protecting and improving the health of Minnesotans inspire me and made me a passionate advocate for this field. This book is also dedicated to the staff and leadership of the Robert Wood Johnson Foundation who have done so much to advance the public’s health. I am proud to have such colleagues and friends.

Contents

Preface xi Acknowledgments xiii Share L eading Public Health Part i: The Call for Public Health Leadership   1

1. Why Leadership? Why Now?   3 Past Successes, Future Opportunities   3 What Is Leadership?   17 The Time Is Now   20 Conclusion  26 2. A Framework for Public Health Leadership   27 Approaches to Leadership   28 Our Framework  37 Existing Competency Models for Public Health Leadership   42 Conclusion  49 PART ii: Preparing for Public Health Leadership   51

3. Values and Traits of Public Health Leaders   53 Values Unify the Field   54 Legal and Ethical Foundations of Public Health   55 Values of Public Health Leaders   58 Traits of Public Health Leaders   67 Conclusion  75



vii

viii

Contents

4. Knowledge for Public Health Leadership   77 Public Health Science   80 Understanding People  93 Understanding Complex Systems   99 Changing People, Organizations, and Communities   103 Conclusion  104 PART Iii: Competencies For Public Health Leadership   105

5. Invigorate Bold(er) Pursuit of Population Health   107 Values and Traits   110 Knowledge  112 Five Competencies for Invigorating Bold(er) Pursuit  of Population Health  113 Conclusion  130 6. Engage Diverse Others in Public Health Work   133 Nature of Collaboration   134 Values and Traits   138 Knowledge  140 Five Competencies for Engaging Diverse Others   141 Conclusion  154 7. Effectively Wield Power to Increase the Influence   and Impact of Public Health   155 Values and Traits   157 Knowledge  159 Five Competencies for Effectively Wielding Power   160 Conclusion  179 8. Prepare for Surprise in Public Health Work   183 Values and Traits   185 Knowledge  190 Five Competencies for Preparing for Surprise   192 Conclusion  203 9. Drive for Execution and Continuous Improvement   in Public Health Programs and Organizations   205 Values and Traits   206 Knowledge  207 Five Competencies for Driving Execution  and Continuous Improvement  209 Conclusion  230



Contents

PART iv: Sustaining Public Health Leadership   231

10.

Lifelong Leadership Development   233 Leadership as a Lifelong Endeavor   234 Understanding Oneself  239 Planning for Development   243 The Development Process   245 Sustaining a Life of Leadership   248 Conclusion  251

References  253 Index  283

ix

Preface

This book is a current, compact guide to the values and traits, knowledge, and competencies needed by public health professionals to mobilize people, organizations, and communities to effectively tackle tough public health challenges. To our knowledge, it is the only c­ ompetency-based leadership book designed specifically for students and p ­ ractitioners in public health, highlighting those aspects of l­eadership unique to this field. We wrote this book to empower students and practitioners of public health with knowledge and with a framework for self-development. In doing so, we anticipate that readers and the field as a whole will make progress toward achieving a more powerful position in health policy and practice. As a result, the individuals and populations we all serve will have improved chances for healthy lives. We firmly believe that what is good for public health as a field is good for the public’s health. The book comes at an important time. The evidence base for a social determinants framework for health policy and practice is strong and ever-cumulating, and it is harder and harder for politicians, community leaders, business leaders, leaders of philanthropic organizations, and others to ignore the evidence. There is growing appreciation for the “systems perspective” that public health embraces, both within academia and the policy and practice sectors. Now is the time to press for bolder public health action. Leadership development in public health has a checkered past; it has performed well for a select group of “emerging leaders” or “leaders,”

xi

xii

Preface

usually working in the public sector, but with less attention to the field as a whole. We believe that everyone who belongs to the field of public health can perform leadership activities. Indeed, leadership education should be offered in public health educational curricula, for all specialties, including epidemiology, biostatistics, environmental health, and other specialties whose sponsors do not traditionally consider leadership development to be part of the core education. Accordingly, we intend this book to be accessible to a wide range of entry-level and inexperienced leaders. We think that experienced leaders as well will find the framework to be a useful way to understand and build on their own experiences. The genesis of this book comes from our joint teaching of leadership courses to diverse groups of public health students, including many students from countries other than the United States and from a variety of public health specialties. The book focuses on leadership in the context of the United States, but most of the competencies apply across the globe. We write with two qualitatively different voices—one (JB) academic and research-based, one (JM) practical and experience-based. We find this combination of academic and practitioner to work well in teaching leadership, because it enables theory and research to be linked to application and application to be linked to theory and research. We have not tried to homogenize the two voices in the book. Particularly, Chapter 3 (“Values and Traits of Public Health Leaders”) and the five chapters of Section III, Competencies for Public Health Leadership, are purposely written with a more subjective and normative voice. We think the chapters “speak” to the reader better that way. To further emphasize application of the material, 19 cases of leaders or leading organizations in action are presented throughout the book. We look forward to a new era in the improvement of population health, and the significant contributions of public health leaders at all levels to those improvements. Nationally and globally, the work of ­public health has never been more critical. We hope this book gives ­public health leaders—both current and future—a framework for thinking about the attributes and acts of leadership that can elevate the importance and impact of public health programs and organizations.

Acknowledgments

This book would not have been initiated or completed without the assistance and support of many friends and colleagues. Thanks to Tony Kovner of New York University for his early support of this project. Katie White (University of Minnesota) and Ken White (University of Virginia) provided suggestions for improvement of the original outline for the book. At Springer Publishing, Sheri W. Sussman was an early proponent and flexible partner on this project. An important contributor to this book is Linda M. Kahn. She is a master of public health (MPH) candidate in the Executive Program in Public Health Practice at the University of Minnesota, School of Public Health. Linda transitioned into graduate studies following more than two decades of experience in health care administration, where she led management analysis and reporting teams at academic health centers and in management and technology consulting. Her area of concentration is community health care system integration through public and health policy focused on community health, social connectedness, health equity, and access, especially in underserved communities. Our association with Linda began in fall, 2012, when Linda was a student in our Public Health Leadership course. She then served as a research assistant who contributed well beyond our expectations. Linda is a valued colleague, a superb editor and writer, and a joy to work with. She made primary contributions to almost all of the In Practice cases in the book, as well as several other inserts and editing. The book would not be nearly as strong and as engaging without her contributions.

xiii

xiv

Acknowledgments

Other students and research assistants who contributed to this book include Katie French, Luqman Lawal, Samantha Mills, Ngozi Njoku, Pearl Ometan, Brooke Vagts, and Elliott Wortham. We thank all of the students in our Public Health Leadership courses for energizing us and for sharpening the content of the book. Within the University of Minnesota School of Public Health, champions for leadership content in the graduate curriculum include Mary Ellen Nerney, Sandra Potthoff, Donna McAlpine, and John Finnegan, Jr. We appreciate their efforts. Anne Barry, Aggie Leitheiser, Ruth Mickelsen, Lowell Kruse, Mary Selecky, and Nicole Lurie all served as fountains of wisdom on their respective areas of expertise. We are grateful to them for sharing their knowledge and experience with us. Jim Begun thanks his (extended) family—Jean, Michael, Mitch, Stephanie, Blythe, and Murray—for filling his life with joy, wonder, and hope for the next generations of leaders. Jan Malcolm thanks Kris for constant support and for putting up with the piles of paper all over the house, and Nancy for always telling her she could do anything, even write a book.

Share Leading Public Health

part i

The Call for Public Health Leadership

A first step in any social or organizational transformation is making the case for change. In Chapter 1 (“Why Leadership? Why Now?”) we make the case that public health is undervalued in policy and practice arenas. Public health offers the best hope for cost-effective and value-adding solutions to intractable population health challenges in the United States and around the globe. The social determinants model developed by the field provides a foundation for stronger public health leadership. Performing leadership activities effectively can leverage the impact of every public health practitioner and advance the power and influence of public health. In Chapter 2, “A Framework for Public Health Leadership,” we introduce a framework for the book based on the values, traits, knowledge base, and competencies of effective public health leaders. The framework builds on four complementary perspectives on leadership (servant leadership, complexity leadership, integrative leadership, and adaptive leadership) and several existing competency frameworks for public health. Seven key values and seven traits of effective public health leaders are forwarded. Five competency sets, comprised of five competencies each, form the basis for leadership development: invigorate bold(er) pursuit of population health; engage diverse others; effectively wield power; prepare for surprise; and drive for execution and continuous improvement.

chapter 1

Why Leadership? Why Now?

key terms Frieden health impact pyramid Health in All Policies movement Healthy People 2020 leadership management population health public health challenges

public health professional public health solutions public health workforce romance of leadership social determinants model World Health Organization  (WHO)

P

ublic health is undervalued and underutilized in relation to its capacity to improve the health and well-being of individuals and populations. In this chapter, we weigh the gap between public health’s potential and its current contribution. Stronger leadership from public health professionals can reduce that gap and accelerate improvement in the health and well-being of individuals and populations. PAST SUCCESSES, FUTURE OPPORTUNITIES The field of public health has made enormous contributions to human welfare. For example, public health interventions have been credited with adding 25 of the 30 years of average lifespan gained in the 20th century in the United States (Bunker, Frazier, & Mosteller, 1994). Vaccinations, motor

3

4

I  The Call for Public Health Leadership

vehicle safety, safer workplaces, control of infectious diseases, safer food, fluoridation, and regulation of tobacco are among the public health interventions responsible for these and other improvements in the quality and length of lives (Centers for Disease Control and Prevention, 1999). Around the globe, the results of public health work are equally compelling. Cholera, typhoid, smallpox, and polio are among the infectious diseases that have been largely controlled by improvements in sanitation, water and food safety, improved nutrition and living standards, and vaccines (Schlipköter & Flahault, 2010). Simple screening programs can drastically reduce death rates from cancer. Rapid investigation of disease outbreaks has saved untold lives. Prevention and recovery efforts directed at natural disasters such as tsunamis continue to improve with learning and experience.

Public Health Challenges The need for enhanced contributions from public health is increased by the fact that public health challenges are growing, not diminishing. Nearly 2.4 million children around the world die each year from ­vaccine-preventable diseases (Schlipköter & Flahault, 2010, p. 92). Efforts to ­control HIV/AIDS, malaria, and several other diseases ­continue to struggle. As some disease sources are controlled, other problematic diseases emerge, due to the complex interaction of animal species, ­ expanding human populations, changes in technology, and environmental conditions, among other causes. Complex new health challenges, deriving from resource depletion and climate change, are looming. Chronic food shortages, natural disasters, population growth, wars, and epidemics will continue to challenge the public health sector in some countries, while obesity and addiction will plague others. People are living longer, leading to aging populations with more chronic disease load. Technologies to keep people alive are improving, adding to the cost of providing care. Some would add the impact of modern culture, particularly individualism and materialism, on well-being as substantial public health problems (Hanlon, Carlisle, Hannah, & Lyon, 2012). Global inequities in health outcomes are a particular challenge of the future. Marmot (2005) notes that huge differences in life expectancy among countries (for example, a difference of 48 years between Sierra Leone and Japan) and within countries (for example, a difference of 20 years between the most- and least-advantaged populations in the United States) are not inevitable. Large inequities in income within and between countries are associated with a host of health outcomes



1  Why Leadership? Why Now?

5

and challenges, including mental health, infant mortality, violence, obesity, and life expectancy (Wilkinson & Pickett, 2009). The Rio Political Declaration on Social Determinants of Health, endorsed by the World Health Organization (WHO) in 2012, explicitly targets inequity within and between countries in the distribution of power, money, and resources as a health challenge (WHO, 2013c). In the United States, cost, quality, and access problems continue to vex the health care delivery sector. Residents of the United States pay twice as much or more and have significantly worse population health statistics than many people in the world, with the situation worsening since 1990. For example, among 34 Organization for Economic Co-operation and Development (OECD) countries, the U.S. rank for life expectancy at birth fell from 20th to 27th between 1990 and 2010 (U.S. Burden of Disease Collaborators, 2013). In many countries around the globe, health services are taking increasing proportions of national budgets, as the availability of new and expensive drugs and medical technology and consumer demand continue to grow. If not contained, government spending on health will rise to 14% of Gross Domestic Product over the next 50 years on average in the OECD nations, from 6% in 2010 (OECD, 2013). The budget situation is particularly dire in the United States, with Medicare and Medicaid programs continually labeled as unsustainable in their current forms, and driving much of the ongoing budget deficits in federal and state governments. The conclusion of Harvey Fineberg, MD, President of the Institute of Medicine, is stark: “Despite a level of health expenditures that would have seemed unthinkable a generation ago, the health of the U.S. population has improved only gradually and has fallen behind the pace of progress in many other wealthy nations” (Fineberg, 2013b, p. 585). Inequities in health based on race, ethnicity, and economics persist in the United States. For example, infants born to black women are 1.5 to 3 times more likely to die than infants born to women of other races/ethnicities (Centers for Disease Control and Prevention, 2011). Table 1.1 summarizes the wide range of public health challenges facing society in the future, with an emphasis on issues that have emerged in recent decades. Given the range and impact of the health and cost challenges faced in the United States and around the globe, the need for effective public health solutions has never been greater.

Public Health Solutions What does public health have to offer? What are public health ­“solutions” to the challenges listed in Table 1.1?

6

I  The Call for Public Health Leadership Table 1.1 Future Public Health Challenges Conventional challenges

•  Infectious diseases—prevention •  Water quality and sanitation

•  Access to personal health care services

•  Nutrition and hunger

•  Life expectancy

•  Natural disasters

–  Maternal mortality

•  Epidemics and pandemics

–  Infant/child mortality

•  Food safety Recent and emerging challenges

•  Chronic disease burden –  HIV/AIDS

•  Early childhood education and kindergarten readiness

–  Aging populations

•  Mental health

–  Rehabilitation services –  Disability services •  Antibiotic resistance •  Quality and cost of personal health care services •  Cost, regulation, and equitable distribution of medical technology and pharmaceuticals •  Environmental quality –  Natural resource depletion, including water, land, and soil –  Climate change –  Pollution •  Wars and dislocation –  Refugee services

–  Availability of preventive   services –  Institutional care capacity and competency—hospitals, prisons, schools –  Community support services •  Physical activity, obesity –  Physical, behavioral, social, and environmental factors causing obesity •  Oral health –  Lifelong access to oral care –  School-based dental sealant programs for children, especially in underserved communities

•  Economic development, poverty, employment

•  Weapons of mass destruction— chemical, nuclear

•  Personal and community safety, including schools and neighborhoods, domestic   violence

•  Substance abuse •  Bioterrorism

(continued)



1  Why Leadership? Why Now?

7

Table 1.1 (continued) Future Public Health Challenges Recent and emerging challenges

•  Inequities in health services and health outcomes

•  Social support for healthy living

•  Transportation access and   safety

•  Physical environment and urban design for healthy living

•  Housing and shelter

•  Use of genetic information to modify health

•  Legal protections and legal   services •  Reproductive and sexual health

•  Cultural support for healthy living

•  Genetic modification of food •  Food security

–  Sexually transmitted infections –  Juvenile vaccination for human papilloma virus –  Gay, lesbian, bisexual, and transgender health issues

An expansive view of the field of public health has been widely adopted in recent decades by many public health professionals and governments. This expansive view has been referred to by such terms (with some distinctions among the terms) as the synthetic model, ecological model, multilevel framework, social determinants model, and New Public Health (Braveman, Egerter, & Mockenhaupt, 2011; Fielding, Teutsch, & Breslow, 2010; Kaplan, 2004; Tarlov, 1999; Tulchinsky & Varavikova, 2010; U.S. DHHS, 2011; WHO, 2013c). We generally use the term “social determinants model” to refer to this broader perspective in this book. An example of the perspective is provided in Figure 1.1, which displays the framework of the U.S. government’s Healthy People 2020 program. At the individual level, genetics, biology, and behavior all play a role in health. The social environment, which includes economic and social conditions in communities, and the physical environment, which includes chemical pollution and natural threats to health, join individual-level factors and “health services” as determinants of health outcomes. Historically, health policy in the United States and many other countries has focused on individual-level health determinants and interventions, while the Healthy People 2020 framework argues for an expansion of emphasis on health-enhancing social and

8

I  The Call for Public Health Leadership Figure 1.1  Conceptual framework of Healthy People 2020.

Healthy People 2020 A society in which all people live long, healthy lives Determ

Overarching Goals:

inants

-Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death.

Physical Environment Social Environment

Health Services

Individual Behavior

Biology & Genetics

Health Outcomes

-Achieve health equity, eliminate disparities, and improve the health of all groups. -Create social and physical environments that promote good health for all. -Promote quality of life, healthy development, and healthy behaviors across all life stages.

Reprinted from U.S. Department of Health and Human Services (2011)

physical environments (U.S. DHHS, 2011). A similar framework guides the World Health Organization’s practices (WHO, 2013b), as well as those of many governments (see Figure 1.2). One popular framework is Frieden’s five-tier health impact pyramid (Frieden, 2010). The base of the pyramid consists of “socioeconomic factors”—the first tier and the root driver of health outcomes, followed in tier 2 by the “context” of health decisions and protective interventions at the second level. Only then do preventive interventions (tier 3) and clinical interventions (tier 4) enter in the pyramid, followed at the top (tier 5) by counseling and education. In general, the social determinants model challenges the “medicalization” of health status problems, which leads to neglect of social and economic causes of health vulnerability and disparities (Lantz, Lichtenstein, & Pollack, 2007). Another popular social determinants framework was developed by the University of Wisconsin Population Health Institute (2013). In that model, causes of variation in health outcomes are allocated among four categories: health behaviors (30%), clinical care (20%), social and economic factors (40%), and the physical environment (10%). Social and economic factors include education, employment, income, community safety, and family and social support. The social determinants framework for public health has implications for the definition of “public health solutions” to improving individual and population health. This broader, bolder, and more powerful



1  Why Leadership? Why Now?

9

Figure 1.2  Conceptual framework of World Health Organization   Commission on Social Determinants of Health. Socioeconomic & political context

Governance

Policy (macroeconomic, social, health)

Social position Education Occupation Income

Cultural and societal norms and values

Gender

Material circumstances Social cohesion

Distribution of health and well-being

Psychosocial factors Behaviors Biological factors

Ethnicity/Race Health care system

SOCIAL DETERMNANTS OF HEALTH AND HEALTH INEQUITIES

Reproduced with the permission of the publisher from World Health Organization (2008) (Figure 4.1, p. 43, http://whqlibdoc.who.int/publications/2008/9789241563703_eng.pdf,   accessed December 6, 2013). Figure is amended from Solar, O., & Irwin, A. (2007). A conceptual framework for action on the social determinants of health. Discussion paper for the Commission on Social Determinants of Health. Geneva, Switzerland: World Health Organization.

view links public health to social services and social policy. Researchers found that the United States is one of only three industrialized countries to spend the majority of its health and social services budget on health care, versus social services, with negative effects on health indicators (Bradley, Elkins, Herrin, & Ebel, 2011). The Health in All Policies movement suggests that decision makers (public and private) in all sectors that influence health, such as transportation, agriculture, land use, housing, public safety, and education, consider the effects of their policies on health outcomes. The U.S. Institute of Medicine and a variety of ­public health associations in the United States recommend the approach to more fully address social determinants of health (Institute of Medicine, 2011a; National Association of County & City Health Officials, 2013c). The recommendations of the WHO Commission on Social Determinants of Health illustrate the broad range of public health solutions as applied to global public health problems (WHO, 2008). The Commission’s recommendations for improving health equity are as follows: 1. Improve the conditions of daily life. 2. Tackle the inequitable distribution of power, money, and resources.

10

I  The Call for Public Health Leadership

3. Measure the problem, evaluate action, expand the knowledge base, develop a workforce that is trained in the social determinants of health, and raise public awareness about the social determinants of health. The recommendations reflect serious consideration of all levels of ­public health solutions to drive improvements in health outcomes. Population health, defined as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group” (Kindig & Stoddart, 2003, p. 381) is viewed by many as demarcating the domain of a broader public health. Kindig and Stoddart argue that “a hallmark of the field of population health is significant attention to the multiple determinants of such health outcomes. . . . These determinants include medical care, public health interventions, aspects of the social environment (income, education, employment, social support, culture) and of the physical environment (urban design, clean air and water), genetics, and individual behavior” [italics in original] as well as their interactions (Kindig & Stoddart, 2003, p. 381). Referring back to the Frieden health impact pyramid (described above), tiers in the pyramid can be characterized by “ease of change.” The ­levels at the top require the least political commitment and, one might argue, the least “leadership” on the part of public health to achieve. As observed by Gostin and colleagues, the broader vision of public health is politically charged, as it shines a light on the poor condition of public health agencies; requires a transition to an intersectoral public health system; promotes the adoption of bold changes in physical, social, and economic conditions; and requires a values shift toward collective interest (Gostin, Boufford, & Martinez, 2004). The lower levels at the base of the pyramid, despite their impact on population health, are not within government’s appropriate sphere of action, in the opinion of powerful elites (Frieden, 2010, p. 591) and those who advocate for a narrow role for public health (Epstein, 2003). Similarly, a health care system organization applying the University of Wisconsin Population Health Institute framework classified the socioeconomic and environmental factors as under “limited control” of the organization, compared to the “shared control” over health behaviors and “high control” over clinical care (May, 2013b). In all of these frameworks, public health solutions involve far more than health care. The broad vision for public health requires integration of public health into the education of clinical care providers and into clinical care practice, a long-standing position of many in the history of public health (Lurie & Fremont, 2009; Sava, Armitage, & Kaufman, 2013).



1  Why Leadership? Why Now?

11

The broad and bold vision for public health reflects a complex systems approach, depicting that determinants of health are embedded within larger systems (or contexts) that affect them. The systems approach includes an understanding of root causation, tracing problems far back in the causal chain. In this sense, the public health approach is a long-term perspective, accompanied by diagnosis of the deepest underlying roots of issues. In summary, there is growing, strong, and pervasive support for the social determinants of health approach to public health, which has been documented in the literature (Braveman, Egerter, & Williams, 2011). It is time that such intellectual and evidence-based movement be accompanied by broader social and political action. In Practice cases 1.1 and 1.2 illustrate examples of public and private organizations that are adopting a broader view of public health action. They detail efforts of the New Orleans Health Department and two private health care delivery systems in Minnesota to expand their services to more directly address social determinants.

in practice 1.1 TACKLING SOCIAL DETERMINANTS OF HEALTH DISPARITIES: NEW ORLEANS HEALTH DEPARTMENT Undertaking the challenge of reducing deeply engrained socioeconomic and health disparities is not an enviable job for any public or private organization. This would seem especially true in a major metropolitan city that survived one of the worst series of natural disasters and delayed recovery efforts in recent U.S. history. The New Orleans Health Department (NOHD), however, took on this ponderous task and earned recognition in 2013 by the Robert Wood Johnson Foundation (RWJF) as an inaugural “Roadmaps to Health” winner for its “outstanding community partnerships. . . . .which are helping residents live healthier lives” (City of New Orleans, 2013, para. 1).

An Epic Storm Followed by a Chaotic Response Hurricane Katrina hit southeast Louisiana—including Orleans Parish and the City of New Orleans—on August 29, 2005, arriving as a Category 4 hurricane. Katrina’s winds and water surge produced one of the most devastating natural disasters in U.S. history, with thousands killed, injured, displaced, or dispersed from an area of the country already plagued by persistent socioeconomic and health disparities. By most accounts, failures at every level of government occurred in the aftermath of Katrina; according to LaFronza and Burke (2007, p. 4), “Truthfully, everything broke down; governments, private sector organizations, and individuals were ill-prepared to respond in a timely manner.” But the issues ran deeper than preparedness and

12

I  The Call for Public Health Leadership

response, as New Orleans already faced severe problems prior to Katrina: “. . . . social forces that created an economically divided New Orleans emerged from years of inadequate policy, attention, and concern. . . . Katrina more clearly uncovered many social ills that were omnipresent but perhaps lurking just beneath the surface” (LaFronza & Burke, 2007, p. 7).

Recognizing That Place Matters for Health As part of its long-term recovery efforts, New Orleans used the community health assessment process to bring together cross-sector leaders and community members. This collaborative effort identified poverty as a major determinant of residents’ health, especially childhood poverty. Poverty impacts health in the extreme: as deficits, such as lack of access to affordable food, housing, and health care; and as excesses, including rates of infant mortality and morbidity, obesity, and unemployment higher than the national average. Those living in the poorest neighborhoods experience a 25-year lower life expectancy compared with those in the wealthiest neighborhoods (NOHD, 2013). These findings are supported by research published by the Joint Center for Political and Economic Studies (2012, p. 1), which found that in Orleans Parish, “people living in neighborhoods characterized by poor housing, inadequate schools, polluted environments, insufficient transportation, and lack of safety typically have significantly poorer health than people living in neighborhoods that don’t suffer from these characteristics.” Historic patterns of discrimination resulted in residential segregation, with environmental conditions in specific neighborhoods creating the fundamental causes of health inequities across different racial, ethnic, and socioeconomic groups. While not unique to Orleans Parish and New Orleans, segregation based on these demographic characteristics has been substantial and persistent.

Addressing Persistent Social Determinants Through Cross-Sector Partnerships Using accreditation guidelines developed by the Public Health Accreditation Board (PHAB), NOHD has focused its post-Katrina efforts on implementing a prevention and public health model. This “modern public health agency” approach replaces its previous “broken and outmoded” clinical care model. Through a collective of cross-sector partners—including schools, businesses, health care and nonprofit organizations, and government agencies—the city moved quickly from being “a place where we were treating the consequences of poor health decisions and the impacts of social determinants of health . . . into a place where we’re upstream and we can prevent it” by working across sectors, according to Dr. Karen DeSalvo, Health Commissioner for the City of New Orleans (RWJF, 2013a, paras. 5–6). A primary factor in New Orleans’ success has been this collaborative approach to improving population health. With all sectors involved in decision making, diverse partners have represented and considered the breadth of social determinants in new policies. Dr. DeSalvo cited the success of the approach: “As we rebuild our



1  Why Leadership? Why Now?

13

roads, buildings, parks, and playgrounds, we are thinking about not only health from a physical activity and a nutritional standpoint, but also mental health and addressing those chronic disease needs that communities have” (RWJF, 2013a, paras. 7–8). In the aftermath of Katrina, clinical care has also been improved to address the needs of the most vulnerable in the city. Examples include community-based health care access points for uninsured, underinsured, and low-income patients; electronic medical records across the health care system; and the Greater New Orleans Health Information Exchange to share clinical data for the improvement of population health (RWJF, 2013a, para. 12). Along with community health programs focused on wellness, fitness, healthy food access, school-based gardening and education, and urban farming, New Orleans is undertaking an intentional “work-in-process” approach to its ongoing experiment with a new approach to public health.

“Health in All Things” as a National Model of Community Wellness One of NOHD’s goals in the wake of its post-Katrina efforts is PHAB accreditation; it received funding as an accreditation support initiative site and submitted its accreditation application in May 2013 (National Association of County & City Health Officials, 2013d). Hurricane Katrina is viewed as a catalyst that exposed, not created, the effects of deep and persistent socioeconomic and health disparities in New Orleans. As Dr. DeSalvo stated, “Our challenges are great, but so is our opportunity. . . . . as we seek to establish New Orleans as a model for community health improvement for the nation” (DeSalvo, 2013, para. 4), as well as “a rallying cry for all of us to come together and find a way to solve those problems as a community” (RWJF, 2013a, para. 18). LaFronza and Burke (2007, p. 7) put it this way: “In a post-Katrina environment, there are new opportunities to recreate institutions and organizations, and restructure the interactions among them.” Given its efforts and progress to date, NOHD is demonstrating that a public agency can be a public health leader by engaging all sectors of the community to overcome disparities and adversity through an attitude and practice of “health in all things.”

in practice 1.2 TACKLING SOCIAL DETERMINANTS THROUGH HEALTH   SYSTEM–COMMUNITY COLLABORATION With clinical care accounting for only 20% of the health factors impacting health in the United States (University of Wisconsin Population Health Institute, 2013), the role of health care delivery systems in improving population health may be questioned. Yet health systems hold a unique place in the communities they serve and their influence can be far-reaching to members of the community and the communities at large. In Minneapolis and Saint Paul, Minnesota—the Twin Cities— two large health systems are collaborating with their communities to impact the

14

I  The Call for Public Health Leadership

lives and health of those they serve. While these providers are not unique in their approach to population health, HealthPartners and Allina Health are demonstrating organizational leadership that has captured national interest in their commitment to improving community health. A critical feature of programs offered by both HealthPartners and Allina Health is the focus across the life course. The health systems partner with local community organizations such as schools, media, and a variety of service providers. Together they develop and deliver programs and resources that are valuable to all ages, especially those early and late in life.

Early Lessons in Healthy, Active Living to Young Community Members Isham, Zimmerman, Kindig, and Hornseth (2013, pp. 1448–1449) describe the partnership between HealthPartners, schools, and Radio Disney to form the yumPower School Challenge. Part of an evidence-based, integrated healthy eating campaign, the program’s goal is to increase healthy eating behaviors in school-aged children. Elementary students from participating urban and suburban school districts voluntarily track fruit and vegetable consumption, a key indicator in childhood of future health outcomes. Representing predominantly low-income households from ­public school districts in the Twin Cities, students and parents, along with teachers, administrators, and nutrition staff, all engage in learning about healthy eating. HealthPartners contributed funding of the initiative and engagement of its leaders to collectively improve community health results. Allina Health offers similar school-focused initiatives to instill lifelong health behaviors in young children. One program is Health Powered KidsTM (HPK; Allina, 2013a, p. 12), which provides online curricula for children ages 3 to 14. The focus of HPK is empowering students to make healthier choices about eating, exercise, keeping clean, and managing stress, including fruit and vegetable consumption and physical activity ideas for home and classroom. Resources are made available for free to a wide-reaching audience, including elementary schools, home-schooled families, daycare providers, individuals, and community organizations, such as local Girl Scout and YMCA participants. In addition, School Health ConnectionsTM and Neighborhood Health ConnectionsTM (Allina, 2013a, pp. 6–8) provide grants to elementary school and community organizations, respectively, to support healthy activities that increase healthy, active lifestyles; build health literacy; and increase social connectedness. Allina’s partnership with Free Bikes for Kidz (FB4K), a Minneapolis-based nonprofit organization, has provided thousands of new and gently used bikes and helmets to promote active play and physical activity along with bike safety for children from low-income and underserved families.

Community Health Programs for Life Both health systems offer programs to support individuals and families to stay healthy and understand health conditions and health decision making. By promoting health and wellness programs delivered online and in person, health systems reach diverse community members with resources that are meaningful to them.



1  Why Leadership? Why Now?

15

For example, Allina Health has invested in the Heart of New Ulm Project to improve cardiovascular health for residents living in New Ulm, Minnesota; the work of the Cultural Wellness Center profiled in Chapter 6; and the Healthy Communities Partnership, a health screening and assessment initiative with 13 communities (Allina, 2013b). HealthPartners, which operates half the mental health beds in the eastern Twin Cities, has collaborated in partnerships on a growing number of topics related to mental health, including education, advocacy, and reduction of stigma. The “Make It OK” campaign is geared toward increasing awareness about and comfort in individual and community discussions about mental illness (Isham et al., 2013). Each of these programs allows the health system to work with and provide resources to patients, stakeholders, government leaders, businesses, and organizations in its communities on vital issues facing the varied needs of community members.

Support and Care to Face End-of-Life Issues HealthPartners and Allina Health also address end-of-life issues within their communities. Allina is undertaking the Robina LifeCourseTM study, which is developing improved ways to allow those with serious illness to choose how to live their lives by collaborating with their entire health care team, including care providers, social service and support practitioners, and care guides (Allina, 2013c). HealthPartners is one of the partners in the Honoring Choices Minnesota initiative (Isham et al., 2013, p. 1449), which aims to improve end-of-life care. Through Honoring Choices, community leaders and health care providers work together to share information with patients and community members to raise awareness about the options and importance of advanced care decisions and directives.

Competing Health Systems Can Collaborate, Too HealthPartners and Allina Health are working collaboratively to address community health in the Twin Cities. In 2010, the competing health systems launched the Northwest Metro Alliance to improve the care of over 300,000 people in the northwestern suburbs, including over 27,000 patients with HealthPartners insurance who receive their health care at HealthPartners and Allina facilities in the northwest metro (HealthPartners, 2013, p. 2). The partnership was developed as a long-term collaboration to achieve the “Triple Aim” of health care—high-quality care, exceptional patient experience, and affordability—by targeting cost and care improvements, optimizing available care networks and specialty services, and preventing duplicative services or capital projects in the service area, thus serving as an Accountable Care Organization (ACO) “learning lab” (HealthPartners & Allina Hospitals & Clinics, n.d., p. 1). Focusing on providing health care services together across the community allows the Northwest Metro Alliance to reduce care fragmentation and provide b ­ etter care across the inpatient and outpatient care continuum. One initiative involves improved prescribing of generic medications and reduced variation in prescribing to improve cost and quality, with an increase from 75% generic utilization in 2009 to

16

I  The Call for Public Health Leadership

87% utilization in 2012, representing a $3.4 million reduction in prescription spending (HealthPartners, 2013, p. 1). Community outreach through the Northwest Metro Alliance resulted in over 9,000 people completing health assessments at community events and local settings, such as schools and employers, in 2012, with 87% of participants receiving counseling on health improvement activities (HealthPartners, 2013, p. 2). Electronic health information sharing is a key strategy of the Northwest Metro Alliance, which allows Allina and HealthPartners to use data-based analyses to target initiatives toward the population and individuals served in the region and better address the “Triple Aims” across the care continuum (HealthPartners & Allina Hospitals & Clinics, n.d., pp. 2–4). Health and wellness are critical goals of health care delivery systems and communities. Consumer and societal demands for more value from health care services are pressuring health care delivery organizations to integrate more fully with public health practice (Zismer, 2013). By partnering together through crosssector collaborations, participants impact the lives of their community members to a greater extent throughout the life course. HealthPartners and Allina Health are providing leadership, innovative program ideas, and funding to their communities to strengthen the bond and outcomes of community health and health care. In the end, these collaborations benefit patients, their families, and communities, as well as the health systems.

Value of Public Health Solutions The American Public Health Association in 2013 adopted “public health is ROI” as one of its tag lines. ROI refers to return on investment. Simply put, public health solutions at the bottom of the Frieden pyramid, to use one example, often provide higher levels of performance improvement per unit of cost than those higher on the pyramid. Maximum value means producing the highest output with the least resources. The greatest value comes from changes at the bottom of the pyramid. Public health interventions often meet that criterion. They are wiser investments for societies with scarce resources. Whether explicitly or implicitly, the proportionately greater investments other countries make in housing, education, transportation, and income security may well be part of the reason they outperform the United States in population health measures, at far lower spending on medical care. The Gap All of the past accomplishments of public health are a source of pride and positive energy in the public health community. The future challenges indicate that public health will be a prominent fixture in the betterment



1  Why Leadership? Why Now?

17

of society in the future. The ability of public health to contribute more to societal gain has been documented in public policy tomes issued by the Institute of Medicine several times in the United States (Institute of Medicine, 1988, 2003a, 2012). However, the fact that the recommendations of Institute of Medicine and other groups have been repeated and have been largely unheeded is troubling (Tomes, 2008). Public health’s influence in current health care policy and funding debates is much less than it should be, given the evidence of its potential. The mismatch between the amount of resources devoted to public health and the influences of public health approaches on ultimate health status outcomes ought to frustrate and be a rallying cry for strengthened public health leadership at all levels. In the United States, government public health activities comprised 2.9% of national health expenditures in 2011 (Centers for Medicare and Medicaid Services, 2012). Many have observed that the “field of ­public health has long been the poor relation of medicine” (Hemenway, 2010, p. 1657). Despite its contributions to social welfare in the United States, public health operates largely at the margins of health policy. The share of national health spending devoted to public health activities in the United States pales in comparison to spending on medical research and attention to reorganization of the system to deliver care for illnesses that are preventable. Fineberg (2013a, p. 85) describes the “paradox of disease prevention” as the fact that prevention is celebrated in principle, but resisted in practice. Reasons for this include the long-term nature of solutions, the diffuseness of the beneficiaries in contrast to the clearly identifiable beneficiaries of clinical health care, the relative lack of drama of prevention, opposition from commercial interests and personal beliefs, and the invisibility of public health leaders and organizations. Public health solutions require change in institutions that are powerful and inertial or opposed to more investment in public health solutions. Such conditions add up to a disconcerting underinvestment in public health (Hemenway, 2010).

WHAT IS LEADERSHIP? The potential for public health solutions to improve lives, save lives, and save money for the health sector is huge. The realization of this potential depends on persuading stakeholders—governments, opinion shapers, and economic elites—of the value of public health solutions. Political will, funding, initiative, and training are needed “to maintain and develop the gains achieved in the past century and to transmit the

18

I  The Call for Public Health Leadership

latest knowledge and technology to many parts of the world where preventable deaths measure in the hundreds of thousands” (Schlipköter & Flahault, p. 110). To transform both the influence and impact of public health, p ­ ublic health leaders need to be increasingly competent in challenging and moving people and organizations, with more urgency and success than they have had in the past. This will not happen unless public health practitioners commit to leadership activities and have the competencies to perform them. Leadership can be defined at a variety of levels (for example, individual, team, organization, community, or society) in a variety of ways (for example, as a personal trait, a process, or a system function). In Chapter 2, we systematically examine the different ways to conceive of leadership, and we derive the definition of leadership used in this book: Leadership is the practice of mobilizing people, organizations, and communities to effectively tackle tough public health challenges. Many different individuals mobilize others to address public health challenges. Next, we consider the pool of individuals who can practice public health leadership.

Who Is a Public Health Leader? Public health is a full-time professional pursuit for a core of approximately 500,000 individuals who provide one or more of the essential public health services, regardless of discipline or work. These individuals hold positions as administrators, biostatisticians, environmental engineers, health educators, public health nurses, physicians, or veterinarians, to name a few public health roles (Evashwick, 2013; Morrissey, 2011; U. S. DHHS, 2000). They are the backbone of the public health practice community. In the United States, a large majority (85%) is employed in governmental public health agencies, including nearly 3,000 local health departments, 56 state and tribal agencies, and the many federal agencies responsible for public health, such as the Centers for Disease Control and Prevention (CDC), the Health Resources and Services Administration (HRSA), and the National Institutes of Health (NIH). The remaining 15% of the public health workforce in the United States is employed at nonprofit organizations, academic and research institutions, medical groups and hospitals, and private for-profit companies. The workforce encompasses many others not included in the 500,000 figure, such as those responsible for occupational safety and health in industry, unions, and government; those involved in population-focused



1  Why Leadership? Why Now?

19

health education and community programs in voluntary organizations and health care systems; and those reducing environmental hazards (Gebbie, Merrill, & Tilson, 2002). A broader definition of public health professional is “a person educated in public health or a related discipline who is employed to improve health through a population focus” (Institute of Medicine, 2003b, p. 4). Due to the diversity and scope of public health work settings, and the absence of funding for enumeration efforts, the exact size and composition of the public health workforce in the United States remain uncertain (Morrissey, 2011). Public health leaders function in all sectors of the economy of the United States and most other countries: public, private for-profit, and private not-for-profit. In fact, a complexity of most public health leadership work is that it typically spans all three sectors. Heifetz, Grashow, and Linsky (2009, p. 53) provide an apt summary of relevant differences among the three sectors: 1. Private, not-for-profit sector: mission driven, consensus decision making 2. Private, for-profit sector: profit driven, competitive environment 3. Public sector: risk averse, security oriented, insulated from marketplace competition Those who practice leadership in public health must be prepared to work with other individuals and groups in all three sectors, requiring a degree of flexibility and openness not needed in more bounded leadership settings. In fact, observers increasingly note that leaders who can move ­easily among the business, government, and social spheres are needed to solve society’s most vexing problems (Lovegrove & Thomas, 2013). In addition to crossing sectors, public health leaders function at all levels of organizations, programs, and communities. Public health workers at the lowest levels of organizational hierarchy can enact leadership competencies in their work with the teams and projects to which they are assigned. They can contribute to mobilizing others through their positive influence on others and on the output of their teams and projects. Their behavior can be “leader-ful” or not. People who serve in staff or volunteer positions may not define themselves as leaders, but the “leader” role is not reserved to those with position power in organizations, programs, and communities (Komives, Wagner, & Associates, 2009). People can lead by role modeling the changes they support, by telling their own stories, by raising questions, as well as by working to change organizational and social cultures, policies, and practices.

20

I  The Call for Public Health Leadership

In the broadest sense, public health is a social movement that encompasses many times the formal public health workforce (Turnock, 2012, p. 11). Some leaders will hold full-time jobs in related fields and will perform public health leadership functions only as members of task forces or other collaboratives. Some leaders will enter and leave the field of public health as they change roles. Local activists may function as public health leaders in their “after-work” time, working as ­volunteers to organize neighborhoods or communities to pursue public health interventions. Corporate executives may do the same through service on boards of not-for-profit public health organizations. All of these people need the competencies of public health leadership. For example, former Mayor Michael Bloomberg of New York City (2001–2013) is a ­modern public health leader (see In Practice 7.2 in Chapter 7). Yet, his career has been largely as a business leader and public official. Governor Jesse Ventura, with whom author JM worked as Minnesota Health Commissioner, championed public health issues and approaches that surprised many. Examples of his administration’s approach are included in several chapters of this book. In his prior work life, Governor Ventura was a professional wrestler and a Navy Seal, among other jobs. These leaders are important because they leverage the impact of public health. Without public officials and others who adopt public health solutions, public health would be a more insulated clan of technicians and scientists. THE TIME IS NOW There are several reasons why more effective leadership can have a growing impact on the health of individuals and populations at this particular point in the evolution of public health. Evidence-Based Knowledge on Leadership Is Growing The knowledge base for leadership has advanced significantly in recent years. In the not-so-distant past, successful leaders were the primary sources of wisdom for future leaders, often writing their own accolades and suggesting that others follow their guidelines. While their advice largely was heart-felt and honest, it often failed to transfer to settings other than their relatively unique ones, and to apply in a world that was rapidly changing. In place of personal testimony of successful leaders, more systematic collection of experiences and more scientific study of leadership



1  Why Leadership? Why Now?

21

effectiveness in different contexts have arisen. Examples of the “collections of experiences” include the work of Kouzes and Posner (2012b) and Collins (2001a, 2011). Recognition of the importance of context for leadership is reflected in such work as Hickman (2010). Academic study and associated scientific research on the topic of leadership, while still relatively young, have added to the possibility that evidence-based leadership is now more than a dream. Another important recent development has been application of the concept of competency in the fields of education and training. Competency models provide an anchor for translating knowledge to action, and public health has taken a strong position of leadership and support in the competency development movement. Several competency models for public health leadership and for diverse segments of public health work have emerged via consensus development of leadership competencies over the past two decades, as well as novel efforts to train public health leaders. Key examples of these competency models are reviewed in Chapter 2. As a result, there is a foundation of knowledge to guide public health leaders that is stronger than ever. There are substantial bodies of accumulated knowledge about leadership that are (1) generic (shared across public and private sectors) and (2) customized to public health. Public health practitioners and students need to attain that knowledge and the skills to apply the knowledge. This book attempts to provide that foundational direction for those who choose to live a life of leadership.

Leadership Leverages Individual Contribution Why pursue leadership as an individual? Leadership creates value for individuals and for society because it multiplies the effect an individual can have on the world. It makes individual lives more productive on many dimensions and thus, for many, more fulfilling. Leadership feeds the need to “be all that you can be” for many individuals. This enhanced productivity of individual public health practitioners (through leadership) pays dividends to the profession of public health. Those who support professionalization of the field of public health note the need for practitioners and academics to convince elites, particularly those with power in the policy sphere, of the value of public health knowledge (Evashwick, Begun, & Finnegan, 2013). A more energized and proactive public health workforce creates the opportunity for a more respected and powerful role for public health practitioners. A vision for the future would be for the next U.S. Institute of Medicine

22

I  The Call for Public Health Leadership

report on the future of public health to marvel at the increase in the influence and effectiveness of the public health sector in driving better health outcomes and helping to solve some of the greatest economic and human challenges faced by the nation.

Leadership Can Be Learned Leadership is learnable, through mastery of its competencies. Leadership competencies are easier for some to learn. Indeed, they seem natural for a few, because some leadership competencies (for example, inspiring others) are easier to master for those with specific personality traits and values that are difficult to “learn” and are hard to change. But there are few, if any, who cannot learn to be effective leaders, regardless of their starting point. Values can and do change with learning. Leadership behavior can be exhibited by all personality types. Being timid, for example, is no excuse to avoid leadership activity, though it makes leadership harder to undertake on one’s own. At the same time, those who find leadership competencies easier to attain can still benefit by being intentional about improving those competencies. Current p ­ ublic health leaders and future leaders can continuously learn new knowledge and skills. Still, proactive pursuit of leadership competencies is not easy or natural for many. It requires forethought and hard work. We comment more on the requirements for learning in Chapter 4 (on knowledge for public health) and in Chapter 10 (on lifelong learning).

Leadership Differs From Management It is useful analytically to separate the concept of leadership from another common term that also describes the work of organizing and directing individuals, teams, organizations, communities, and societies— management. The two concepts have much in common, but there is value in separating the concepts of leadership and management (Taylor, 2012, pp. 2–5). Education and practice in leadership can add meaning and impact to both management and non-management careers. Management means getting things done, as does leadership. Critically, though, leadership works through mobilizing others in situations and to a depth that requires tools not necessarily possessed by managers. Managers rely on authority in order to mobilize others; leaders inspire others through discovering common purpose and passion. A common adage asserts that management refers to doing things



1  Why Leadership? Why Now?

23

right; leadership refers to doing the right things. This adage reflects the importance of values and choice in mobilizing others. Management involves realism and execution. Leadership combines realism with ­idealism and execution with inspiration. Other distinctions between management and leadership include the notion that managers focus on efficiency (doing the most with the least), while leaders focus on effectiveness (goal attainment). This distinction relates to the shorter-term and operational focus of management compared with the longer-term and strategic focus of leadership. Often, the distinction between managers and leaders in organizations is based on position in a hierarchy. Those at higher levels (leaders) have more control over resources and decisions related to vision, mission, and strategy. Ideally, managers would have the competencies of leaders, and leaders would have the competencies of managers. In practice, there is substantial overlap. Many good managers have the potential for greater impact by becoming good leaders, and good leaders are made even ­better by being good managers. For this reason, the leadership competencies in this book include some elements of effective management, but the competencies go well beyond effective management.

Resources Are There; Somebody Will Get Them Resources devoted to population health exist in all societies. Access to basic health care services, including many preventive measures, is a basic right in most countries for that reason. Governments recognize the value of a healthy population, and individuals sacrifice almost anything to achieve health. Some would argue that the absence of abundant resources devoted specifically to public health is an insurmountable problem in the sense that public health leaders can ask, but they will not get. But the distribution of resources within the health sector is subject to change, as is the distribution of resources devoted to health versus other sectors, like defense. As noted above, public health could improve on the allocation of (1) health sector resources to public health versus medical care and (2) societal resources to social and welfare services relative to health services. As well, the allocation of resources to the health and social services sector versus other sectors, such as defense, is a political decision. Proponents of medical care expenditures and solutions are both allies and competitors of public health, in regard to changing the b ­ alance of resource allocation. They are allies because they are often in the best position to help argue for increasing the “total size of the pie”—increasing

24

I  The Call for Public Health Leadership

resources to the health sector, including public health. They may join in arguing for giving a bigger piece of the pie to public health. But proponents of medical care solutions may at the same time be competitors for a share of limited and scarce resource.

Leadership Is Not for Everyone Leadership activities and roles are not for everyone, despite the fact that everyone has the potential to perform leadership competencies. Some individuals do not find leadership activities and roles rewarding, preferring careers in which they are not responsible directly for influencing others to take action on public health challenges. Their activities and roles are just as important to the profession as leadership activities and roles, and they often contribute to achieving the goals of leadership (“mobilizing people, organizations, and communities to effectively tackle tough public health challenges”) in other ways. A public health researcher contributes by adding to the evidence base for public health interventions. A public health teacher contributes by educating new generations of practitioners. Public health practitioners in any specialty contribute by doing their jobs conscientiously, both helping to apply public health solutions and serving as role models for colleagues. Leadership in the form of full-time, public, or high-profile activity, utilizing the full range of leadership competencies, is not easy. It exposes individuals to failure and disappoint­ment. It pushes individuals outside of their comfort zones. It does not guarantee personal success, happiness, wealth, promotion, or respect. Leadership is not for everyone.

Leadership Is Only Part of the Solution The “romance of leadership” is the tendency to assign too much causal attribution to the actions of leaders on the outcomes (both positive and negative) of organized systems (Meindl, Ehrlich, & Dukerich, 1985). This tendency derives from our desire to assign causation in general and to cope with uncertainty, with leaders being a simple and easily identifiable answer to the question, “Why did things work (or not work)?” The romance of leadership causes many people to ascribe magical powers to leaders and leadership. Leaders do not have magic wands. Their ability to exert influence is constrained by the receptiveness of the cultural, social, and political structures and conditions that they attempt to influence. Systems thinking and public health thinking emphasize the



1  Why Leadership? Why Now?

25

causal supremacy of underlying social, cultural, economic, and political conditions. Several forces will continue to limit the influence of public health leaders. First is the role of private corporations in the political systems of governments, particularly in the United States. Private corporations lobby for policies that often conflict with a public health approach. Lobbies for the tobacco, food, and chemical industries have resources to influence legislation that promotes sale of their products. Medical equipment manufacturing and pharmaceutical companies are in a similar position with regard to emphasizing intervention rather than prevention of illness. As we have noted, the proponents of clinical care, to the extent that they argue for resources that could otherwise go to public health, are another powerful force limiting public health success. Second, strong cultural forces reinforce investment in short-term intervention for health problems rather than long-term, public health solutions. Societal culture supports the allure of heroic intervention to cure disease after it appears, rather than preventing it. The popularity of television shows about medical detective work and emergency room and inpatient hospital care are examples of this popularity. Third, much of public health is provided by publicly funded organizations that are expected to “do their job” and avoid taking controversial stands on policy issues. They are not expected to be advocates for transformational change, but bureaucrats who administer programs paid for by others (taxpayers). Even among legislators and administrators who are “pro-public health,” there are legitimately different views about the proper role of government versus individual freedoms and responsibilities. There is an ethical and legal argument for constraining the role of public health largely to the control of communicable diseases (Epstein, 2003). Finally, corruption, nepotism, authoritarianism, and other human and organizational “bad behavior” challenge not only public health but most public policy initiatives and constrain the influence of leaders driven by the general good. Many potential public health leaders are constrained by their position in organizations that are not well led. While recognizing that leadership alone will not drive change and effectiveness, a source of optimism is that the notion of “leaders” used here (and increasingly in other settings) refers to all of us, rather than one individual at the head of a program, organization, or community. The power of “all of us” as leaders is much stronger than the power of a single, formal leader. Second, if underlying conditions and environments are to be changed, leaders should try to shape that change rather than leaving it to other forces (like nature, resource scarcity, religious

26

I  The Call for Public Health Leadership

belief, technological change, and the host of forces driving the future of our societies and cultures). Leadership can affect all levels of the frameworks proposed by Frieden and others discussed above. Indeed, only leadership can affect all the moving parts of pieces of the complex systems that determine population health. Public health is fundamentally about making change, and since making change requires leadership, greater public health effectiveness requires greater leadership effectiveness. CONCLUSION We define leadership in public health as mobilizing people, organizations, and communities to effectively tackle tough public health challenges. The time is ripe for a radical expansion of public health leadership. Public health has a proven track record and growing evidence base for the creation of value in the use of scarce resources. Past solutions dependent on a narrow model of health problem causation have fallen far short of expectations. Challenges that require value-driven, long-term fixes continue to multiply. It has been said that radical change is most likely under conditions of crisis, consensus, or bold leadership. A health care crisis exists around cost, quality, and access. There is growing consensus that supports a social determinants model of causation. A renewed push to mobilize people, organizations, and communities to tackle tough public health challenges can ensure that the upcoming decades demonstrate wiser use of scarce resources to improve population health.

chapter 21

A Framework for Public Health Leadership

key terms adaptive leadership Association of Schools and   Programs of Public Health collaborative leadership competency complexity leadership Council on Linkages Between   Academia and Public Health  Practice generic leadership models integrative leadership knowledge Leadership Challenge  Model

National Public Health  Leadership Development Network not-for-profit setting public setting resource scarcity servant leadership skills traits transformational leadership Turning Point Initiative United Kingdom Department of  Health values

Public health leadership is the practice of mobilizing people, organizations, and communities to effectively tackle tough public health challenges.



27

28

I  The Call for Public Health Leadership

Our definition of public health leadership reflects several assumptions about the nature of leading and the nature of public health. In this chapter, we explore these assumptions. We then introduce the framework for this book, which is centered on five key competency sets for public health leaders. These competencies, along with the values, traits, and knowledge base of public health leaders, provide the framework for public health leadership used in this book. The framework builds on strengths of existing competency models for public health and leadership. We review several of those models and explain differences and similarities of our framework with those. The values, traits, and knowledge base of public health leaders are then examined in more detail in Chapters 3 and 4. Each of the five competency sets is examined in turn in Chapters 5 to 9.

APPROACHES TO LEADERSHIP In a general sense, the meaning of leadership as applied to individuals is quite clear and widely understood: Leadership means influencing others. It means expanding one’s influence beyond one’s self. When individuals consider “becoming” leaders, they intend that they will do things through others and with others, rather than alone. Leaders influence others, whether they do so by intent or by accident. Influencing others expands the breadth of one’s own impact on the world. The range of methods to influence others and the goals of exerting influence on others, however, invite controversy and produce infinite variety in approaches to leadership. Influence can occur through consensus building, fiat, education, coercion, or persuasion. The ways that others are influenced, and the leader’s ability to influence others, are bound to the leader’s genetic profile and personality, the conditions of the time and place in which influence is being exerted, and the characteristics of those who are to be influenced. Influence can be used to further selfish goals, the goals of subgroups, the goals of whole organizations or communities, or any mixture. The goals of leaders vary by setting, for example, in for-profit organizational settings compared with public settings. In combination, this means that effective leadership always requires customization to particular circumstances. In academic jargon, the fact that effective leadership is tailored to particular circumstances is known as a contingency or situational approach to leadership. If those contingencies or circumstances show some regularity that can be specified, however, approaches to leadership can be targeted to those typical circumstances. What are the typical



2  A Framework for Public Health Leadership

29

circumstances faced by public health leaders, and what are the implications for effective leadership in public health? The Circumstances of Public Health Six distinctive circumstances of public health that affect leadership are listed in Table 2.1. First, public health services are predominantly delivered in not-for-profit and public settings, by organizations, programs, and agencies that serve the common good. This is not always the case— for-profit organizations are often key partners and sometimes leaders in confronting public health challenges. However, leadership that is effective in not-for-profit and public settings is commonly called for in public health. In practice, most public health organizations do not focus on profit as a primary indicator of organizational success. This means that effective public health leaders are motivated by service and motivate others by appealing to their desire to serve. This theme is carried throughout the discussion of leadership competencies in this book. The leadership approach known as “servant leadership,” presented below, is one that fits many public health leaders. The “public” setting of public health leadership also means that public health leaders must effectively use the tools of government and Table 2.1 Distinctive Circumstances of Public Health and Implications for Leadership Circumstance

Implications for Leadership

Predominance of not-for-profit and public settings

Appeal to service values Work with government programs and government bureaucracy Understand public policy and politics

Resource scarcity

Use political acumen to fight for share of resources Be conscientious stewards of resources

Complexity of challenges

Use multisector partnerships and indirect influence

Long-term solutions

Lead with persistence, patience, and passion

Unique role in emergencies

Expect emergencies Prepare to perform effectively in emergencies

Political

Be comfortable with public health values Expect controversy

30

I  The Call for Public Health Leadership

government bureaucracy, as well as be able to deal with its frustrations. For all the growing interest in broader population health approaches among private and nonprofit organizations, it is still the case that only government has the explicit responsibility to protect the health and safety of all people, without regard to whether or by whom they are insured or get health care. Public health leaders by definition must learn to work effectively with public policy and policymakers. An implication is that effective leaders must be concerned about public policy and the politics by which policy is made, a theme carried throughout this book. A second circumstance of most public health leadership activities is that they are performed under conditions of resource scarcity. In all societies, there are limited resources for health care. Selected governments globally, for example, spend from 1.2% to 7.4% of Gross Domestic Product (GDP) for health care, with only a small proportion of that typically going to public health (OECD, 2013). In the United States, total health care expenditures (not just the government expenditures noted in the previous sentence) have changed from 7.2% to 17.9% of GDP over the 40-year period 1970 to 2010, creating extreme pressure on expenditures in other sectors, such as defense, transportation, and agriculture. There is a lid on the amount that societies will pay for the pursuit of health. This circumstance of public health (resource scarcity) requires that public health leaders struggle for a share of a fixed supply of resources, including financial resources. Resource scarcity requires that public health leaders “play politics”—sway enemies and pursue alliances. It requires that the idealism of a service ethic be combined with political acumen. We emphasize the competency of wielding power (see Chapter 7) in our leadership framework. Resource scarcity also means that public health leaders must be conscientious stewards of resources, recognizing not only that resources are limited but that public health programs and organizations are inherently “spending other people’s money.” Fund raising through grants and philanthropy, effective leverage of resources through interagency and cross-sector partnerships, and rigorous financial management of resources attained are underdeveloped skills of many public health leaders. These are included in our framework. Third, public health leaders address complex challenges. Public health challenges are rarely, if ever, simple to understand or to address. Complex challenges are rooted in multiple layers of diverse and interconnected causes. Public health solutions are generally complex as well—they involve multisector partnerships, attacking multiple causes from different angles. Complexity means that the process of developing and gaining support for solutions—leading—involves influencing many diverse



2  A Framework for Public Health Leadership

31

actors pursuing diverse goals, and getting them to act in concert. This process of influence is far from direct and simple. The competencies in our framework require that leaders acknowledge and embrace complexity. Fourth, public health is a long-term undertaking. Rarely are results visible immediately with public health solutions. Interventions to reduce disparities in health outcomes, cut smoking rates, reduce violence, and improve child health, for example, unfold over months and years, and even generations. The long-term nature of public health interventions means that values and traits are needed to gird public health leaders for ups and downs and for the long journey. Our framework begins with an understanding of key values and traits of public health leaders, featuring those that supply motivation for the long run—persistence, courage, and passion. A fifth particular circumstance of the public health field is its role in helping individuals and communities prepare for and cope with emergencies. No other profession has this broad responsibility across the different types of emergencies. For specific events, experts outside of public health are drawn into the response. But the consequences of emergencies on human health and safety create particular obligations for public health and for public health leaders specifically. Emergencies put public health in the spotlight under stressful conditions. Many a public health leader’s career has been defined or at least shaped by his or her performance in emergencies. Another notable feature of public health practice is the near certainty that public health emergencies will happen with some regularity, on just about every leader’s watch. The specific type and timing of the emergency will be unpredictable, but emergencies will happen and stakeholders will expect leaders to be at the top of their game when emergencies occur. While the body of knowledge of emergency preparedness and response needs to be understood by virtually all civic agencies and officials, public health leaders need to be prepared to do it better than anyone else. Therefore, our framework devotes a separate competency set to preparing for and managing unexpected events. A sixth and final circumstance of public health is that it is political. One dimension of politics, distributing scarce resources, was noted above in the discussion of resource scarcity. Virtually every public health solution invites questions of the extent to which government should impinge on individual and corporate freedom and property rights (Turnock, 2012, pp. 16–20). Individuals will differ in their beliefs on the extent of government involvement in population health—­differences that are worked out in the political arena. In sum, these six circumstances suggest certain approaches to leadership that are particularly relevant to public health leaders: servant

32

I  The Call for Public Health Leadership

leadership, adaptive leadership, integrative leadership, and complexity leadership. Servant leadership is a philosophy that many public health workers embrace. It provides a useful philosophy for communicating and drawing on the energy and service commitment that many public health workers feel. Adaptive leadership emphasizes the need for change in transformational ways in most programs and organizations. Integrative leadership is based on the need for cross-sector and multiorganization and multiprogram collaborations to address complex problems. Public health leadership inevitably involves multiple stakeholders whose interests must be negotiated, compromised, and meshed together. Finally, complexity leadership builds on the interactive, ­relationship-based, and complex nature of much of public health work. The four approaches are not mutually exclusive and are relatively consistent with one another. Most leadership activities in public health exemplify all four approaches, not any single approach. Each perspective does highlight distinctive and relevant features of public health leadership, however. Table 2.2 lists each approach, along with salient concepts. Servant Leadership The phrase “servant leadership” was formally explicated over half a century ago by Robert Greenleaf. Greenleaf’s primary thesis was that effective leaders are motivated to serve others, and that leadership activities Table 2.2 Four Complementary Approaches to Public Health Leadership Approach

Salient or Related Concepts

Servant Leadership

Service as motivator Commitment to developing others Power of spirit

Adaptive Leadership

Technical versus adaptive challenges Transactional versus transformational leadership

Integrative Leadership

Collaborative leadership Cross-sector alliances Systems thinking

Complexity Leadership

Leadership emerges from interaction around   common goals Importance of sensemaking, exploration, and  connecting Leadership as convening



2  A Framework for Public Health Leadership

33

by individuals should flow from a desire to serve. Leadership activities are necessary in order for programs and organizations to succeed, and servant leaders step into the leadership role so that their organizations can succeed. Their motivation stems from the goals of the program, organization, or community with whom they are affiliated, not from their own goals independent of that entity and those who work for it. Importantly, the leader’s responsibility to serve others extends to those who work in the program or organization. The leader is servant not only to the organizational goals but to the goals of others who serve in it (Greenleaf, 2002). Like many leadership approaches, servant leadership is more a philosophy than a set of behavioral directives. However, scholars identify several common skills, traits, or behaviors often associated with the pursuit of a servant leadership philosophy (Barbuto & Wheeler, 2006; Melchar & Bosco, 2010): listening, empathy, healing, awareness, persuasion, conceptualization, foresight, stewardship, growth, and community building. Dye (2010) adds four practices common to servant leaders: they share rather than hoard information, delegate and coach in order to develop others, celebrate and praise accomplishments of others, and connect with their employees. Servant leaders are most effective when their colleagues share their commitment to their program, organization, or community and its vision and values. This is the case in much of public health work. The use of the servant leadership approach in our framework is reflected in the emphasis on intrinsic motivation to mobilize others. While hierarchy is well and good under the right circumstances (e.g., for rapid decision making during emergencies), the reservoir of spirit and service waiting to be tapped in the public health workforce is a powerful resource, unrivaled in most other sectors of work. Effective public health leaders tap that resource. The philosophy is also reflected in our choice of specific values and traits that help generate public health leader effectiveness, like valuing service, as well as in the emphasis on collaboration with others to achieve common goals.

Adaptive Leadership As developed by Heifetz and colleagues (Heifetz, 1994; Heifetz et al., 2009) and applied to organizations, adaptive leadership begins with the idea that the challenges faced by organizations can be separated into two categories—adaptive and technical. Technical challenges are amenable to relatively simple and straightforward fixes that can be addressed with

34

I  The Call for Public Health Leadership

existing expertise and protocols, often through the use of ­authority— everyone agrees on the solution and its implementation is ordered. Adaptive challenges are less clear to identify and require new ways of thinking and doing. Giving someone a vaccination is a technical solution to disease prevention. In most of public health, technical solutions rapidly become adaptive ones in the implementation phase. For example, many people have objections to vaccinations. Resources to supply vaccinations are limited. Developing effective vaccines, assuring their supply and distribution, and making the vaccine readily available to those who need it at the right time are all complex processes. Solving the problem involves listening to and working with multiple partners and coevolving joint solutions. In fact, announcing solutions to problems prior to their thorough vetting is a recipe for failure. The notion of transformational leadership, contrasted with transactional leadership, draws on a similar distinction to the technical ­versus adaptive distinction. Transformational leaders engage, inspire, and involve others. Transactional leaders rely on traditional rewards—­ typically, compensation—and keep their eye on targeted goals, reminding others when goals are not being met (Bass, 1990). Transactional leadership may be effective with technical changes, but not with adaptive changes. Those who work with transformational leaders feel more passionate about and more committed to organizational goals. The most challenging public health problems require transformational or adaptive leadership. If these were straightforward technical problems, leaders could assume that the weight of the evidence and the power of hierarchy alone would be sufficient to make change. The use of the adaptive leadership approach in our framework is reflected in our attention to the knowledge bases of complexity science and change leadership, as well as several competencies and skills that emphasize the need for others to identify strongly with the vision of public health organizations, programs, and communities, in order for public health aspirations to be realized.

Integrative Leadership Integrative leadership emphasizes the need for broad collaboration in order to address complex problems (Crosby & Bryson, 2010). The integrative leadership philosophy is built around the realization that all social problems have roots in multiple interdependent causes and effects on multiple stakeholders. Attacking gun violence in poor urban neighborhoods, for example, requires shared efforts on the part of



2  A Framework for Public Health Leadership

35

community organizations, police, fire, and emergency services, public and private schools, employers, social service providers, and a host of other organizations, programs, and individuals. Therefore, the focus of integrative leadership is on the process of collaboration—bringing diverse groups and organizations together in semipermanent ways, and typically across sector boundaries (Crosby & Bryson, 2010). Among the key practices of integrative leadership are using forums, arenas, and courts to clarify and discuss underlying issues; forging initial agreement; planning; managing conflict; building trust, leadership, and legitimacy among members; and structuring and governing the efforts. Measuring outcomes and holding programs accountable complete the cycle of creating and maintaining cross-sector collaborations. Collaborative efforts often fail, and the integrative leadership approach helps us understand why—independent entities integrated into collaboratives are much more complex to effectively design, govern, and implement than the traditional hierarchical organization. The distinctive goals and priorities of the constituent members are powerful and often supersede the goals and priorities of the collaborative, so progress is often slow and accountability is difficult to enforce. Closely related to the integrative leadership approach, but with less focus on cross-sectorial alliances, is the broad approach often labeled collaborative leadership. Many public health leaders would describe their leadership style as collaborative. An example of the collaborative approach is given in a study of community health partnerships, which identified five themes in the collaborative approach (Alexander, Comfort, Weiner, & Bogue, 2001): 1. Systems thinking produces a vision for the collective that is deep, broad, and long run 2. Use of vision to motivate partners and assure cohesion 3. Collateral leadership: the use of rotating and diverse subgroups to implement vision and mission 4. Power sharing among the partner organizations 5. Listening skills on the part of participants Intractable problems demand complex solutions, and the philosophy and practices of integrative leadership are particularly useful in discussing competencies involving collaboration (see Chapter 6). Koh and McCormack (2006, p. 108) contend that, “In public health, the traditional leadership trait of fierce independence must give way to the higher value of fierce interdependence.” The integrative and collaborative leadership approach takes on this challenge head-on.

36

I  The Call for Public Health Leadership

Complexity Leadership We have stated that public health leaders face complex challenges. In Chapter 4, which delineates the knowledge base of public health leadership, we emphasize understanding complex systems. A leadership approach that flows directly from an understanding of complex systems is complexity leadership. The term is a loosely applied one, with various interpretations of complexity and its implications. Particularly useful for public health leaders are the interpretations of Drath (2004a, 2004b). Drath begins with the position that all complex human systems have three needs: direction, commitment, and the ability to adapt. Leadership must emerge from the system in order to meet those needs. In the words of Marion and Uhl-Bien (2001, p. 394), leadership is a process not for “controlling the future,” but rather “fostering interactive conditions that enable a productive future.” Under conditions of ambiguity, uncertainty, confusion, or complexity (to loosely use several related terms), leadership does not emerge from the brilliance of any single individual or group of individuals. It emerges from intense and meaningful interaction among members of an organization, program, or community and its stakeholders (including those affected by the actions of an organization or program). Drath et al. (2008, p. 636) argue that “it is the presence of leaders and followers interacting around their shared goals that marks the occurrence of leadership.” Therefore, the task of formal leaders is to create the conditions for such dialogue and learning. The competencies of leaders facing complex circumstances include sensemaking, exploration, and connecting. Sensemaking is developing ideas with explanatory possibilities for events or processes in which an individual is engaged and making a contribution (Begun & White, 2008). Exploration is the search for new directions, and connecting refers to establishing relationships and building networks. Clearly, the three competencies reflect that leaders are part of a larger process of discovery in the face of high uncertainty. Connecting, exploring, and sensemaking enable leaders (all members of a system are leaders, in this sense) to exert some proactive influence over their emergent future (Begun & White, 2008; Drath, 2004a, 2004b). Block’s notion of “leadership as convening” is directly consistent with a complexity approach to leadership. Block (2008, p. 88) lists three tasks that define leadership: 1. Create a context that nurtures an alternative future, one based on fits, generosity, accountability, and commitment.



2  A Framework for Public Health Leadership

37

2. Initiate and convene conversations that shift people’s experience. 3. Listen and pay attention. Public officials particularly have the ability to convene, in the form of meetings, hearings, neighborhood summits, speaking engagements, and special events. Leaders promote gatherings that build spirit and joint exploration, rather than inform people of answers. Leaders are those who sponsor such activities. The use of the complexity approach in our framework is reflected in several different ways, beginning with a focus on the knowledge base of understanding complex systems. Our choice of competency sets on collaborating with diverse others (Chapter 6) and preparing for surprise (Chapter 8) directly relates to the complexity leadership philosophy. OUR FRAMEWORK The approaches to leadership outlined above provide general guidance and philosophy for individuals. To translate into action, though, leadership approaches need to be communicated to individuals in the form of competencies or skills. Leadership frameworks in educational and training settings typically are assembled from individual competencies or skills, rather than one specific approach to leadership. A “competency” in the workplace has become parlance for the ability to do well on a certain range of job-related activities. Competencies require effective application in particular contexts, such as an industry, organizational, or service setting. We define a competency as the effective application of values, traits, knowledge, and skills in complex situations. Competency comes from putting one’s values, traits, knowledge, and skills to good use. Education and training that are focused on the workplace are built on competencies that are rewarded by success in the workplace. The choice and content of such competencies is critical to designing a framework that is useful for learning and development. Figure 2.1 portrays the components of competencies, along with the five competency sets that are introduced below and detailed in ensuing chapters of this book. Values are broad preferences concerning appropriate courses of action or outcomes. As such, values reflect a person’s sense of right and wrong or what “ought” to be. Recommended values of p ­ ublic health leaders are outlined in a variety of sources, such as the Public Health Leadership Society’s Principles of the Ethical Practice of Public Health. Values are strongly held and hard to change, but new knowledge and new

38

I  The Call for Public Health Leadership Figure 2.1  Competency framework for public health leadership. Invigorate Bold(er) Pursuit of Population Health

Values and Traits

Engage Diverse Others Knowledge

Competencies

Effectively Wield Power Prepare for Surprise

Skills

Drive for Execution and Continuous Improvement

experience can have an impact on values. Holding public health values is basic to leadership effectiveness in public health. Being passionate about public health values is even more important. Personal alignment with the shared values of the field gives rise to authenticity, without which leadership is hard or even impossible to sustain. Leaders are role models, and their credibility to others depends on the leader’s long-term allegiance to deeply held values. Deeply held values in public health include a commitment to social justice, community self-determination, and a requisite role for government in the pursuit of population health. Authentic public health leaders know and live these basic values. In Chapter 3, we discuss the basis for and key elements of values for public health leadership. Traits are distinguishing features of one’s personality, probably fairly “hardwired” and not something a leader can change at will (at least not while being genuine). Given the unique circumstances of public health outlined above, certain traits like persistence, empathy, and courage are notable in successful public health leaders. Knowledge is the key technical and contextual information, theories, and concepts needed to be competent. Knowledge for leadership in public health comes from three domains: public health science, understanding people, and understanding complex systems. Public health science refers to the technical specialties within public health, including epidemiology, environmental health, community health, biostatistics, health education, public health administration and policy, nutrition, maternal and child health, public health ethics, and global health. Many public health leaders have deep knowledge within one or more technical specialties. Understanding people is critical to knowing how to



2  A Framework for Public Health Leadership

39

move people to effectively tackle public health challenges. Knowledge for understanding people comes from a variety of social and behavioral sciences, including psychology and sociology. Understanding complex systems is critical to moving organizations and programs to effectively tackle public health challenges. Understanding complex systems is often referred to as systems thinking, which has been described as ­“forest” rather than “tree-by-tree” thinking. In complex systems, understanding the relationships among elements of a system and their evolution over time is equally important to understanding the elements themselves. Skills are the behavioral practices needed to carry out public health leadership, such as speaking and writing effectively. Skills can be developed by practice and experience. They are less easily developed by reading and coursework. Skills are more likely to be imparted by repetitive training, while competencies are harder to master. To summarize, we use “competencies” to refer to broader actions that require multiple skills, knowledge, and particular attitudes or values in order to be proficient in them in particular contexts. For example, the competency of “articulating a more compelling agenda” (Chapter 5) may include multiple skills, such as reflection, listening, and articulate speaking, as well as knowledge of the relevant subject matter and a positive attitude toward communicating with others. In practice, it is difficult to separate the effects of values, traits, knowledge, and skills on one’s proficiency in a competency. When learning to perform that competency, however, it is useful to analytically distinguish among those factors, so that each can be developed.

Competencies for Public Health Leadership Five competency sets comprise a strong foundation for public health leadership: 1. Invigorate bold(er) pursuit of population health. 2. Engage diverse others in public health initiatives. 3. Effectively wield power to increase the influence and impact of public health. 4. Prepare for surprise in public health work. 5. Drive for execution and continuous improvement in public health programs and organizations. These competency sets are displayed in Table 2.3 and described briefly below.

40

I  The Call for Public Health Leadership Table 2.3 Five Competency Sets for Public Health Leadership

COMPETENCY SET

COMPETENCIES

Invigorate Bold(er) Pursuit of Population Health

1. Critically assess the current state of your program or organization 2. Articulate a more compelling agenda 3. Enlist others in the vision and invigorate them to drive toward it 4. Pursue the vision with rigor and flexibility 5. Marshal the needed resources

Engage Diverse Others in Public Health Initiatives

1. Assess local conditions, in ways relevant and credible to the local stakeholders 2. Search widely for the right partners 3. Apply a social determinants perspective to planning 4. Take time to build relationships, teamwork, and common understanding 5. Clarify roles and governance

Effectively Wield Power to Increase the Influence and Impact of Public Health

1. Understand and strategically use both positional authority and informal influence 2. Analyze a given public health problem and proposed solution in “campaign” terms 3. Build coalitions of core supporters, new partners, and issue-specific allies 4. Deal effectively with opponents 5. Be strategically agile

Prepare for Surprise in Public Health Work

1. Promote resilience in individuals and communities 2. Develop and critique an emergency response plan 3. Communicate effectively during surprises 4. Execute an emergency response plan with flexibility and learning 5. Learn and improve after surprises (continued)



2  A Framework for Public Health Leadership

41

Table 2.3 (continued) Five Competency Sets for Public Health Leadership COMPETENCY SET

COMPETENCIES

Drive for Execution and Continuous Improvement in Public Health Programs and Organizations

1. Build accountability into public health teams, programs, and organizations 2. Establish metrics, set targets, monitor progress, and take action 3. Proactively demonstrate financial stewardship of public health funds 4. Employ the methods and tools of quality improvement 5. Encourage innovation and risk-taking

Invigorate Bold(er) Pursuit of Population Health The first competency set emphasizes the need to create a strong foundation for public health programs, through facing realities, making choices among alternative paths, and enlisting others in the journey. Developing realistic and targeted plans and building a strong base of resources are other needed competencies in creating a strong foundation for action. Engage Diverse Others in Public Health Initiatives Engagement of others in public health work is a theme emphasized throughout this book. The problems of population health are rarely so simple that any one isolated program or group can make progress on its own. Engaging others requires searching broadly for partners, understanding their world view and practical circumstances, outlining potential responses, and identifying the “right” partners for a particular activity. True collaboration with partners requires giving up control to the partnership. Finally, leaders can draw from a set of best practices demonstrated by successful collaboratives. Effectively Wield Power to Increase the Influence and Impact of Public Health With a competency set around wielding power, we reinforce the need for public health to more proactively fight for its share of resources and influence. Wielding power means using both formal and informal authority,

42

I  The Call for Public Health Leadership

analyzing solutions in terms of political campaigns, building coalitions, dealing effectively with opponents, and being strategically agile. Prepare for Surprise in Public Health Work Public health has a unique responsibility to help individuals and communities prevent and cope with public health emergencies. Emergencies and other surprises will occur, and planning for them is the first step in preparation. When surprises occur, the communication skills of public health leaders are tested. Practicing plans under a variety of conditions, executing plans when emergencies occur, and conducting after-action reviews comprise the remaining competencies of preparing for surprises. Drive for Execution and Continuous Improvement in Public Health Programs and Organizations The final competency set drives home the point that implementation of public health programs is hard and critical work. It is not enough to mobilize others to tackle public health challenges. To do so effectively requires tremendous concentration on the tools of execution and continuous improvement. These include holding others accountable, establishing metrics and targets and using them, being good stewards of funds, conducting quality improvement, and encouraging risk-taking and innovation.

EXISTING COMPETENCY MODELS FOR PUBLIC HEALTH LEADERSHIP Scholars and practitioners have produced several extensive competency models for generic leadership and for leadership in public health. It is important to build on the insights of prior efforts. Our framework builds on and around the work of those scholars and practitioners. Next, we compare and contrast our framework with several of the major competency models for leadership.

Generic Leadership Perhaps the most popular generic model for leadership (crossing all sectors of leadership activity) comes from the work of Kouzes and Posner (2012b), whose Leadership Challenge model consists of five “practices,”



2  A Framework for Public Health Leadership

43

each with two “commitments.” The practices and commitments can be roughly equated to competency sets and competencies, respectively. The five practices and associated commitments are as follows: 1. Model the way a. Clarify values by finding your voice and affirming shared ideals. b. Set the example by aligning actions with shared values. 2. Inspire a shared vision a. Envision the future by imagining exciting and ennobling possibilities. b. Enlist others in a common vision by appealing to shared aspirations. 3. Challenge the process a. Search for opportunities by seizing the initiative and by looking outward for innovative ways to improve. b. Experiment and take risks by constantly generating small wins and learning from experience. 4. Enable others to act a. Foster collaboration relationships.

by

building

trust

and

facilitating

b. Strengthen others by increasing self-determination and developing competence. 5. Encourage the heart a. Recognize contributions by showing appreciation for individual excellence. b. Celebrate the values and victories by creating a spirit of community. The Leadership Challenge approach is popular due to its anchoring in an empirical base (John Wiley & Sons, Inc., 2013), its parsimony, and its directness (e.g., using action verbs directed at individuals). Disadvantages for our purposes include that it downplays some of the “tougher” competencies of leadership and is generic, so that it applies more or less depending on the specific conditions facing an industry, organization, community, etc. For use in specific settings, the model needs to be customized and supplemented. Kouzes and Posner underpin the Leadership Challenge model with a discussion of the characteristics or qualities of effective leaders, with a focus on four characteristics: leaders are honest, forward-looking, competent, and

44

I  The Call for Public Health Leadership

inspiring. Their first competency set (model the way), features the need to examine one’s values. We separately examine the values and traits of public health leaders in Chapter 3. We discuss the knowledge base that contributes to competence, specific to public health, in Chapter 4. Like Kouzes and Posner, we also identify five overarching competency sets. The five competency sets incorporate the Leadership Challenge model’s emphasis on building a shared vision, collaborating, using intrinsic motivation, and pushing for improvement. We add a competency set relatively specific to public health (prepare for surprise) and competencies related to financial and political acumen and the execution of plans. We think that our framework emerges as more robust for specific application in public health as a result. Within public health itself, a number of competency models have been developed to guide leadership and management education. Next, we review and comment on several of the most central ones. While there are similarities among them and with ours, our framework is generally shorter, as we try to “go upstream” to focus on common roots of some of the longer lists of specific skills or competencies. Also, we try to give relatively more attention to the ways in which values, traits, knowledge, and skills are applied in practice. In general, though, our model is consistent with and builds on the efforts of previous ones. Specific similarities and differences are noted in the discussion below.

National Public Health Leadership Development Network A long-standing competency framework was developed by consensus by a consortium of institutes providing leadership development in public health, the National Public Health Leadership Development Network (NLN). The framework was developed over the 1995 to 2000 time period (Wright et al., 2000). The 2005 version of the framework lists 80 competencies in 4 categories: core transformational competencies, political competencies, transorganizational competencies, and team-building competencies. Significant in this framework is the weight given to political processes and to collaboration across organizations. The notion that “public health is a team sport” is exemplified by the 25 team building competencies. Encouragement of servant leadership is explicit, through a competency to “facilitate development of servant leadership capacity including selflessness, integrity and perspective mastery.” While the NLN model is summarized by four clusters of competencies, the large number of competencies (80) makes the model



2  A Framework for Public Health Leadership

45

appropriate for large-scale and long educational processes. (In contrast, our framework includes 25 competencies grouped into five competency sets, implying a shorter time to cover.) Our model’s 25 competencies are largely consistent with the 80 competencies listed in the NLN model, but we include a financial management competency and an emergency preparedness cluster of competencies.

Turning Point The Turning Point initiative, funded by the Robert Wood Johnson Foundation and operating from 1997 to 2006, comprised a network of 23 state partners and the Centers for Disease Control and Prevention, Public Health Foundation, American Public Health Association, Association of State and Territorial Health Officials, and National Association of Local Boards of Health (Turning Point, 2006). Collaborative Leadership was the summary label for a leadership perspective selected by the initiative, which developed six Collaborative Leadership learning modules: assessing the environment; creating clarity—visioning and mobilizing; building trust; sharing power and influence; developing people; and self-reflection. The six are similar in level to our five competency sets. As with the NLN framework, the emphasis on servant leadership (developing others) and collaboration is notable. The self-reflection component recognizes the need to understand oneself, particularly one’s motivation and values. We cover developing people and self-reflection in Chapter 10 on lifelong learning. Note the definition of leadership as “collaborative” from the outset, which is consistent with our emphasis on the importance of collaboration in public health leadership. The Turning Point framework emphasizes sharing power, while we add an emphasis on wielding power as well. We also add competencies specifically devoted to continuous improvement, a movement in public health that was not as prominent when the Turning Point framework was developed.

Council on Linkages Between Academia and Public Health Practice The Council on Linkages Between Academia and Public Health Practice (COL), a forum of 19 national organizations formed in 1992, issued competencies for public health practitioners in 2001. The competencies are cross-walked and designed to be compatible with the 10 essential public

46

I  The Call for Public Health Leadership

health services identified in 1994 by a Core Public Health Functions Steering Committee that included representatives from the U.S. Public Health Service and other major public health organizations (Public Health Foundation, 2010; Public Health Functions Steering Committee, 1995). A significant advantage of this framework is that competencies are specified for three levels: entry, program management/supervisory, and senior management/executive. (Observe that the focus is on organizational roles.) The original listing was updated in 2010. The COL developed competencies in eight domains: analytical/assessment, policy development/program planning, communication, cultural competency, community dimensions of practice, public health sciences, financial planning and management, and leadership and systems t­ hinking. Notable is the combination of leadership and systems thinking into a single arena, a feature we essentially retain in our framework. Within that domain, there are seven competencies, with attention to meeting ethical standards, integrating systems thinking, partnering, personal development, and continuous improvement. All are covered in our framework. Also significant is the inclusion of financial planning in the competency sets. We identify aspects of financial planning and management that are most relevant to public health leaders in our framework. Among the competency frameworks reviewed here, our framework most closely resembles the COL leadership and systems-thinking competencies in terms of content, with some differences in the form of presentation. We separate discussion of personal development from the competency sets, presenting the former in Chapter 10 on lifelong learning. We move systems thinking to the knowledge base that informs all competencies (Chapter 4) and discuss ethical values in terms of personal preparation (Chapter 3).

Association of Schools and Programs of Public Health The Association of Schools and Programs of Public Health (ASPPH; formerly the Association of Schools of Public Health, or ASPH) has developed competency frameworks for the master of public health (MPH) and doctor of public health (DrPH) degrees (ASPH, 2006, 2009). MPH competencies are defined for five specific disciplines (biostatistics, environmental health sciences, epidemiology, health policy and management, and social and behavioral sciences) and seven cross-cutting or interdisciplinary areas: communication and informatics, diversity and culture, leadership, public health biology, professionalism, program planning, and systems thinking. The leadership competency cluster is summarized as



2  A Framework for Public Health Leadership

47

“The ability to create and communicate a shared vision for a changing future; champion solutions to organizational and community challenges; and energize commitment to goals.” Nine specific competencies cover knowledge about leadership, articulating mission and vision, engaging in collaboration, dialogue, team building, and conflict management. Interestingly, two public health values are noted in the listing: social justice and human rights principles, which are to be applied when addressing community needs. As well, personal traits of integrity and honesty are mentioned, along with the need to demonstrate transparency. The DrPH competencies include Leadership as one of seven domains. (The others are Advocacy, Communication, Community/Cultural Orientation, Critical Analysis, Management, and Professionalism and Ethics). The Leadership competencies are summarized as “The ability to create and communicate a shared vision for a positive future; inspire trust and motivate others; and use evidence-based strategies to enhance essential public health services.” Among nine specific competencies for leadership are communication of mission, vision, and value; collaborating with diverse groups and teams; influencing others to achieve high standards of performance and accountability; and developing capacitybuilding strategies. In addition, leaders are expected to prepare lifelong learning plans and “demonstrate a commitment to personal and professional values.” From the ASPPH competency frameworks, we point out the obvious fact that Leadership is identified as a critical competency or competency cluster for all public health graduates (MPH and DrPH), reinforcing the importance of leadership development in public health. As one might expect in a set of educational competencies, some of the MPH competencies focus on the attainment of knowledge. For example, the competency “Describe the attributes of leadership in public health” requires mastery of knowledge, but no particular behavioral practice. In our framework, we identify a knowledge base of public health that is a foundation for leadership competencies, but we do not list competencies that reflect attainment of knowledge alone. In that sense, our framework is oriented to practice more than to academic achievement.

United Kingdom Department of Health The Department of Health in England and affiliated professional groups and organizations produced a Public Health Skills and Career Framework, updated in 2009 (Skills for Health, 2009), that outlines the competencies and underlying knowledge base for public health

48

I  The Call for Public Health Leadership

practitioners, differentiated for nine career levels, from beginner to executive level. Competencies are grouped into four core topic areas (surveillance and assessment, assessing evidence, policy and strategy, and leadership and collaborative working) and five noncore areas that represent typical work settings (health improvement, health protection, public health intelligence, academic public health, and health and social care quality). Competencies are separated from “knowledge needed in this area,” a practice we adopt in our framework. Notable again is the separate identification of leadership as a defined competency area for those in public health careers (Taylor, 2012). This supports the argument that public health practitioners around the world define leadership as an expectation of those practicing in the field. Another example of this recognition is the U.S. Agency for International Development project on Leadership, Management, and Government, a multiyear program to improve leadership of health systems in low- and middle-income countries (Management Sciences for Health, 2013). Within the leadership and collaborative learning cluster, 52 individual competencies are listed across the nine career levels, perhaps best summarized by the “key elements” of the core area: working in teams; managing delivery of public health functions; managing change; influencing and managing others; building alliances; and setting strategic direction. The similarities between those key elements and the five competency sets in our framework are substantial, with both frameworks focused on inspiring and working with others in a dynamic world. The NHS framework reflects competencies for leaders in government sector organizations, while our framework reflects competencies in a more pluralistic political and economic system. For example, we include wielding power, raising money, articulating a more compelling vision, using best practices of successful collaboratives, and employing the methods and tools of quality improvement, which are arguably less essential in bureaucratic systems where resource allocation and strategic planning are highly centralized.

Existing Competency Models: Summary As is evident, the field of public health has made extensive progress in identifying targets for education and development, including leadership development. In several ways, however, existing competency models for public health leadership can be refined or augmented. First, existing models, almost by definition, are strongly anchored in the past. Models that rely on consensus development by multiple and diverse



2  A Framework for Public Health Leadership

49

expert or stakeholder groups take several years to produce. Those who contribute to the decisions generally have deep experience bases. Despite the best efforts of those involved to project into the future, the frameworks are likely to reflect the needs and accomplishments of the public health sector over the decades prior to formalization of the framework (e.g., the 1970–2000 period for consensus models produced in 2010). The knowledge base, technology, and environmental context of public health are changing fast (Jarris & Sellers, 2013). New frameworks are needed to reflect recent developments in communication and information technology, health policy, understanding of complex systems, and understanding of leadership in complex systems. In addition, the “new economic normal” means managing and leading in what is likely to be a protracted era of resource constraints. Resource constraints mean increased political conflict over available resources, and public health needs to be prepared to fight for its share. As noted in Chapter 1, public health is underutilized and not optimally productive. The field, and organizations within it, needs push and innovation. For this reason, our framework adds knowledge and competencies that we think are increasingly relevant today and in the future, while incorporating “tried and true” classical competencies. As alluded to above, both a strength and weakness of existing ­public health leadership competency models is that they were developed by committees. As a result, they tend to be inclusive, avoiding or compromising on hard decisions about cutting and priority setting. The public health leadership competency models of the NHS and the NLN reviewed above, for instance, contain over 50 competencies. While valuable for some purposes, for initial self-development of busy practitioners and constrained educational offerings for students, there are simply too many. We tried to focus on what is unique to the leader’s role and how leaders go about making a difference on the long list of issues in which public health must be involved.

CONCLUSION Public health leadership is value-laden work that is performed under conditions of resource scarcity, often in organizations that are public or nonprofit, dealing with issues of complex cause and effect over the long term. The public health work domain includes helping communities prepare for and cope with unexpected emergencies. Several philosophies or approaches to leadership have emerged in recent years that are particularly useful in public health work. Integrative leadership,

50

I  The Call for Public Health Leadership

servant leadership, collaborative leadership, complexity leadership, and adaptive leadership are among those complementary approaches that inform public health leadership. Recognizing the critical leadership position that public health professionals need to play in the world, the field has a healthy recent history of developing competency models to guide leadership growth and development. Our framework builds on these efforts, expanding focus on competencies that will be of enhanced value to the field and to society in future generations.

part ii

Preparing for Public Health Leadership

The two chapters in this section survey the values, traits, and knowledge base of effective public health leaders. Along with behavioral skills, these values, traits, and knowledge base are the foundation for mastering the competencies presented following in Section III. Chapter 3, “Values and Traits of Public Health Leaders,” summarizes the legal and ethical foundations of public health, noting the strong anchoring in social justice and community benefit. Because community benefit may require constraining the liberties of individuals, p ­ ublic health leaders are obliged to explicitly examine the balance among competing values. We suggest that seven values of public health leaders are particularly critical for their effectiveness: social justice, reliance on evidence, interdependence, respect, community self-determination, transparency, and the requisite role of government. Seven traits, as well, are required or helpful for long-term effectiveness: integrity, initiative, empathy, comfort with ambiguity, passion, courage, and persistence. Chapter 4, “Knowledge for Public Health Leadership,” overviews the nature and content of the knowledge base of effective public health leaders. We make the case that in addition to understanding basic p ­ ublic health science, leaders need to be armed with a deep understanding of people and complex systems, particularly as regards changing people and changing complex systems. This flows directly from defining ­public health leadership as “mobilizing people, organizations, and communities to effectively tackle tough public health challenges.”

chapter 3

Values and Traits of Public Health Leaders

key terms comfort with ambiguity community self-determination courage empathy initiative integrity interdependence knowledge passion persistence

public health law Public Health Leadership Society reliance on evidence requisite role of government respect social justice traits transparency values, personal

T

he concepts of personal values and traits are closely linked but not the same. Personal values are broad preferences concerning appropriate courses of action or outcomes. They represent a person’s sense of right and wrong or what ought to be. They are strongly affected by what we learn from parents, teachers, religious traditions, and peers, as well as life experience. While deeply ingrained, we can examine and redefine personal values. Indeed, we often carry them subconsciously, unless circumstances allow us or force us to examine or test them.

53

54

II  Preparing for Public Health Leadership

Traits are an even broader concept, covering distinguishing features of the behavioral and mental characteristics that make us unique. Traits are fairly hard-wired and may be harder to change than values—at least they would be hard to change in an authentic manner—and nothing derails leaders like being inauthentic. Certain themes about the characteristics or qualities of leaders surface repeatedly across multiple, diverse contexts throughout the ­general leadership literature. For example, Kouzes and Posner (2012b, p. 34) report results of surveys of “characteristics of admired leaders” across six continents from 1987 to 2012, with four characteristics consistently top ranked: admired leaders are honest, forward-looking, competent, and inspiring. Intelligent, dependable, and fair-minded are among other highly ranked descriptors. Some of these characteristics may primarily be values, others may be traits, and others behaviors; most likely they are mixtures. There is a young but growing evidence base on personal qualities of effective leaders (Arvey, Rotundo, Johnson, Zhang, & McGue, 2006; Judge, Piccolo, & Kosalka, 2009; Yukl, 2013; Zaccaro, 2007; Zaccaro, Kemp, & Bader, 2004; Zhang, Ilies, & Arvey, 2009). Personal attributes have been classified into such categories as (a) cognitive functioning, (b) personality, (c) interests and values, and (d) physical capacities (Arvey et al., 2006). Another useful distinction is between distal attributes (cognitive abilities, personality, and motives/values) and proximal attributes (problem-solving skills, social appraisal skills, and expertise/tacit knowledge; Zaccaro, 2007). Distal attributes are more genetically anchored and harder to change than proximal attributes. As discussed in Chapter 2, our framework separates values, traits, knowledge, and competencies. In this chapter, we call out specific values (beliefs about what ought to be) and traits (patterns of personal characteristics) that are particularly helpful to developing public health leadership. Our choice of priorities is subjective, based on our own experiences, observations, and reading.

VALUES UNIFY THE FIELD Koh and Jacobson (2009, p. 199) observe that a “sense of purpose motivates [public health leaders] to leave the comfort of the sidelines and wade into controversy, despite the uncertainty of outcomes.” This is a powerful statement, given both the depth of the controversy that attends much of public health, and what’s at stake if public health leaders can prevail and play a larger role in the nation’s health policy in the coming



3  Values and Traits of Public Health Leaders

55

years. Bernard Turnock has written extensively about the public health field’s history and contributions. He cites the “uncommon culture” and bond among public health professionals as one of the defining features of the field (Turnock, 2012, pp. 21–22). The strong values orientation of the field is part of what creates those bonds. For public health leaders, personal alignment with the values of the field is critical. When it comes to values, our central premise is that it is difficult for public health leaders to be effective if their personal values do not align well with the values of the field itself. In appointed governmental public health leadership roles, this personal alignment can be a predictor of whether someone new to the field thrives in it or doesn’t. Governors, mayors, or county boards often appoint people to top public health leadership roles based on their high profile in medicine or other aspects of the health care business, quite often without any formal public health training. In 1999, the Robert Wood Johnson Foundation (RWJF) started the State Health Leadership Initiative in part to respond to this dynamic. Newly appointed State Health Officers are invited to participate in a year-long program to build their skills in a job that historically has had very high turnover and short average tenures. Over the years, these cohorts have been notable for the diversity in professional and political backgrounds of their participants. In author JM’s experience as part of the first cohort of this program, shared values created powerful professional collaborations and enduring friendships among 12 individuals—a very disparate group of physicians, insurance executives, lawyers, politicians, and experienced local public health staff.

LEGAL AND ETHICAL FOUNDATIONs OF PUBLIC HEALTH The legal and ethical bases of public health give rise to some values that have come to characterize the field. A solid understanding of legal and ethical guidelines allows for their application to specific situations as they arise in practice. Individual values and traits may also influence perceptions and actions, so a strong foundation is critical to the success of public health leaders. Gostin (2010a, p. 6) makes the point that it “matters a great deal in law and ethics to understand who is acting, with what authority, and with what resources” [emphasis added]. Public health law is the “study of the legal powers and duties of the state, in collaboration with its partners . . . to ensure the conditions for people to be healthy and of the limitations of the power of the state to constrain the autonomy, privacy, liberty, proprietary, or other legally

56

II  Preparing for Public Health Leadership

protected interests of individuals” (Gostin, 2010a, p. 9). In the United States, the inherent interplay and tension between two fundamental duties—the state acting on behalf of the community’s greater good through its “police powers” on the one hand and protecting the rights of individuals on the other—is grounded in the Constitution, which also provides a system of checks and balances. Separation of powers is essential to fair and balanced execution of public health: the legislature enacts health policy and allocates necessary resources; the executive agencies propose policies and programs to the legislature and implement and enforce what is passed; and the judiciary interprets laws and regulations and resolves legal disputes. In order to protect the larger community, public health powers often constrain fundamental civil liberties of individuals, including “privacy, bodily integrity, and freedom of movement and association” (Gostin & Powers, 2006, p. 1054). This in turn raises potential concerns about social justice. Social justice demands “fair disbursement of common advantages and the sharing of common burdens” (Gostin, 2010a, p. 16), thus moving public health authority beyond law and into ­ethics. To safeguard the public’s health, the government is expected to show equal respect and regard for all community members, including the needs of the underprivileged and underserved. Public health law uses the ­language of duties, powers, and rights to determine the circumstances under which it can impose limitations on personal and economic liberties to influence the public good, all the while keeping both fair disbursement and human dignity as core principles to achieve social justice in the process. The simultaneous exercise of power to ensure community health and avoidance of the abuse of power are at the crux of public health ethics, which are goals and standards to guide public health institutions and practitioners. Public health ethics differs from bioethics or medical ethics due to a focus on the principles and values of populations, rather than individuals or patients, as well as prevention, rather than cure. These focal differences impact the laws and ethics around the practice of public health. Callahan and Jennings (2002) point out that public health has experienced a resurgence of public visibility in the last two decades, without displacing biomedicine’s prominence through such activities as the Human Genome Project during the same period. Yet “public health is once more a force to be reckoned with, and it is increasingly apparent that public health must contribute to the definition of the ends as well as the means of health policy” (Callahan & Jennings, 2002, p. 169). They identify HIV/AIDS, multiple-drug-resistant tuberculosis, chronic



3  Values and Traits of Public Health Leaders

57

illness, high-risk health-related behavior, injuries, and the interaction between health and the environment as arenas for increased ethical controversy. With the increased prominence of the public health field will come the ethical issues associated with it. While fundamental individual interests—autonomy, privacy, liberty, and prosperity—are critical to health and wellness, public health places greater weight on the impact and benefit to the community over the individual. Individuals benefit from a “well-regulated society” because shared risks to health, safety, and security are reduced, reinforcing our common bond and duty to promote the common good through public health activities. Conversely, research summarized in Chapter 1 shows that where the largest disparities exist between population subgroups, the greatest potential for overall inferior health exists. Professionalism and moral trust bestowed upon public health professionals are key elements of ethics in public health practice, even though this profession has not enforced an official code of ethics like medicine, law, and others. Specifying clearly the “ideals of the field” as well as illustrative general guidelines for applying those ideals in practice to a continuum of problems is the greatest challenge of writing a code. According to Callahan and Jennings (2002, p. 173), “the integrity of the profession of public health is sound, but the changing situation of public health practice may be a good reason to more precisely specify the ethical obligations that those in the field take on when they become practitioners.” This challenge is one that the public health community has started to embrace in an effort to provide sound guidance to practitioners. The Public Health Leadership Society (PHLS) underwent an iterative, consultative process to develop an unofficial yet well-regarded code of 12 principles for the ethical practice of public health (PHLS, 2002). Development was initiated at the 2000 American Public Health Association (APHA) conference, completed at the 2001 APHA conference, and adopted at the 2002 APHA conference. Included in the PHLS principles are the responsibility to ground prevention-oriented policies and programs in evidence, to appropriately use information, and to respect communities and their legitimate engagement in public health work. Notably, “Public health should advocate and work for the empowerment of disenfranchised community members. . . .” Thomas (2004) links core skills to each of the 12 principles, including the comprehensive recognition of ethical issues, determinants of health, and basic ethical concepts, such as justice and human rights. These skills reinforce the need for public health leaders to pursue a solid understanding and application of legal and ethical elements in their practice. The PHLS

58

II  Preparing for Public Health Leadership

website contains informative references on its code of ethics and the linkage of skills to ethics (www.phls.org). VALUES OF PUBLIC HEALTH LEADERS From the legal and ethical guidelines discussed above, we distill seven critical public health values—those core beliefs about how things ought to be. They are listed, along with brief definitions, in Table 3.1. We encourage public health leaders to assess their own commitment to each of these seven values and to identify additional deeply held ­personal values. Consider the fit of your values with the particular leadership challenges in public health described in this book and elsewhere. We suggest that the degree of fit between a leader’s personal values with those of the field is highly predictive of that leader’s effectiveness and enjoyment of or ability to tolerate the particular gifts and burdens of public health leadership. Table 3.1 Values of Effective Public Health Leaders 1 Social Justice—acceptance of health as a universal, fundamental human right for all, and a strong commitment to correcting patterns of systematic disadvantage to population subgroups 2 Reliance on Evidence—requirement that evidence informs and challenges decision making, accompanied by a healthy skepticism about existing practices, mindsets, and outcomes; helps mitigate groupthink among likeminded public health practitioners 3 Interdependence—recognition of the need to work with and in collaboration with diverse individuals and communities rather than independent pursuits; enhanced by the impact of social determinants on population health 4 Respect—at the personal level, a way of regarding another individual that denotes the individual is important; manifested in soliciting input from the individual, listening, and doing so in a way that is sensitive to the individual’s culture and individuality 5 Community Self-Determination—respect for the right and ability of communities to define their own issues and interventions; serve as a coalition builder rather than the agenda-setter 6 Requisite Role of Government—belief in the value of public service and the role of government action to protect the public’s health 7 Transparency—public and other stakeholders have the right to information; develops trust and promotes constructive politics



3  Values and Traits of Public Health Leaders

59

Social Justice A socially just society values and protects human rights, and public health leaders generally support the belief that health is a human right. The World Health Organization Constitution casts health in terms of universal fundamental human rights, a framing with which most health leaders inherently agree: “The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being. . .” (WHO, 2013a). As stated above, social justice is fundamentally about whether human rights and responsibilities are fairly distributed. Gostin and Powers (2006) sum up the concept of justice as fairness and reasonableness in how people are treated and how decisions are made. Social justice in particular requires understanding and correcting patterns of systematic disadvantage. They argue that grounding the field in social justice requires and legitimates public health’s focus on the social determinants of health, stretching the field beyond the earlier challenges of infectious disease and environmental hazards. Many public health leaders pursue issues of disparity as a result of their interpretation of the meaning of social justice. Social justice is a deeply motivating value for many in public health; in fact, some maintain that “Public health is the science of social justice” (Horton, 2011). This helps sustain leaders in their efforts to keep working on such complex issues and fighting for a greater share of public resources. One such leader, Angela Glover Blackwell, is portrayed in the In Practice 3.1 case.

in practice 3.1 A LIFELONG COMMITMENT TO EQUITY AND JUSTICE ANGELA GLOVER BLACKWELL, JD As a respected, tireless voice in the national conversation to enable equal, just, and fair health outcomes for all people, Angela Glover Blackwell is not partial to the word “health disparities.” Ms. Blackwell, Founder and Chief Executive Officer (CEO) of PolicyLink, urges that “disparity”—meaning “unequal, different”—does not capture the depth of issues in the United States, where race, income, and place matter in the achievement of one’s potential. In order to change outcomes, she believes the term “inequities” captures the extent to which the forces impeding health, education, housing, transportation, and overall opportunity across this country—­ especially for those with the greatest need—are “unjust, unfair, and not just different” (New Public Health, 2012). For a public health leader and advocate with a lifelong commitment to equity and justice, this is an important distinction to make.

60

II  Preparing for Public Health Leadership

A Foundation and Focus on Equity Angela Glover Blackwell leads by example as a social justice advocate. Raised during the racially segregated 1950s in St. Louis, Missouri, Ms. Blackwell attended Howard University and earned a law degree from the University of California at Berkeley (Moyers, 2013). For a decade, Ms. Blackwell was a partner at Public Advocates, Inc., a California-based nonprofit law firm and advocacy organization dedicated to “making rights real” by “strengthening community voices” through public policy and litigation (Public Advocates, n.d.). Using strategic partnerships, collective power, media advocacy, grassroots collaboration, and litigation, Public Advocates represents “low-income communities” and “people of color and immigrants” to engage and empower advances in education, housing, transit, health care, employment, and economic security (Moyers, 2013; Public Advocates, n.d.). Upon a platform of collaboration and broad-based public interest policy and advocacy, Ms. Blackwell has sought to bring equity and justice to all people. In 1987, Ms. Blackwell channeled her passion for strengthening communities and individuals to “challenge systemic causes of poverty and racial discrimination” (Public Advocates, n.d.) into a new venture, Urban Strategies Council (USC), an Oakland, California-based community building organization (Moyers, 2013). With a mission to “eliminate persistent poverty by working with partners to transform low-income neighborhoods into vibrant, healthy communities,” USC focuses on understanding communities and local conditions to drive “sustainable change” through partnerships, alliances, capacity building, strategy, and leadership (Urban Strategies Council, 2008). Following USC, Ms. Blackwell served for 3 years as a senior vice president at the Rockefeller Foundation. She continued to focus on the underserved by leading efforts to elevate national policy issues about race and inclusion through her leadership of the Foundation’s domestic and cultural departments (Moyers, 2013). Firmly established as a compelling and intelligent voice for building capacity and policy solutions to cross-sector equity issues, Ms. Blackwell elevated her national presence and impact by establishing PolicyLink.

“Lifting Up What Works” Founded in 1999, PolicyLink is a “national research and action institute ­advancing economic and social equity by Lifting Up What Works®,” a mission focused on “new and innovative solutions to old problems” that advance people “working successfully to use local, state, and federal policy to create conditions that benefit everyone, especially people in low-income communities and communities of color” (PolicyLink, n.d.; Poverty Forum, 2009). In addition to decades of dedicated advocacy to empower economic and social justice, Ms. Blackwell connects a network of likeminded capacity-building and equity-focused colleagues and organizations through PolicyLink. This cross-sector collaborative brings their collective power and attention to local, regional, and national issues that disproportionately limit the potential of members of communities of color, immigrants, and underserved populations.



3  Values and Traits of Public Health Leaders

61

Through her strong national following and reputation for determined action and persuasive collaboration, Ms. Blackwell uses PolicyLink as a forum to improve communities’ “access to quality jobs, affordable housing, good schools, transportation, and the benefits of healthy food and physical activity.” PolicyLink elevates what many in public health call the “social determinants of health” into the “conviction that equity—just, fair, and green inclusion—must drive all policy d ­ ecisions.” By using a variety of forums for sharing their findings and analysis, including publications, website and online tools, convenings, national summits, and briefings, PolicyLink expands its reach and impact on national and local policy makers and the diverse communities and people its work benefits (PolicyLink, n.d.).

Looking Toward Prosperity and Equality in a Diverse America A critical message and persistent theme of the work of Angela Glover Blackwell and PolicyLink is that diversity is an asset in the United States, albeit one not yet fully embraced or realized. Ms. Blackwell believes that we “must create real pathways for people of color to shape the new economy, enter the middle class, and contribute to growth and democracy” (Blackwell, 2012). America’s growing diversity is the subject of the 2013 online book, All-In Nation (http://allinnation.org/), a collaboration of the Center for American Progress and PolicyLink. In the book’s preface (p. vii), Blackwell and Tanden point out that America has an “extraordinary asset” in its racial, ethnic, and cultural diversity that allows for innovation “through the mix of different ideas, cultures, and attitudes.” By 2042, America will be a majority “people-of-color nation,” which mandates that public policies today focus on strengthening opportunities and removing barriers from communities of color (Blackwell, 2012) to overcome inequities and the resulting “significant gaps in education, employment, health, and wealth among the fastest-growing population groups” (Blackwell & Tanden, 2013, p. vii). Ironically, those suffering the greatest inequities are the communities from whom the United States has the most to gain due to the shifting population majority. Yet “[o]n every measure of well-being or distress—economic security, academic achievement, access to health care and fresh food, incarceration—communities of color suffer disproportionately” (Blackwell & Tanden, 2013, p. x). In the spirit of PolicyLink’s mission, the challenge that the United States must undertake—with a critical role for public health leaders—is to “move the national conversation beyond a focus on what’s wrong to illuminate what works” (Blackwell & Tanden, 2013, p. x). To do this, Ms. Blackwell reiterates her long-proclaimed message: encourage cross-sector collaboration to harness the “vast knowledge and experience of local communities and civic leaders” to ensure that as a nation we “grow together, not apart” (Blackwell & Tanden, 2013, p. viii). While the challenge is admittedly difficult, public health leaders have the lifelong example of Angela Glover Blackwell’s collaborative, equity-focused, persistent dedication to “lifting up what works” to follow and pursue in achieving health and wellness for members of all communities.

62

II  Preparing for Public Health Leadership

Reliance on Evidence The importance of knowledge and evidence in building the science base of public health is explored in some detail in Chapter 4. The field’s grounding in science has been widely acknowledged, for example, in Turnock’s (2012) list of the unique features of the field. The assertion that decisions should be evidence-based is of more recent vintage, and it extends beyond science. Gostin and Powers (2006) add that empirical evidence is critical for communicating to the public who are most vulnerable and at greatest risk how best to reduce risk or ameliorate harm, and how to fairly distribute services and benefits. For individual leaders, reliance on evidence extends to a healthy skepticism of entrenched practices and an orientation to critique what’s working and what’s not, a notion further developed throughout this book. Furthermore, effective leadership requires integrating evidencebased interventions with community preferences and with political action, as explored in Chapters 6 and 7. As Fielding and Briss (2006, p. 977) state, “High-quality, evidence-based information is not always available, and even when it is, policy choices should always be informed by available resources, community priorities, perceived value, feasibility, culture, and other factors. Evidence-based information will not change strong ideological support for or opposition to policy positions.” Reliance on evidence to inform (and challenge) decision making can also help leaders counter groupthink, which may be a downside of the generally positive structure of shared beliefs among public health practitioners. Groupthink is the failure to seriously consider alternatives and challenges to what individuals perceive to be a group consensus. It results from the desire to produce harmony in groups. Given the strong emphasis on collaboration and shared values in public health, groupthink is a potentially powerful and debilitating feature of the field. The value of evidence-based decision making helps to balance that force.

Interdependence Given the broad number of stakeholders involved in public health issues, the public health leader’s role is often compared with that of a symphony conductor as opposed to an individual musician. For most work in public health, interdependence among causes, solutions, and constituencies trumps the independence of any of them. This is part of what makes the work hard to define and almost impossible to communicate with precision. It adds complexity and increases the difficulty of



3  Values and Traits of Public Health Leaders

63

building and maintaining consensus. But appreciating the primacy of interdependence also leads to more accurate understanding of the true causes of population health problems and to the robustness of solutions. Complexity science is described in Chapter 4 and underscores this point. Interdependence is an empirical fact that public health leaders need to deal with. However, whether you as a leader see interdependence not as merely a messy fact but as an advantage—whether you inherently value it—is another predictor of how enjoyable you will find the challenges of public health leadership to be. Koh and Jacobson (2009, p. 200) perceptively note that valuing interdependence is part of what makes “wrenching trade-offs” tolerable in the inevitable bargains and priority setting we explore in the context of coalitions and political acumen in later chapters. We should note a distinction between values that drive one’s personal life and those that drive one’s work life. Here, we are addressing the value of interdependence in conducting public health leadership work. One may be quite content to live a personal life driven by a strong philosophy of independence, individualism, and even isolation, while deeply adhering to a value of interdependence in conducting work activities. Adding another layer of nuance, the values of interdependence and independence are relevant to different aspects of leadership. As we see in later chapters, leaders have to be able to draw on a deep value of interdependence in building and sustaining successful collaborations, but must also draw on a core strength of independence in being able to make tough decisions when needed.

Respect Respect is a critical value in any service profession, because one is meeting the needs of others. Respect at the personal level is a way of regarding another individual that denotes the individual is important. It is manifested in soliciting input from the individual, listening, and doing so in a way that is sensitive to the individual’s culture and individuality. Respect is a foundation for the personal relationships and understanding that fuel the collaborative work of public health.

Community Self-Determination Respect taken to the community level can be expressed as respect for a community’s right to self-determination. This value reflects the belief that communities fundamentally own their issues and assets and have

64

II  Preparing for Public Health Leadership

the right and responsibility to determine their own futures. Chapter 6 deals with the need for public health leaders to be extraordinary coalition builders. Unless a leader genuinely respects the right of communities to define the issues that are important to them and the most appropriate ways to intervene, he or she will find it hard to engage them. Public health has too often attempted to impose expert solutions from the outside in, often without knowledge of what the community believes about the issue at hand. But how likely is it that the “experts” will have accurately framed the issue, or the solutions? And once the leader asks for the community’s partnership (assuming the leader eventually does), how will the community’s suspicion and resistance be overcome? A servant leader approach to honoring the community’s role helps to avoid these missteps. It is important to note that respecting communities’ rights of selfdetermination does not mean abandoning the search for common values. Kouzes and Posner (2012b, p. 57) write that while “credible leaders honor the diversity of their many constituencies; they also stress their common values.” Indeed, that is a key to forging alliances across differences.

Requisite Role of Government The WHO Constitution states that “Governments have a responsibility for the health of their peoples which can be fulfilled only by the provision of adequate health and social measures” (WHO, 2013a). Public health leaders generally demonstrate a strong belief in the potential of government to improve people’s lives. A belief in the value of ­public service is another way to say this. In fact, public health leaders are unapologetic that sometimes government action is required to protect public health. As an example, given the economic power of the tobacco industry and its pervasive influence on the culture in the last century, only concerted changes in laws and regulations could have addressed the negative public health consequences of a deadly behavior then common to 50% of adults. A leader who believes in the inherent superiority of private-sector institutions or extrinsic incentives in all things probably would not enjoy public health work, nor be very likely to use its tools well. As an example, questions of whether to privatize certain core public health functions often arise. Sometimes this is driven by a desire or need to cut the budgets of public agencies, and sometimes as a matter of ­ideology. Public health laboratory services, which include clinical diagnostic



3  Values and Traits of Public Health Leaders

65

testing, disease surveillance, environmental and radiological testing, and emergency response support, are a frequent target. It could be that a private laboratory could competently perform public health functions, but given the critical dependence of public health protection on rapid and accurate detection of rare events, many performance standards would have to be tightly assured through contracts and consequences, not just assumed. A public health leader who is not sensitive to such distinctions would be unlikely to insist on such protections. Transparency A belief in transparency as the right way to lead reflects a conviction that information and actions taken on behalf of the public’s health should not be secret from the public. Leaders are there to serve the public, after all, not the other way around. Especially given the regulatory powers inherent in governmental public health, stakeholders may be wary. Appreciating that reality and understanding the need to win trust, leaders who are very open about what they know, what they intend, and what they are doing are ahead of the game. The leader who embraces an attitude of “the less shared the better” is not likely to do well under the harsh glare of the political spotlight described in Chapter 7. The importance of transparent stewardship and accountability is illustrated in In Practice 3.2, about the American Red Cross.

in practice 3.2 TRANSPARENT FINANCIAL MANAGEMENT IN PUBLIC HEALTH ORGANIZATIONS Founded in 1881 by Clara Barton, a heroine of the Civil War, the American Red Cross (ARC) charitable organization is unique in its federal mandate to provide assistance to Americans when crises such as fires and floods occur (Salmon, 2006, p. 1). The ARC is chartered by the U.S. Congress to provide “compassionate care” to five critical groups and activities: disaster victims in the United States, military members and their families, blood bank services (including collection, processing, and distribution), health and safety education and training, and international relief and development (American Red Cross, 2013). Responding to severe financial and operational scandals, while not in its charter, has proven to be the sixth area of focus for the ARC over the last several decades.

66

II  Preparing for Public Health Leadership

Questions of Accountability, Transparency, and Trust Charitable organizations, including those whose mission is to address the public’s health and welfare, are under considerable scrutiny. According to a 2008 Brookings Institution survey cited in Stanford Social Innovation Review (SSIR), about one-third of Americans have little or no confidence in charitable organizations, particularly in terms of charities’ handling of donated funds (Rhode & Packel, 2009, p. 2). The SSIR article (p. 2) also cited a 2006 Harris Poll that found only 10% of Americans believed that charities use these funds in an “honest and ethical” fashion, representing a deep mistrust that can impact funding of the important work of public health nonprofits. Publicized scandals involving major-scale operational and financial mismanagement have plagued the ARC since the 1980s, when poor handling of tainted blood supplies at the height of the AIDS crisis (Dees, 2005) rocked public confidence in receiving and giving blood. The alleged mismanagement of several natural disasters, particularly in terms of financial mishandling, renewed national scrutiny in the early 2000s (Dees, 2005), most notably after the terrorist attacks in the United States on September 11, 2001. In the wake of record donations following September 11, the public eventually learned that more than half of the over $500 million contributed to help victims and their families was set aside for operations and reserves for future disasters (Rhode & Packel, 2009, p. 7; Walker, 2001). The ensuing public outrage and loss of trust upon disclosure of this long-standing yet unpublicized ARC donation allocation practice resulted in a ­ ­“public apology and redirection of funds,” and a tarnished image for the ARC (Rhode & Packel, 2009, p. 7). Iowa Republican Senator Charles E. Grassley, the Senate Finance Committee chairman, called for an investigation into the ARC’s management of resources in the wake of the 9/11 scandal. Distracted by other national and international priorities, like the Iraq war, the investigation stalled, and the ARC continued its operations unchecked (Strom, 2006, p. 2).

Stormy Responses to Hurricane Relief Two catastrophic U.S. hurricanes and the ARC’s alleged mismanagement of funds, supplies, and volunteers in the wake of these disasters provide further lessons for the stewardship of public health funds. In late August 2005, Hurricane Katrina devastated the Gulf Coast of the United States. As the largest recipient of post-Katrina donations, the ARC received approximately 60% of the $3.6 billion in hurricane relief donations from Americans (Strom, 2006, p. 1). Blamed in part on weak Gulf Coast chapters, the ARC was accused of the “improper diversion of relief supplies,” poor management procedures to track and distribute supplies, and unauthorized “use of felons as volunteers in the disaster area,” which violated ARC rules (Strom, 2006, p. 1), as well as competencies of accountability and stewardships among public health leaders, teams, programs, and organizations. Senator Grassley again called for an investigation—prompted in part by ARC volunteers’ reports of misconduct, including the misallocation of assets and diversion of supplies for personal use or gain—with threats this time “to rewrite or revoke the organization’s charter if it does not thoroughly overhaul its operations”



3  Values and Traits of Public Health Leaders

67

(Strom, 2006, p. 2). Inventory control procedures, improper billing, and violation of organizational practices went unchecked at the ARC, which had at the time a ­50-member board and a reputation for appointing high-profile outsiders as CEO with short ­tenures and “generous” severance packages (Rhode & Packel, 2009, p. 9; Salmon, 2006, p. 2). In June 2006, among pervasive allegations of wrongdoing in managing the Katrina disaster and its publicized lack of accountability and stewardship, the ARC overhauled its chapter structure, making its 200 largest ­chapters responsible for hundreds of smaller chapters’ administrative functions using a ­“hub-and-spoke” system (Salmon, 2006, p. 1). Just over 7 years later, in November 2012, Hurricane Sandy, also known as Superstorm Sandy, hit the U.S. East Coast in densely populated urban areas, leaving widespread destruction and losses in its wake. As with past disasters, the ARC came to the rescue of storm victims, and, yet again, scandal followed almost immediately. One example is the complaint filed in July 2013 by the Disaster Accountability Project with New York State. According to the complaint, as many as 1,000 victims were promised “grants for up to $10,000 to help them rebuild and recover their homes,” but subsequent eligibility changes left most storm victims without funding (Goldberg, 2013). The complaint followed renewed allegations that upward of one-third of the approximately $30 million in funds donated specifically to relieve Sandy’s victims remained unspent almost 9 months later. Many residents of the area remained homeless during the winter of 2012 because so much money was left “to the side” instead of being used to resolve housing issues, according to Kathleen McCarthy, Director of the Center for the Study of Philanthropy and Civil Society at the City University of New York (Goldberg, 2013). The ARC’s public statements about its own performance have been strikingly at odds with these criticisms. In a November 2012 NBC News interview on the ARC’s Hurricane Sandy response, the President of the ARC (as of August 2013) said, “I think that we are near flawless so far in this operation” (Goldberg, 2013). Faced with overwhelming criticism of financial mismanagement in the wake of Hurricane Sandy, the ARC apparently remained confident that “it approached the storm relief in the best way possible” (Goldberg, 2013). According to the 2006 Harris Poll cited earlier, about one-third of Americans indicated “nonprofits have ‘pretty seriously gotten off in the wrong direction’” regarding perceptions about whether nonprofits are “honest and ethical in their use of donated funds” (Rhode & Packel, 2009, p. 2). As stewards of philanthropic funds, public health leaders are well-advised to be vigilant, transparent, and judicious in their financial management practices and to reconcile their own perceptions of performance against those of the general public and government.

TRAITS OF PUBLIC HEALTH LEADERS Successful public health leaders overwhelmingly resonate with the core values of the field itself and share the values listed above as “right,” or “the way things ought to be.” Obviously, leaders don’t all share the same traits, but some traits are more common in effective public health

68

II  Preparing for Public Health Leadership

leaders than others. Traits are “relatively coherent and integrated patterns of personal characteristics,” and leadership traits are those that foster consistent leadership effectiveness across settings and situations (Zaccaro, 2007, p. 7). Some researchers argue that as leadership situations become more complex and varied, personal traits become more important in predicting leader effectiveness (Zaccaro, Kemp, & Bader, 2004, p. 104). Leaders in those situations, which are common in ­public health, are less able to rely on knowledge and experience to make decisions. The empirical study of leadership traits is still relatively young. Zaccaro (2007) notes a widening in the definition of leadership traits from those that are largely genetic and immutable to include those that are more malleable, including even values within the scope of traits. In addition, he notes the need to consider traits in interaction with each other, rather than in isolation, and to consider traits that are linked clearly with leadership effectiveness, as opposed to perceptions of effectiveness. Finally, it is important to note that “too much” of a trait can be dangerous, and moderate levels of traits, and balance among traits, are important (Judge et al., 2009; Yukl, 2013). With the important additional caveat that such traits are not deterministic, understanding their role can be useful. We firmly do not believe in a checklist of traits, the presence or absence of which means one will either succeed or fail at leadership. Even if one is fortunate enough to be “born with” some leadership traits, we all have a responsibility to understand and work to improve on both those attributes that are natural to us and those that aren’t, if we want to be intentional about developing leadership competencies over a lifetime. Overreliance on what we think are our own innate traits can blind us to our weak spots. Conversely, thinking “I’m not a leader because I don’t believe X or don’t do Y” may make us miss opportunities to contribute our competencies at important times. Long lists have been generated to describe traits of leaders generally, many of which apply in various degrees to public health (American Library Association, 2013; Zaccaro et al., 2004). Some of those traits are particularly noteworthy and relevant, given the context of public health challenges and the values noted above, and many have been noted in the public health leadership literature (Day et al., 2012; Koh & Jacobson, 2009; Russell Reynolds Associates, 2013). Table 3.2 lists seven traits that we observe to rank highest, based on our own experience and learning. Again, we note that public health leaders need not possess all of these traits to succeed. They make public health leadership easier and more rewarding if they are part of one’s personal qualities. We advocate that



3  Values and Traits of Public Health Leaders

69

Table 3.2 Traits of Effective Public Health Leaders 1 Integrity—honesty, truthfulness, and consistent action in accord with one’s values; key to credibility and strength in the face of attack 2 Initiative—drive to change; willingness to take charge and take risks when necessary 3 Empathy—interest in and ability to relate to people 4 Comfort with ambiguity—comfort with lack of clear boundaries and hierarchy in work settings 5 Passion—deep commitment to values of public health, profession of public health, and service 6 Courage—willingness to take unpopular stands on high-visibility issues and to push harder, to insist more vigorously, more effectively, and over a longer period of time 7 Persistence—patience with long-term cultural, social, and multigenerational change

a “leader-ful life” should be joyful, especially if leadership is to be sustained and growing throughout a career and a lifetime.

Integrity Living with integrity requires that one live a life of honesty and truthfulness. Integrity is a primary determinant of interpersonal trust, and lack of it is a common reason for manager and leader failure (Yukl, 2013, p. 143). While integrity is a key trait in its own right, it is also the visible result of leaders operating in alignment with their other traits and values—­sometimes also described as authenticity, which is very important to a leader’s ability to be credible in pursuing virtually any of the competencies presented in this book. Consistency in the application of one’s values is a form of honesty to one’s self. George (2007, p. 148) compares the different aspects of a leader’s life—personal, professional, domestic, and the like—to the rooms in a house. The leader living with genuine integrity can “knock down the walls between these rooms and be the same person in each. . . .” Furthermore, because of the contentious nature of many public health issues and the political nature of many solutions, public health leaders will be targets of criticism and anger. Their confidence in their own integrity and others’ awareness of it is powerful inoculation.

70

II  Preparing for Public Health Leadership

Initiative The significance of the issues and even the very “messiness” of public health seem to attract ambitious people who want to make a big difference. To want to fundamentally change the agenda of an organization, a team, or a community takes a certain drive. Especially in a political arena—in which public health always functions to some degree—one needs a pretty healthy ego (some might say a dose of megalomania) to thrive. The case study of New York City’s public health advances is in part a story of individuals willing to wield authority and push its boundaries, including former Mayor Michael Bloomberg, Dr. Thomas Frieden, and Dr. Thomas Farley (In Practice 7.2 in Chapter 7). Setting aside politics for a minute (which we do at our peril, as explained in Chapter 7), public health likes to celebrate its collaborative, nonhierarchical environment. Even so, it helps when someone can step forward to provide direction at critical moments. Particularly in public health emergencies, discussed in Chapter 8, the willingness to step forward and be accountable, even perhaps beyond the technical bounds of one’s authority, is key. We should note that having a “mellow” personality does not preclude exhibiting initiative when it is necessary, such that this “trait” could be viewed as more behavioral or malleable than the others on our list. The contributions of introverted leaders, and humble leaders, have been well documented (Cain, 2012; Collins, 2001b; Grant, Gino, & Hofmann, 2010). Introverted leaders, who may listen more easily and make colleagues and others feel more valuable, take charge in more subtle ways, but the end result—action—is the same. As explained in later chapters, a big part of leadership is recognizing when the moment is right to advance an initiative. Informed decisions to push an issue or initiative will bring risk, almost no matter the specifics, again because of the number and divergence of stakeholders in almost every public health issue. But having read the environment, there are those who are more primed than others to “go for it” because the potential gain is so great and the risks are thought to be manageable. Windows of opportunity to advance public health issues may be very narrow due to the confluence of interests that have to converge. Thus, a certain degree of risk tolerance accompanies opportunism, since success is not guaranteed. This recalls the quote attributed to Robert F. Kennedy: “Only those who dare to fail greatly can ever achieve greatly.” In other words, you must accept the consequences of failure to have a chance to obtain significant achievements in life. At the same time, looking (carefully) before you leap is key to your survival, especially since anything big you are trying to do is likely to take sustained effort over the long term.



3  Values and Traits of Public Health Leaders

71

Empathy Empathy is a key part of emotional intelligence, the skills of which are summarized in Chapter 4 as knowledge about working with people. While these skills can be worked on and improved (Goleman, 2013), it helps if a leader has a genuine interest in people and an ability to connect with others. Lacking the trait of empathy, a leader will likely struggle to learn or apply the skills of emotional intelligence. Empathy goes both ways between the leader and others. If leaders demonstrate empathy, they tend to receive it in return from their team. There is an emotional component to the kind of leadership that can take a team, organization, or community to a new level. To sustain it, a leader has to benefit from a lot of support and a wide berth of understanding. Conversely, leaders without empathy are apt to encounter resistance and resentment when asking their team or organization to do something difficult. New York City Mayor Rudy Giuliani was widely praised for the empathy he genuinely showed for the victims, families, responders, and greater community of the city and the United States after 9/11. Of course, too much emotional empathy can be paralyzing, so effective leaders are able to cognitively recognize the emotion, label it, and move beyond it to action.

Comfort With Ambiguity When people enter the public sector from the private sector, they are often surprised (and dismayed) by the lack of the clear boundaries and hierarchies they are used to. By virtue of the breadth of the issues and stakeholders in public health work, few clear boundaries exist. Even other public agencies, like public safety or transportation, seem to enjoy more clear delineations of their roles and responsibilities. Skillful public health leaders have at least a high tolerance for the resulting ambiguity and at best an ability to thrive in that environment by stepping in to provide a suitable kind of leadership. Given the multitude and extreme variety of public health issues, leaders will find themselves in radically different situations on a regular basis. One day it’s whether you’re too tight or not tight enough on nursing home regulations, the next (and sometimes in the same day) it’s whether a number of cancer cases are an outbreak due to environmental contamination, what is the source of the food-borne pathogen the lab just picked up, who approved that teen pregnancy prevention educational campaign, why didn’t the biggest health system in the state

72

II  Preparing for Public Health Leadership

get that grant for health disparities, and how can we assure that all the health care workers get the flu vaccine this season. Being able to handle the range of critical public health issues, much less enjoy it, is bolstered by one’s adaptability to different situations. Three remaining traits are expressed when there is particularly good alignment between the leader’s values and interests and the “moment.” These are passion, courage, and persistence. Passion Public health is full of passionate people. They are passionate about the values of public health, about their profession, and about their service. Author JM recalls a statement she made in a speech to a group of state and local public health leaders from around the nation shortly after she left office as Minnesota Health Commissioner: “Public Health is easy to fall in love with.” This is what I meant. I was inspired from the day I stepped into the Department of Health to be as good as the people who were devoting their careers to protecting the health of all the people in my state. I bet every commissioner or secretary who lasted more than 6 months felt the same way. At the bare minimum, leaders need to match the passion of the groups they hope to lead. Not many effective public health leaders are listless. What impresses any group, in any sector, is a leader who first understands and respects the passions of the people who were already there before the leader was anointed, but then adds to it. However, there is also such a thing as overexuberance. People who are always passionate about everything can wear thin. Passion in the context of a compelling cause and plan is particularly compelling. This is the subject of Chapter 5. Courage Certainly, the public health leader must be willing to take unpopular stands on high-visibility issues. A repeated theme throughout this book is that public health leaders need to push harder, to insist more vigorously, more effectively, and over a longer period of time to see what the field of public health knows, implemented as local, state, national, and global policy and practice. The In Practice 7.1 case of



3  Values and Traits of Public Health Leaders

73

Dr. Dora Nkem Akunyili in Chapter 7 dramatically illustrates such personal courage. Poet and writer Maya Angelou (Beard, 2013, p. 152) offers some telling advice about the notion of courage as a malleable trait: “I realized that one isn’t born with courage. One develops it by doing small courageous things—in the way that if one sets out to pick up a 100-pound bag of rice, one would be advised to start with a fivepound bag. . . .” Whether the issues are in the headlines or not, a leader has a responsibility to be on the front line, personally taking the heat, often for others so that they can continue doing the work of implementing a program or policy that attracts some fire. As we have said, there is little about public health that doesn’t attract fire from somewhere. Author JM recalls the following example: In my first week on the job as Health Commissioner, I had two long-time department leaders in my office, in tears, offering to resign because key legislators were up in arms about an issue. (It happened to be nursing home regulation—the legislators feeling the Health Department was unduly harsh in sanctioning nursing homes that were using restraints to keep residents from falling out of their beds, and the U.S. Centers for Medicare and Medicaid Services and patient advocates insisting the Department was not being aggressive enough. Welcome to the “no-win” role of the regulator.) Without even knowing what they were really talking about, I knew it was my job to take the heat from the legislature at least until a new policy direction was set. The week I left office 4 years later, several long term staff told me they would not forget how I handled that issue. I was proud of that. Being courageous means taking risks, as does being opportunistic, discussed above. Both qualities mean that sometimes the leader will fail and will have to sacrifice career advancement, popularity, or other extrinsic rewards. It is difficult to be courageous or opportunistic without an underlying passion and commitment to one’s work. Persistence As we and many others have stated, public health faces long odds in many resource allocation battles and has rarely gotten the credit it deserves. The attainment of greater population health will require changes that are deeply cultural and likely multigenerational. To think

74

II  Preparing for Public Health Leadership

bigger and not accept limits takes an ability to keep getting up after ­getting knocked down. Author JM’s first boss, Paul M. Ellwood, Jr., MD, exhibits this trait to perfection. Dr. Ellwood had the temerity to think he could change national health policy away from a singular focus on paying for units of “cure” to the maintenance of health for whole populations. He was the architect of the Nixon Administration’s strategy of encouraging the formation of Health Maintenance Organizations (HMOs) and a shift away from fee-for-service medicine to global budgets. This was in the early 1970s. Sound familiar? Even though HMOs came to be pilloried just about everywhere in the culture of the United States, the “Accountable Care Organization” concept now at the heart of U.S. health policy and private market transformations bear a lot of the same ­characteristics. Dr.  Ellwood is still pushing, at this writing, though his focus has expanded well beyond economic incentives to questions of quality measurement, consumer engagement, and the depth of patient/professional relationships. Persistence in public health efforts may derive from an understanding of the nature of the work itself, that is, a strategic choice to be persistent in order to achieve outcomes. The trait of persistence is bolstered by a belief in evidence and the power of evidence, as illustrated by this passage from the memoirs of Alfred Sommer, MD, MHS, dean emeritus of Johns Hopkins University’s Bloomberg School of Public Health. Dr. Sommer relates his response to challenges to his research findings on the need to address vitamin A deficiency in diets (Sommer, 2013, p. 83): Had we not repeated, and helped others to repeat, our vitamin supplementation trials, we’d never have established the basis for what is widely regarded today as a core child survival strategy . . . we would one day prevail, by “burying the naysayers with data.” The trait of persistence is also bolstered by a sense of optimism. Colleagues of author JM joke that she is a “pathological optimist,” to which she usually replies (on good days) “well, someone needs to be!” Realistic optimism (optimism that is credible and informed) engenders energy and commitment from others toward future change, as well. Maintaining the energy to keep at it, especially through almost inevitable and sometimes long-lasting defeats, is taxing. Getting the extra energy needed for the long haul comes from engaged staff and support of colleagues and partners.



3  Values and Traits of Public Health Leaders

75

CONCLUSION Leadership effectiveness is determined by characteristics of leaders and the situations in which they find themselves. Among personal characteristics that influence effectiveness are personal values and traits. Values in public health leadership work are influenced by the history of the field and by legal obligations to protect the public health codified in law. Public health leaders generally recognize the necessary role of government in reducing the risks people can’t manage on their own, and the pursuit of social justice. They honor respect, community self-determination, transparency, interdependence, and evidence in ­ performing their work. If leaders do not hold those seven values, they may find public health work less satisfying and may find “followers” less engaged or fewer in number. Public health leaders also can benefit from having the following seven traits: integrity, initiative, empathy, comfort with ambiguity, passion, courage, and persistence. While those seven traits in no way guarantee leadership effectiveness, they make the leadership journey more enjoyable and make challenges more tolerable.

chapter 4

Knowledge for Public Health Leadership

key terms Association of Schools and ­Pro­grams of Public Health Competency Model change leadership change management complex adaptive systems core disciplines Council on Linkages Competency Model cross-cutting domains dynamic emotional intelligence

equity theory evidence-based goal setting interpersonal skills motivation, intrinsic positive deviance prevention-focused public health science social intelligence systems thinking transdisciplinary value-laden

T

he potential for leadership effectiveness is enhanced if individuals possess basic knowledge that helps them to be competent in performing leadership tasks. In this chapter, we describe three key areas of knowledge for public health leaders: (a) public health science; (b) understanding (and changing) people; and (c) understanding (and changing) complex systems.

77

78

II  Preparing for Public Health Leadership

The first area of knowledge, public health science, is widely accepted as a part of the foundational knowledge of public health leaders. We use the term “science” broadly, to refer to rational and reliable knowledge about a topic. Public health science refers to the knowledge base of the specific subdisciplines or specialties within public health. Such public health specialties include community health, nutrition, emergency services, environmental health, global health, administration, and biostatistics. All of these specialties have underlying knowledge bases that grow in depth and validity everyday. There are limits, however, on the need for public health leaders to have public health science specialty knowledge in at least two senses. First, some public health leadership tasks require little technical expertise in public health science. Such tasks include inspiring and directing diverse coalitions of specialized workers and organizations during emergencies. Civic and military leaders may perform this task, for example, then “return” to their full-time civic or military work after the emergency. Leaders from sectors other than public health may contribute their collaborative leadership or political competencies to public health initiatives, such as large-scale prevention and health promotion activities, and those leaders can be successful without a detailed understanding of the knowledge base underlying the activity. An example is the work of former Mayor Michael Bloomberg in New York City, detailed in Chapter 7. A second limitation on the need for public health science expertise is that depth in a specialized knowledge base can be a barrier to leadership if the individual leaders see everything solely from the perspective of their own specialty. Leadership in most public health initiatives requires “getting out of the box” of one’s specialty. A prominent expert in infection control, for example, needs more than expertise in infectious disease science to lead a cross-sector alliance to prepare for pandemics. Since much of public health work is transdisciplinary (discussed in the section on Characteristics of Public Health Science), specialized expertise has to be coupled with an interest in and respect for other specialties and disciplines. Even recognizing these limitations, specialized knowledge is very valuable for public health leaders. Expertise is a source of power among peers in one’s specialty, often associated with a successful career and a platform for future leadership activities that expand outside of one’s specialty. Success in one’s specialty creates legitimacy both within the specialty and with outsiders. Also, specialized knowledge is a foundation of innovation. While leaders can support innovations that they do not understand in detail, initiating and understanding innovation



4  Knowledge for Public Health Leadership

79

requires technical knowledge. For example, innovations in smoking cessation are unlikely to come from those who do not understand the biology of nicotine addiction. Another benefit of a deep base of specialized public health science knowledge results from the fact that there are commonalities across public health specialties in the characteristics of the different knowledge bases. Deep knowledge in a specialty comes with deep understanding and appreciation for the value of prevention, for example. Or, mastery of any public health specialty area imparts appreciation for and ability to critique an evidence base for public health action. As evidence supplants opinion and formal position power (power associated with one’s standing in a hierarchy) as an arbiter of effectiveness of public health policy and practice, the importance of public health science to public health leadership is enhanced. A requirement of leaders of the future is that they appreciate the nature of public health science and its power (as well as limitations) in mobilizing people, organizations, and communities. Leaders in all spheres of activity (in public health and other sectors) can benefit from up-to-date knowledge of and investment in learning the second and third bodies of knowledge: understanding people and understanding complex systems, both with the goal of change. Change is essential for accomplishing public health leadership, which we define as “the practice of mobilizing people, organizations, and communities to effectively tackle tough public health challenges.” Mobilizing people and mobilizing entities comprised of people are the essential processes of leadership. The more knowledge one gains about these two topics, the higher the chances of success and mobilizing others. Much of the knowledge on these two subject areas is gained through experience, rather than formal education. At the same time, the science underlying the understanding of people and complex systems is advancing rapidly, and leaders can benefit by keeping informed. These two domains (understanding people and understanding complex systems) are less commonly recognized as foundational knowledge in the field of public health, though all of the competency models for public health education include some recognition of both domains (see Chapter 2). The inclusion of “social and behavioral science” as a core discipline and “systems thinking” as a cross-cutting content area in the Association of Schools and Programs of Public Health (ASPPH; formerly the Association of Schools of Public Health, or ASPH) competency model, for example, indicates acceptance of the importance of understanding people and complex systems. However, there is limited attention to understanding people and complex systems in most public health educational curricula.

80

II  Preparing for Public Health Leadership

PUBLIC HEALTH SCIENCE In this section, we outline the knowledge base of public health science. After acknowledging the breadth of core disciplines in public health science, we describe knowledge that cross-cuts the core disciplines and identify five key characteristics of public health science. Then, we review selected examples of knowledge about understanding people and complex systems that are relevant to public health leadership.

Core Disciplines There are myriad ways to differentiate the components of public health science. One way of classifying the scientific base of public health is to examine the consensus views on requirements for education and proficiency in public health practice. The master’s degree in public health (MPH) is a common entry point to the field. As introduced in Chapter 2, the ASPPH competency model for the MPH degree differentiates five core discipline areas: 1. Biostatistics 2. Environmental health sciences 3. Epidemiology 4. Health policy and management 5. Social and behavioral sciences These core disciplines are essentially the same as the five “sciences” identified in the more practice-oriented Council on Linkages competency framework, also introduced in Chapter 2: biostatistics, epidemiology, environmental health sciences, health services administration, and social and behavioral health sciences. Senior managers and leaders are expected to be able to critique, apply, and contribute to the scientific foundation of the field of public health (Public Health Foundation, 2010). A key point is that the field is built on a scientific foundation, in the eyes of both academics and practitioners. MPH graduates typically specialize in one of the five core disciplines, but a wide range of other public health specialties also exist. More detailed categorizations of public health knowledge might refer to additional clusters of basic public health knowledge, such as health education, public health ethics, emergency preparedness, or public health law; geographic areas for application of knowledge, such as community health or global health; special populations such as maternal



4  Knowledge for Public Health Leadership

81

and child health or aging studies; health or disease categories such as mental health, infectious disease, or chronic conditions; or associated professions, such as nursing, nutrition, pharmacy, preventive medicine, or veterinary medicine. All of these clusters of knowledge have a scientific base, where again science refers broadly to rational and reliable knowledge about a topic. Some of these bodies of public health science knowledge are older and some more anchored in hard (physical or natural) science versus soft (social) science. For example, epidemiology has a long history based on the study of epidemics and their causality, and a link to the hard sciences through the use of mathematical methods and experimental research design (among other designs). Its knowledge base includes an understanding of disease processes, research design, and statistical methods. The knowledge base of health policy and management, in contrast, is much closer to that of business and public policy, fields that are younger and in which experimental design is rarely used to develop knowledge. Experience, cumulated anecdote, and analogy are more common sources of knowledge development in the specialty of health policy and management. Linking the diverse specialties of public health is their underlying purpose, the improvement of population health, as well as cross-cutting content and key characteristics identified below. Cross-Cutting Content Areas in Public Health Science As introduced in Chapter 2, the ASPPH competency framework for the MPH degree identifies seven cross-cutting content areas in addition to the five core discipline areas of public health: 1. Communication and informatics 2. Diversity and culture 3. Leadership 4. Public health biology 5. Professionalism 6. Program planning 7. Systems thinking The leadership content area, one of the seven cross-cutting areas, includes nine competencies, with the “attributes” of leadership, strategies for collaboration, mission, values, vision, social justice and human rights principles, and conflict management among the knowledge areas

82

II  Preparing for Public Health Leadership

needed to meet the nine leadership competencies. While required content on leadership is scarce in MPH curricula, it is notable that a major governing body of the field’s curriculum (the ASPPH) does recognize the importance of leadership competencies and knowledge. It is also notable that systems thinking is distinguished as a competency of ­public health leaders, again consistent with many of the themes in this book. The eight domains in the Council on Linkages competency model (Public Health Foundation, 2010) provide another way of thinking about cross-cutting knowledge, because practice requires the application of knowledge across the boundaries of specific disciplines or specialized knowledge clusters. The eight domains follow: 1. Analytic/Assessment 2. Basic Public Health Sciences 3. Cultural Competency 4. Communication 5. Community Dimensions of Practice 6. Financial Planning and Management 7. Leadership and Systems Thinking 8. Policy Development/Program Planning The Council on Linkages domains are similar to the cross-cutting content areas of the ASPPH, with the addition of Basic Public Health Sciences. The attainment of knowledge is clearly required for the Basic Health Sciences domain, but most of the remaining domains and skills in the Council of Linkages model speak to applications of knowledge rather than attainment of it, as would be expected by the practitioner focus of the model. One exception might be “systems thinking,” where application and integration of it into public health practice would presumably require basic understanding of the content of systems thinking.

Characteristics of Public Health Science The knowledge base of public health, including both the basic public health sciences and the cross-cutting domains, shares certain u ­ nderlying characteristics that may not be evident from the discussion above. We identify five key characteristics of knowledge in public health s­ cience: it is evidence-based, focused on prevention, dynamic, ­transdisciplinary, and value-laden. These key characteristics are listed and briefly described in Table 4.1.



4  Knowledge for Public Health Leadership

83

Table 4.1 Five Key Characteristics of Public Health Knowledge 1 Evidence-based •  Correlates with an emphasis on science and scientific research •  Uses evidence as a key weapon in tackling public health challenges in political arenas •  Grows largely through accumulation of scientific evidence •  Empowers societal influence of public health leaders and the field 2  Dynamic •  Changes frequently, particularly knowledge connected to scientific disciplines •  Invites an attitude of learning by public health leaders •  Demands the push for new evidence where it is needed •  Requires leaders’ openness to change their minds where compelling evidence is identified 3  Prevention-focused •  Directs most public health knowledge toward preventing the emergence of health problems •  Compels focus on addressing the root causes of health problems to prevent them •  Enables a “return-on-investment” mindset that reflects the shared belief in the value of prevention 4  Transdisciplinary •  Driven by problems rather than traditional boundaries of scientific disciplines •  Welcomes acceptance of relevant information from other fields and disciplines, as well as their potential limitations •  Encourages cross-sector collaboration within and outside clinical and scientific fields 5  Value-laden •  Characterized by strongly political nature of field due to value conflict inherent in most population health issues •  Raises questions about the allocation of public resources relative to government regulation and intervention, legal and ethical concerns, and political influences •  Requires political debate over both the means and ends for improving population health

Evidence-Based The Institute of Medicine states a widely accepted position that “The rationale for all population health interventions, including laws, must be based on the best evidence available” (Institute of Medicine, 2011a, p. 10). Evidence that is a poor basis for intervention is that derived from

84

II  Preparing for Public Health Leadership

intuition, bias, fallacy, rhetoric, or tradition, among other things. All forms of information, from personal experience, experience of ­others, expert opinion, and descriptive information, help comprise an evidence base, but evidence from scientific research is generally preferred and encouraged to complement and supplant other sources (Kovner & Rundall, 2006). Thus, an emphasis on evidence base correlates with an emphasis on science and scientific research. Scientific evidence is a key weapon in tackling public health challenges in political arenas. Turnock (2012, pp. 20–21) argues that the grounding of public health in science separates public health from many other social movements. As such, development of a scientific knowledge base is a key to advancing the status of public health as a profession (Evashwick, Begun, & Finnegan, 2013). The knowledge base of public health grows largely through accumulation of scientific evidence, again noting that the term “science” is used broadly, to include evidence that is rational and reliable but not necessarily derived solely from the scientific method of hypothesis testing and experimental design. Observers have noted that establishing an evidence base for action in public health is more difficult than doing so for clinical interventions, due to the complex and long-term causal pathways of root causes of public health problems (Braveman, Egerter, Woolf, & Marks, 2011). Careful assessment of the evidence base is necessary to secure credibility for recommendations for public health interventions. Methods of assessing the evidence base for public health issues are improving (Anderson et al., 2005), with systematic reviews available on a variety of issues. The County Health Rankings and Roadmaps website, for example, classifies evidence on the effectiveness of specific public health strategies, with six ratings ranging from “evidence of ineffectiveness” to “scientifically supported” (University of Wisconsin Population Health Institute, 2013). “Evidence” is defined as one or more systematic reviews, three experimental or quasi-experimental studies, or six descriptive studies, all with strong design and statistically significant findings. (The other evidence ratings are “mixed evidence,” “insufficient evidence,” “expert opinion,” and “some evidence.”) Another key issue in applying public health evidence is the need to consider community preferences and culture, as evidence is ­invariably still value-laden. A widely adopted definition of evidence-based public health notes this explicitly: evidence-based public health is “the ­process of integrating science-based interventions with community p ­ references” (Fielding & Briss, 2006. p. 970). There are serious constraints on existing scientific evidence in many fields of public health, including public health administration and



4  Knowledge for Public Health Leadership

85

leadership, that should be recognized (Begun, 2009; Hanlon et al., 2012). It is likely more difficult to develop scientific evidence for interventions that are less proximal to health outcomes and for problems that are more complex, for example. Reliance on evidence means supplementing, not replacing, decision-making that is driven by values, philosophies, and ideologies. The Council on Linkages competency model (in the domain of Public Health Science) suggests that Tier 3 practitioners (senior m ­ anagers or leaders) should be able to integrate and critique scientific evidence on public health issues. In the ASPPH model for MPH graduates, e­ vidence critique and synthesis does not receive explicit attention, perhaps because it is so embedded in the nature of the core disciplines. Public health action increasingly requires evidence, and scientific research is a key asset in public health’s increasing influence on society. Public health leadership needs to overcome significant political and cultural resistance. It is relatively powerless to do so without scientific evidence. Decisions about funding public health research are important for this reason. A significant example of this is the reversal of the ban on federally funded gun violence research in the United States, as policymakers realized its critical role in arbitrating policy disputes. In Practice 4.1 illustrates the importance of improving the evidence base of public health science.

in practice 4.1 IMPROVING THE EVIDENCE BASE ON GUN VIOLENCE IN THE UNITED STATES The knowledge base of public health is dynamic and evidence based, requiring continuous improvement. A significant example of this evolution is the reversal of the federal ban on gun violence research in the United States in early 2013. Policymakers, including President Barack Obama, set forth to correct the effect of almost two decades of political pressures that had restricted vital research on gun violence, the leading cause of preventable deaths in the United States (Jamieson, 2013).

Background A 1993 study published in the New England Journal of Medicine (Kellerman et al., 1993) underscored the association of guns kept in the home and an increased risk of homicide, based on consistent findings from several researchers. Rather than offer protection, these guns were “strongly and independently associated” with an increased homicide risk (Jamieson, 2013). According to a 2013 interview on

86

II  Preparing for Public Health Leadership

National Public Radio (NPR) with lead study author Dr. Arthur Kellerman, “on the balance, the risks of tragedy in the home—a homicide or suicide—were actually increased if a gun was kept there rather than not” (Rovner, 2013). Following extensive media coverage of the study’s findings—which were in direct contrast to positions of the National Rifle Association (NRA), the powerful U.S. gun lobby—the NRA took action against this important public health issue. Initially, the NRA’s campaign against government funding of gun violence research focused on the Centers for Disease Control and Protection (CDC) and its National Center for Injury Prevention (Jamieson, 2013; Marshall, 2013). This funding had reached an estimated $2.6 million in 1996; the following year, an equal amount was removed from the CDC’s budget. Although there were no details about which programs to cut, the message was clear (Jamieson, 2013; Marshall, 2013). Former U.S. Congressman Jay Dickey authored a 1997 appropriations amendment that reinstated the $2.6 million within the CDC’s injury prevention center, earmarking the amount for traumatic brain injury research. The “Dickey amendment” specified that the Center’s funds could not be used to “advocate or promote gun control” (Jamieson, 2013; Luo, 2011; Mayors Against Illegal Guns, 2013b). The NRA’s influence exacted a heavy toll on the funding of gun violence research for almost two decades in a manner unique to this field of scientific inquiry (Luo, 2011). With primary funding of firearms research from the CDC ­essentially cut off, other public and private funding followed suit—including the U.S. Department of Justice and the National Institutes of Health—forcing r­esearchers like Dr.  Kellerman to pursue other areas of study (Jamieson, 2013; Luo, 2011; Marshall, 2013; Rovner, 2013). According to the national coalition, Mayors Against Illegal Guns (2013b), only $100,000 of the CDC’s $5.6 billion budget in 2012 related to firearm injury research—a 96% drop from peak funding in 1996—with academic publications on the subject down 60% through 2010. Other groups such as law enforcement, local governments, the military, health care practitioners, and even the 2010 Affordable Care Act have been impacted by the NRA’s successful lobbying to restrict funding for and public policy on gun violence, firearms tracking, mental health issues, and sharing of information about gun ownership (Mayors Against Illegal Guns, 2013b).

Critical Public Health Issue The public health issues related to gun violence did not stop when funded research on the subject was essentially eliminated. According to U.S. statistics published by the Children’s Safety Network (CSN, 2013), over 31,000 people were killed in 2010 by firearms, with approximately 11,000 homicides and 20,000 suicides. Total firearm injuries in 2010 cost the United States $174 billion, of which the government’s bill exceeded $12 billion; the societal cost per fatal firearm assault was over $5 million. Mass gun violence since 2010 alone, including Newtown, Connecticut; Aurora, Colorado; and Tucson, Arizona, revealed that mental illness and unrestricted access to firearms create a dangerous combination. To pursue the most effective interventions to address this critical public health issue, fundamental evidence-based research is tragically overdue. President



4  Knowledge for Public Health Leadership

87

Obama’s January 2013 executive order in the form of a national plan for addressing gun violence indicated that the CDC and other scientific agencies must move forward with funding gun violence research. Echoing the language of the 1997 Dickey amendment, the President stated that “research on gun violence is not advocacy; it is critical public health research that gives all Americans information they need” (Jamieson, 2013). Scientific, law enforcement, health care, and policy advocates alike began demanding restoration of public funding for this vital research after an almost two-decade ban.

Research Agenda Planned In conjunction with his 2013 executive order, President Obama directed Kathleen Sebelius, Secretary of the Department of Health and Human Services, to restart funding by the CDC for research into the “causes of gun violence and ways to prevent it,” along with a call to Congress to invest $10 million in CDC research and another $20 million to expand nationally the National Violent Death Reporting System (Jamieson, 2013; Marshall, 2013). The research agenda and related ­policy initiatives are broad, given the extensive reach of firearms and violence in the United States: mental health implications of ­violence in video games and media; school- and military-based violence prevention; data reporting of firearms used in homicides and suicides; restrictions on the types of guns and ammunition sold; and improved requirements for tracking and reporting gun sales and thefts (Benjamin, 2013; Jamieson, 2013; Marshall, 2013; Mayors Against Illegal Guns, 2013b; Rovner, 2013). As APHA Executive Director Dr. Georges Benjamin stated, “The issue of gun violence is complex and deeply rooted, which is why we must take a comprehensive public health approach to ensuring our families and communities are safe. We must place a renewed emphasis on improving gun injury and violence research and expanding access to mental health s­ ervices to those who most need it . . . to ensure ­evidence-based public health principles are at the heart of any efforts to reduce gun violence-related injury and death” (Benjamin, 2013). The gun violence research issue illustrates opportunities for public health science to lead to new policies, illustrating the importance of improving the evidence base on issues that affect all of us individually and at a population level.

Dynamic New ideas and evidence are emerging daily in public health science (as well as in the sciences of understanding people and complex systems, discussed below). Public health knowledge changes frequently, particularly knowledge that is connected to scientific disciplines, in which thousands of researchers around the world are pursuing relevant new research. Openness to learning is an attitude and behavior that helps leaders succeed. Continuing education as an ongoing pursuit is covered further in Chapter 10 on lifelong learning.

88

II  Preparing for Public Health Leadership

Leaders need to be connected to the latest knowledge and to be open to new evidence that challenges their past assumptions. Indeed, they need to push for new evidence where it is needed (as shown in In Practice 4.1), which in turn influences the agenda for the allocation of research funds by their own professional organizations, public entities like the NIH, and private foundations. The Council on Linkages competency model (Public Health Foundation, 2010) recognizes this as a separate competency for senior managers and leaders—Competency 6C10 in the Public Health Sciences domain states that a leader “Establishes partnerships with academic and other organizations to expand the ­public health science base and disseminate research findings.” In addition, leaders need to be open to changing their minds on key issues if evidence compels it. This may be difficult, as an ­individual ­visibly identified with a position may not want to admit to being wrong. Continued espousal of a position in the face of strong ­opposing evidence destroys a leader’s credibility. For example, public health l­ eaders in the United States have defended the practice of flu vaccination, ­sometimes in the face of evidence that its efficacy is highly limited. In Practice 4.2 later in this chapter profiles actions of one public health leader in ­dealing with the complexities of flu vaccine promotion. Prevention-Focused While not obvious from the categories of knowledge produced by ASPPH or the Council on Linkages, most public health knowledge is directed at preventing the emergence of health problems, as applied to both the causes of health problems and solutions to them. This is a direct result of root cause or systems thinking about population health problems and solutions. Thus, the knowledge domain of “Social and Behavioral Science” in the ASPPH competency model does not encompass all of the enormous range of those sciences, but rather the subset that explores the causes of population health problems, such as “identify the causes of social and behavioral factors that affect health of individuals and populations” (Competency 2 in the Social and Behavioral Sciences domain of the ASPPH model; ASPH, 2006). An implication is that addressing the root causes of health problems is necessary to prevent the problems. All of the specialty clusters within public health teach the value of prevention. “ROI” is an acronym for “return on investment.” The proposition that “Public Health is ROI” and the tag line “Save Lives, Save Money” were adopted as central communication themes in 2013 by the American Public Health Association, again reflecting this shared belief in the value of prevention.



4  Knowledge for Public Health Leadership

89

In Practice 4.2 describes the need for improvements in the efficacy of flu vaccines, and the efforts of one public health leader to push for new research and development. His efforts illustrate the three characteristics of public health science knowledge that we have discussed so far: evidence-based, dynamic, and focused on prevention.

in practice 4.2 CONFLICTING EVIDENCE ON FLU VACCINE EFFICACY Michael T. Osterholm, PhD, MPH, of the University of Minnesota Center for Infectious Disease Research and Policy (CIDRAP), is an infectious disease expert who believes in the indispensable role of evidence-based research in public health. Yet he also challenged the status quo thinking about a fundamental public health tool, namely the efficacy and effectiveness of the current influenza (flu) vaccines. By promoting research on a better flu vaccine and disseminating evidence on the limits of current vaccines, Dr. Osterholm illustrates a public health leader’s focus on evidence and dynamism in public health science knowledge, which requires leaders to be both current and open-minded to the fact that the consensus may be wrong (CIDRAP, 2012a).

Study Sheds Light on Long-Held Public Health Beliefs On October 15, 2012, the cusp of what turned out to be a “moderately severe” influenza season (Centers for Disease Control and Prevention [CDC], 2013c), CIDRAP released a report with results of a groundbreaking influenza vaccine study, led by Dr. Osterholm. The use of “compelling” in the report’s title (CIDRAP, 2012b) foretold the significance of the findings and recommendations contained therein: The Compelling Need for Game-Changing Influenza Vaccines: An Analysis of the Influenza Vaccine Enterprise and Recommendations for the Future. What had started as a comprehensive review of the 2009 to 2010 pandemic influenza vaccine preparedness and response—the Comprehensive Influenza Vaccine Initiative (CCIVI)—evolved into a 3-year odyssey that ultimately challenged flu vaccine efficacy and effectiveness rates reported since the 1940s (CIDRAP, 2012a).

A Brief Lesson in Influenza Considered one of the “lion kings” of infectious diseases throughout history, flu is a respiratory-transmitted viral disease occurring as both annual seasonal epidemics and global pandemics. Annual flu season typically runs from October through May, while pandemics can occur at any time and may last more than 1 year (CDC, 2013c, 2013d; CIDRAP, 2012b). The CDC (2013b) reports that between 3,000 and 49,000 people die annually of the flu in the United States, based on data from 31 flu seasons; CIDRAP (2012b) noted that World Health Organization (WHO) estimates

90

II  Preparing for Public Health Leadership

of global annual deaths are between 3 and 5 million, which CIDRAP stated is “likely an underestimation.” The cause of a flu pandemic, including the four that occurred during the last 100 years (1918, 1957, 1968, and 2009), is the genetic mutation of novel flu viruses in animals that allows human-to-human transmission (CIDRAP, 2012b). The WHO estimated that the 2009 pandemic, caused by a strain of the novel H1N1 (swine) flu virus, infected approximately 24% of the global population, with at least 18,500 deaths (Roos, 2013b).

Findings, Fallacies, and Recommendations Dr. Osterholm, Director of CIDRAP and an Environmental Health Professor, and his team of five CIDRAP researchers, conducted the CCIVI with the primary objective to review “all aspects of influenza research” and the flu vaccine enterprise. Elements of the latter included development, financing, manufacturing, efficacy, safety, regulatory issues, procurement, distribution, vaccine usage, public education, consumer acceptance, and public policy (CIDRAP, 2012b). As researchers peeled back each layer of the “proverbial onion,” the comprehensive initiative expanded into “one of the most exhaustive reviews of any vaccine ever undertaken,” according to Dr. Osterholm. The “cradle to grave” examination of the seasonal and pandemic influenza vaccines led the CIDRAP team to a surprising conclusion: the current flu vaccine provides a suboptimal level of protection. To illustrate the study’s scope, over 12,000 flu vaccine-related documents from 1936 to 2012 were reviewed, 88  flu experts from broad disciplines were consulted, and a 13-member CCIVI Expert Advisory Group of international flu vaccine experts was established, chaired by Alfred Sommer, MD, MHS, the former dean of the Bloomberg School of Public Health at Johns Hopkins University (CIDRAP, 2012b). Of the CCIVI’s 10 key findings, the team began by validating long-held beliefs that the annual flu vaccination typically provides “substantially more protection” for those vaccinated than those unvaccinated. But that’s where the team diverged in its support of conventional public health guidelines, arguing that the United States “can no longer accept the status quo regarding vaccine research and development” (CIDRAP, 2012b, p. 2). Most publicized in U.S. media—principally as quotes by and interviews with Dr. Osterholm—were findings that the traditional trivalent inactivated influenza vaccine (TIV) provides only about 59% protection for healthy adults 18 to 64 years of age, and the newer live-attenuated influenza vaccine (LAIV) provides consistent protection (83% protection) only for young children 6 months to 7 years of age. These findings challenged conventional flu vaccine efficacy findings of 70% to 90%, with CCIVI citing “optimal testing methodology” behind the studies with the smaller percentages. Overstated rates give a false perception of efficacy and effectiveness to current vaccines, which is a barrier to the development of “novel-antigen game-changing” flu vaccines, which is further hampered by the U.S. focus on increasing production capacity rather than developing these game-changing vaccines (CIDRAP, 2012b, p. 2). The study also presented six primary recommendations, focused on developing novel-antigen game-changing seasonal and pandemic flu vaccines that follow



4  Knowledge for Public Health Leadership

91

internationally adopted standards for evaluating efficacy and effectiveness. To accomplish this goal, Dr. Osterholm recommended a primary leadership role for the U.S. government to drive the comprehensive global flu vaccine enterprise, in conjunction with national and international agencies, governments, and private-sector partners. Due to the global nature of pandemic, the critical need for an available, highly effective pandemic flu vaccine, and the national security threat of a severe flu pandemic, the U.S. government must undertake game-changing vaccine development and production as a “mission-critical priority” according to the CCIVI recommendations (CIDRAP, 2012b).

Giving Voice to Groundbreaking Evidence in Public Health Challenging the status quo is never easy, especially when taking an innovative look at existing evidence to support claims that could save millions of lives in the face of a global flu outbreak. Dr. Osterholm demonstrated many of the five competency sets of public health leaders, guiding his team through a thicket of evidence spanning nearly 80 years of respected research and conclusions that gave rise to conventional, yet inaccurate, beliefs about flu vaccine efficacy and effectiveness. Quoting the 12th Librarian of the Library of the U.S. Congress, Daniel Boorstin (CIDRAP, 2012b, p. 4), Dr. Osterholm provided insight into why he felt compelled to rise to the challenge and give voice to the evidence he uncovered: “The greatest obstacles to discovering the shape of the earth, the continents, and the oceans was not ignorance but the illusion of knowledge.”

Transdisciplinary Public health knowledge transcends traditional scientific disciplinary boundaries. A discipline is an academic field of study. Among academic fields of study, public health is one of the most transdisciplinary by design. Public health is problem-driven rather than discipline-driven. This is because the driving purpose of public health science is improvement in the health of the public, rather than improvement in the knowledge base of a scientific discipline. Improvement in the knowledge base is a means to an end. As a result, public health knowledge is less hampered than most disciplines are by insulation from other fields of academic study. Public health researchers, educators, and practitioners commonly seek and welcome relevant information from other fields and disciplines rather than dismissing such knowledge as “outside the boundaries of our science.” In the formal research world, transdisciplinary research is defined as “an integrative process whereby scholars and practitioners from both academic disciplines and nonacademic fields work jointly to develop and use novel conceptual and methodological approaches

92

II  Preparing for Public Health Leadership

that synthesize and extend discipline-specific perspectives, theories, ­methods, and translational strategies to yield innovative solutions to particular scientific and societal problems” (Stokols, Hall, & Vogel, 2013, p. 6). This interpretation of “transdisciplinary” notes the importance of including knowledge from nonacademic fields. The emphasis is on solving problems, rather than advancing knowledge for its own sake. More than in many other fields, then, public health leaders need to understand the potential contributions (and limitations) of other disciplines and nonacademic fields. Community-based participatory research in public health attempts to bridge the efforts of academics and nonacademics. Collaboration with clinical disciplines, particularly nursing, medicine, nutrition, and veterinary medicine, has a rich history in public health. Leaders in the field recognize the importance of considering genetics, biology, and other disciplines in developing knowledge to improve population health (Tarlov, 2008). Value-Laden A final key characteristic of public health science is that it is value-laden. In Chapter 1, we noted the strongly political nature of the field as a whole. The political nature results from the value conflict inherent in most population health issues. The claim that public health science is value-laden may seem ironic or counterintuitive, since science is often construed to be “objective” and “value-neutral.” But the applied nature of public health science, that is, as a means toward an end, inevitably raises questions about the allocation of public resources and the extent of government regulation and intervention. Legal and ethical issues abound in the study of virtually every public health topic, from surveillance to health education campaigns to control of epidemics to biosecurity (Gostin, 2010b). These issues are explored in Chapter 3. The mere choice to study a phenomenon is value-laden and, inevitably, the choice of variables to include in a study involves beliefs that are not valueneutral. Implications for prevention policy and practice introduce even more obvious issues of ethics and law. Beyond Public Health Science Knowledge of basic public health science is not enough as a basis for competency in public health leadership tasks. Effective mobilization of people, organizations, and communities for the long term requires knowledge about levers for changing people and institutions. The two key knowledge areas of understanding people and understanding



4  Knowledge for Public Health Leadership

93

complex systems are outlined next. Technically, people are complex systems, and understanding people could be presented as a subset of understanding complex systems. For presentation purposes, though, it is useful to separate out the first component (understanding people) because there is a deep base of knowledge on the psychology of individuals and guidelines for affecting individual-level behavior and attitudes, which are critical to public health leadership. We present examples of theory and applied knowledge that we have found useful in teaching or practicing leadership. Public health leaders seek usable knowledge, which typically means knowledge translated for use in social action rather than in research. For this reason, we focus on applications of knowledge about understanding people that can be used in leadership settings. Our coverage is necessarily eclectic. We seek to interest readers in the topic such that they delve more deeply into it and invest in it in their continuing education. We should note that it is difficult for applied researchers as well as practitioners (including ourselves) to identify fads and inappropriate applications of basic research, particularly in social science research. (By the same token, basic researchers may be reluctant or be unequipped to identify and endorse appropriate practical applications of basic research for fear that the evidence is not strong enough in purely academic terms.) Fads in knowledge are common in society in general and no less so in health care (Kaissi & Begun, 2008). Public health leaders should be alert to the pervasiveness of fads in applied knowledge and guard against using knowledge just because it is new and interesting, referring back to the need for evidence-based decision making. General guidelines for avoiding the lure of faddish knowledge include being cautious about applications that seem overly simplistic and make exaggerated claims of generality (Miller, Hartwick, & Breton-Miller, 2004). Still, curious people interested in growing their knowledge base can expect to make some mistakes on this front.

UNDERSTANDING PEOPLE There is no single scientific discipline of “understanding people.” It is an area of study within and across a variety of disciplines, with psychology perhaps chief among them. Scientists from a large number of other disciplines, including sociology, philosophy, anthropology, biology, history, and neurology, do research that impacts the understanding of “what makes people tick.” Study of art and literature and the humanities contributes knowledge as well.

94

II  Preparing for Public Health Leadership

Public health leaders face challenges in understanding and changing people on at least three fronts: their own behavior; the behavior of colleagues, employees, and coworkers; and the behavior of consumers and clients of public health programs. Understanding differences among people and understanding what motivates people is critical to engaging them in pursuing public health goals. Even better is to approach understanding with the goal of finding levers for energizing and promoting others. Author Maya Angelou states that “a leader sees greatness in other people. You can’t be much of a leader if all you see is yourself” (Beard, 2013, p. 152). Angelou’s sentiment is a good starting point for understanding others. Knowledge about oneself and others also underlies the skills generally referred to as “people skills,” or interpersonal skills. These skills enter into many different public health leadership competencies, such as enlisting others in one’s vision, building coalitions, and communicating effectively. Understanding people enables public health leaders to take full advantage of human potential. This is efficient as well as humane. It is efficient because programs, organizations, and communities perform best when human potential is maximized (O’Reilly & Pfeffer, 2000). We focus on two areas that are important to understanding and changing oneself and others: (a) motivation, particularly in the workplace, and (b) social and emotional intelligence. There are other ­topics important to understanding people, so these two may be viewed as ­representative in some way of the general category. As noted above, our coverage is eclectic rather than comprehensive, meant to illustrate the potential for relevant and usable knowledge.

Motivation The science underlying individual motivation comes from psychology, social psychology, and biology, among other natural and social science disciplines. This science, melded with decades of experience of leaders, yields several key insights that are important to public health leadership. These insights align around the importance of (a) intrinsic motivation, (b) goal-setting, and (c) equity/fairness. Intrinsic Motivation The study of motivation includes a distinction between intrinsic and extrinsic motivation. While the distinction is not crystal clear, it has traction through the years and is useful in application.



4  Knowledge for Public Health Leadership

95

Extrinsic motivation is motivation derived from somebody handing you something, whether it is a, “Good job, Jerry!” comment, a nice raise, a pay check and some fringe benefits, or a certificate for employee-ofthe month. Intrinsic motivation does not depend on input from external parties or events. The motivation comes from within and comes from the task one undertakes—the task is motivating by itself, independent of any recognition or reward. Both intrinsic and e­ xtrinsic motivation are important in understanding people. Individuals and managers use extrinsic motivation in every organizational setting. For example, the pursuit of higher income and ­recognition of position in an organizational hierarchy are prime movers in most economies. People with more money and higher position are often presented as role models. In all societies, a subsistence income (or provision of resources for subsistence) for individuals is necessary to even establish an ongoing program, initiative, or organization. Maslow’s (1954) hierarchy of needs, a well-known concept with limited scientific basis, expresses people’s understanding of this need for basic resources very concretely. Maslow’s hierarchy of five needs begins with physiological needs and safety and security needs, followed by love and belonging, self-esteem, and self-actualization. To motivate people, all of those levers are useful. Benkler (2011) notes the historical emphasis on the pursuit of one’s own interests in the United States, particularly in the discipline of economics, portraying the notion that humans are largely selfish (in a narrow sense—they pursue their own interests to the detriment of others’ interests). Benkler argues that newer findings in several disciplines (e.g., economics, political science, and neuroscience) are revealing that people are more cooperative and less selfish than most people believe, and that relying primarily on extrinsic motivators to motivate people is not effective. While extrinsic rewards are necessary (as we state above), “monetary incentives and material rewards can crowd out intrinsic behavior” (Benkler, 2011, p. 83). After a certain point, the effects of extrinsic rewards become shallower and fleeter, reflected by the saying, “A raise is a raise for a day, then it’s part of your salary.” In addition, some evidence suggests that using extrinsic rewards may reduce ­initial intrinsic motivation (Gagne & Deci, 2005). The alternative, Benkler argues, is an incentive system that relies on engagement, communication, and a sense of common purpose and identity—largely intrinsic motivators. A major advantage of public health work in the competition for workers is that public health work is intrinsically motivating for most practitioners. Many are willing to trade some level of extrinsic reward for

96

II  Preparing for Public Health Leadership

the intrinsic satisfaction that public health work provides. Commenting on the motivation of workers in the public sector, m ­ anagement scholars Pfeffer and Sutton (2007, p. 115) state that, “Because they are doing their jobs out of a sense of service and to make a difference, [people] often see more, not less, commitment and effort among public service ­employees.” Leaders in public health can appeal to and draw on this intrinsic motivation. They can reinforce it by recognizing and p ­ raising it. They can role model in their own work (e.g., by eschewing some of the material trappings of position, such as exclusive dining rooms, reserved parking places, or huge offices). A bottom-line implication for leaders, which we emphasize again in Chapter 5, is to leverage intrinsic motivation to the fullest. This does not denigrate the importance of extrinsic motivation (in fact, praise of intrinsic motivation is a form of extrinsic motivation). Public health work is valuable and deserves satisfactory extrinsic reward as well. Several additional threads in the motivation literature support the importance of intrinsic motivation and its value in bringing out the best in people (Fallon, Begun, & Riley, 2013). Building on Maslow’s hierarchy, psychologist Clayton Alderfer’s (1972) work asserts three categories of needs: existence, relatedness, and growth (therefore the labeling of his theory as ERG theory). Alderfer notes that individuals cycle among the needs, rather than proceeding through them in a hierarchy as Maslow’s theory posits. The workplace can contribute to satisfying human drives for social relatedness and for continuous growth. Herzberg’s (1968) research on job enrichment theory provides additional illumination, as he explained why some rewards that satisfy individuals do not really motivate extra effort from them. Such rewards, which include job security and salary and benefits, are labeled hygiene factors. A different set of rewards, referred to as satisfiers, generates extra effort from individuals. Satisfiers include responsibility, advancement, challenging work, recognition, achievement, and personal growth. The implication is that leaders should focus their efforts on improving those dimensions of work, known as job enrichment. Other researchers (Hackman & Oldham, 1976) express that five characteristics of jobs are particularly amenable to enrichment: skill variety, task identity, task significance, autonomy, and feedback. In public health work, task significance is generally high, and leaders can strive to create the conditions for meaningful work on the other dimensions as well. A final strand of relevant thought about workplace motivation is expectancy theory (Porter & Lawler, 1968; Vroom, 1964). The basic premise is that workers expect that their efforts will be rewarded.



4  Knowledge for Public Health Leadership

97

This requires that leaders ensure that they know what is going on in their units, programs, organizations, and communities, so that effort is noticed, tracked, and rewarded. This speaks to the importance of ­extrinsic reward—while intrinsic motivation may carry us a long way, we still want someone else to care. Better yet, if the rewards are ones we value, we work even harder. The three linkages among (a) employee effort and performance, (b) performance and reward, and (c) reward and satisfaction are all points at which managers and leaders can affect performance and get the best out of their employees and colleagues. Goal Setting Goal-setting theory (Latham, 2007; Latham & Locke, 2002) underlies many efforts to improve execution of public health and other programs, as it rationalizes a strong emphasis on the goal-setting process for individuals, programs, organizations, and communities. We stress the importance of this in competencies for public health leadership, particularly in Chapters 5 and 9. Relating goal-setting theory to motivation, the theory states that establishing appropriate goals for people helps to motivate them. Appropriate goals create points of focus for behavior and provide clear targets for performance. Appropriate goals are not vague appeals to “do good work” or “work hard,” on the one hand, and are not micro-level prescriptions for every action, written in stone, on the other hand. Two characteristics of appropriate goals are that they are jointly agreed upon by all parties and that they are challenging. Goals handed off or handed down absent involvement of the person who is carrying them out are unlikely to be pursued with great motivation. Goals that are not challenging are unlikely to bring out the best in people, and goals that are too challenging invite surrender rather than extra effort. Feedback on performance is a critical step in the ­goal-setting process, as well. Attention to monitoring, adjusting, and learning from efforts to achieve goals reinforces the importance of goals and joint investment in their attainment. Equity/Fairness Equity theory (Adams, 1965) identifies another important lesson in understanding people. Independent of other motivators, humans desire to be treated fairly—they care intensively about equity. They seek to be recognized and rewarded in ways similar to others who put forth similar effort. Of course, definitions of “fairness” differ among individuals, and some care more about equity in particular rewards than others.

98

II  Preparing for Public Health Leadership

This underlying trait of human nature relates to the value of social justice discussed in Chapter 3, where equity is applied to the distribution of social goods. It relates to the rising importance of the elimination of inequities in health outcomes and health care delivery access around the globe. Public health practitioners typically view health inequities to be a preventable injustice (CDC, 2013e). The belief in equity is also reflected in the “fair and just culture” movement in health organizations (Brunt, 2010).

Social and Emotional Intelligence Social and emotional intelligence roughly translates into the ability to understand and work effectively with interpersonal relationships and with people’s emotions, including one’s own. The use of the term “intelligence” is somewhat misleading, since intelligence can be defined as cognitive only, excluding such behavioral abilities. But it is clear that leaders benefit from an understanding of their own emotions and of the requirements for relating to others, whatever the label. One popular thread of applied knowledge in this arena was developed by psychologist Daniel Goleman and colleagues (Goleman, 1998, 2000; Goleman & Boyatzis, 2008). Goleman’s notion of emotional intelligence includes four capabilities, each with a specific set of competencies. The four capabilities are self-awareness, self-management, social awareness, and social skill. Self-awareness includes being able to read one’s own emotions and their impact on performance and others, the ability to realistically evaluate oneself, and self-confidence. Self-management involves self-control, display of integrity and conscientiousness, adaptability, initiative, and an achievement orientation. Competencies of social awareness include having empathy, building networks and navigating politics, and displaying a service orientation toward customers and clients. Competencies of social skill include developing others, influencing others, initiating change, communicating, managing conflict, building bonds, and teamwork and collaboration. The competencies of emotional intelligence mirror many of those stressed in this book. Another consultant and writer, Karl Albrecht (2006), argues for the importance in the workplace of social intelligence, defining it as “the ability to get along well with others and to get them to cooperate with you” (p. 3). He derives five dimensions of competence in social intelligence: situational awareness, presence, authenticity, clarity, and empathy. Emotional intelligence is viewed essentially as a necessary foundation for social intelligence. Again, Albrecht’s five dimensions



4  Knowledge for Public Health Leadership

99

echo many of the themes in this book. As with Goleman’s approach, Albrecht argues that leadership success is more likely if leaders possess a high level of social intelligence. These applications are not without controversy, particularly when claims are made of substantial impact on performance. The impact of variables largely outside of the control of the leader, such as resources available and consistency of the program or activity with cultural values, has to be recognized. However, many developing leaders find intuitive appeal in the notion that emotional and social competencies are important to leadership success, and they are competencies that leaders can improve on with learning and practice.

UNDERSTANDING COMPLEX SYSTEMS Scholars and practitioners in a wide variety of disciplines and application areas generally support the practice of “systems thinking” across a wide range of disciplines and applied arenas. As noted in Chapter 2, systems thinking has been endorsed as a key content area or competency by several groups of public health experts. What is systems thinking?

Systems Thinking Systems are groups of interacting or interdependent entities that form a unified whole, and “systems thinking” has been defined as “a general conceptual orientation [that is] concerned with the interrelationships between parts and their relationships to a functioning whole, often understood within the context of an even greater whole” (Trochim, Cabrera, Milstein, Gallagher, & Leischow, 2006, p. 538). Systems thinking has been characterized as forest thinking rather than tree-by-tree thinking. This highlights the importance of understanding the context of relationships in addition to the actual relationships (and in addition to the entities in the relationships). Systems thinking also has been differentiated as dynamic thinking rather than static thinking because it pushes people to consider the consequences of their actions over time (Richmond, 2000). Systems thinking has a distinguished history in a wide range of application areas (Jackson, 2003). Among the concepts of traditional systems thinking are system archetypes, or patterns that occur repeatedly in different settings. An example of a system archetype is “fixes that fail,” a common pattern in the treatment of health problems. In that archetype, a solution to

100

II  Preparing for Public Health Leadership

a system problem (a “fix”) creates an immediate positive effect, but delayed and often unintended consequences of the solution exacerbate the problem, causing the fix to fail in the long run. Treating population health problems with clinical interventions, such as treating kidney failure with dialysis, may be a short-term fix, but treatment costs and side effects of the treatment then create new problems for the health system as a whole. Dropping health insurance coverage due to its cost is a short-term fix to financial problems, which often creates even greater financial burdens in the long run, when illness and disability occur. Another common system archetype in public health (and other) organizations and programs is “drifting goals.” In that scenario, the organization lowers its targets for goals that it cannot reach. Continued poor performance then results in poorer and poorer levels of performance, as targets are reduced over and over again. A hospital’s goals for improved quality may not be reached, for example. The next year, it may announce a goal that is easier to reach. “Tragedy of the commons” refers to the exhaustion in the supply of a shared resource if individuals do not consider that the supply of the resource is limited and moderate their demands in response. As a result, the resource becomes less accessible, or it diminishes in quality. Overuse of insured health services “just because they are reimbursed” results in making health insurance less accessible for all. Systems archetypes can be depicted graphically, which many people find useful, using causal loop diagrams that portray cause-and-effect linkages within a system. They encourage thinking about changes that occur over time and about feedback effects. (Feedback is information about change that leads to further modifications.) Similarly, systems in general can be graphically represented by stocks, which are countable entities like employees, cash, and equipment; flows, which are the rates at which stocks change; variables that influence the level of stocks and flows; and delays. Again, graphical representations are useful for many people in visualizing change over time and effects of a change on other system components. One distinction made in systems thinking that many people find intuitively appealing is a distinction among systems that are simple, complicated, and complex (Glouberman & Zimmerman, 2002). The distinction is not without controversy (Morell, 2013), but it is helpful to some as it applies to public health issues. Simple issues are high on consensus about the nature of the issue and its solution. Simple issues are resolved by assessment of fact and response based on established practice (Snowden & Boone, 2007, p. 70). Complicated issues have



4  Knowledge for Public Health Leadership

101

either low consensus on the nature of the issue or low certainty about ­cause-and-effect linkages, such that compromise, negotiation, ideological control, or incremental changes are needed to resolve complicated issues. Solutions may be equally “good.” Complex issues are low on both certainty about cause-and-effect and consensus. Complex issues are characterized by many competing ideas, no clear right answer, and the need to learn as patterns emerge (Snowden & Boone, 2007). There are pressures on researchers, practitioners, and policymakers to define problems as simple or complicated and to implement solutions accordingly. But if the problems are actually complex, the solutions do little to address the problem. (The practical point of distinguishing complex issues from simple and complicated ones is similar to the point of distinguishing between technical and adaptive issues, discussed in Chapter 2.)

Focusing on Complex Adaptive Systems Applications of systems thinking are relatively straightforward when applied to simple and complicated systems. Contemplating the interrelationships between parts of a system becomes most relevant to public health leadership when the components of those systems include people and organizations. People and organizations often behave in unpredictable ways, and behavior of the systems is therefore emergent, as the response of one individual or organization is dependent on the response of another, and so on. Aggregates of such interrelationships often become complex adaptive systems—aggregates of multiple, heterogeneous agents that are dynamic, massively entangled, emergent, and robust (Begun, Zimmerman, & Dooley, 2003; Eoyang & Berkas, 1998). Van de Ven (1999) has referred to the “buzzing, blooming, confusing world of organization and management theory,” a description that captures this complexity as it applies to theorizing about organization. Change in complex adaptive systems is often nonlinear—changes in outcomes are not (linearly) proportional to the size of changes in inputs—in particular, small changes in variables can have huge system-wide impacts and large changes can have small impacts. Robust systems are able to alter themselves in response to feedback, resulting in high levels of resilience. This is often referred to as “self-organizing.” We suggest that an emphasis on understanding complex systems pushes systems thinking to a level of value-add that can help distinguish public health knowledge. Understanding simple and complicated systems is critical as a foundation for understanding complex systems, but it is arguable that any system studied in public health is a complex

102

II  Preparing for Public Health Leadership

one, if only because humans are part of the system. Certainly with populations of humans, complexity is increased. With interest in change over time, complexity is increased. Major examples of studies that rely heavily on systems thinking and are relevant to public health leadership include the pioneering work of environmental scientist Donella Meadows and colleagues (Meadows, Randers, & Meadows, 2004), first published in 1972, which used computer modeling of systems to explore the interactions of industrialization, pollution, food production, population, and resource depletion over time. Her posthumous primer on systems thinking (Meadows, 2008) details the type of thinking that characterizes much of public health. The WHO sponsored a major review of systems thinking concepts and their application to improving the design and performance of health systems around the globe (de Savigny & Adam, 2009). Among the purposes of the report is “to make the case for a broader systems thinking approach in an easily accessible form for a broad interdisciplinary audience” (p. 35). The report notes the need to identify leverage points in systems where small investments will have large payoffs (something not easily achieved!). Notable is the report’s emphasis on links between causes of health problems and the funding mechanisms and public policies of countries. Further applications and an endorsement of the systems thinking approach for global health improvement are presented by a group of public health scholars (Swanson et al., 2012). A third major example of the use of systems thinking in ­public health is a “transdisciplinary” study of tobacco control and public health s­ponsored by the National Cancer Institute (2007). The study examines the interconnections among international, national, and local governmental agencies; individual advocacy groups; ­ ­ policymakers; health care professionals; nonprofit foundations; and the public, based on a view of tobacco control as comprised of several largely self-­ organizing systems. Changing the complex adaptive system of tobacco use requires ­facilitating and empowering its parts to encourage greater self-organization. The study explores the use of systems modeling and network analysis to better understand the challenges and solutions. Other scholars and practitioners have endorsed the expanded application of systems thinking in public health research and practice (Leischow & Milstein, 2006; Leischow et al., 2008; Resnicow & Page, 2008; Zimmerman, 2011). Among research strategies suggested are greater use of modeling and network analysis (Begun & Thygeson, 2014; Institute of Medicine, 2011b, p. 9; Keane, 2014; Sterman, 2006) and more community-based participatory research (Green, 2006). Among practice



4  Knowledge for Public Health Leadership

103

strategies suggested is greater use of intersectoral coalitions, networks, and collaboratives to address population health issues (Hargreaves, 2013). A “Complexity Science Knowledge Synthesis” produced by the Core Public Health Functions Research Initiative of the University of Victoria, British Columbia (Martin et al., 2012), identifies a host of resources valuable to developing and applying an understanding of complex systems in public health. Understanding Complex Systems—Summary Like the knowledge area of understanding people, the area of understanding complex systems is broad, emergent, and fascinating (or not) in different ways to different people. As with the area of understanding people, public health leaders should be open to the growth and application of knowledge in this area, as well as being cognizant of the potential for exaggeration and fads (Paley, 2010). As understanding of complexity grows over the years and decades, it will be energizing and valuable for public health leaders to be in the forefront of that understanding. CHANGING PEOPLE, ORGANIZATIONS, AND COMMUNITIES To put an understanding of people and complex systems to use in leadership settings, a focus on changing people and changing complex systems is appropriate. Thus, another way of using the knowledge base for leadership is by focusing on how to change individuals, organizations, and communities. It is useful for leaders to consider themselves as students of change and to pursue an understanding of change as a goal for lifetime learning. In doing so, leaders will encounter much of the foundational knowledge on understanding people and complex systems that is partially described above. Like the literature on understanding people and complex systems, the literature on change leadership and change management is vast, rapidly accumulating, and subject to the same cautions (e.g., it is young, and experimental methods are rarely used to advance knowledge). Familiarity with that body of knowledge will help leaders approach their work with a stronger evidence base and more options for accomplishing leadership work. Beyond an understanding of traditional approaches to managing change (Thompson, 2010), leaders can expect the tools for leading and managing change to improve as experience and innovation grow. For example, Westley, Zimmerman, and Patton (2007) probe the social innovation process using concepts from complex

104

II  Preparing for Public Health Leadership

adaptive systems. Another example of innovation in the change literature is the “positive deviance” approach to leading change in the face of intractable and complex problems. Positive deviance attempts to identify solutions that are “hidden in plain sight” in the sense that they are already being achieved by a small portion of people or units in an organization or social system (Pascale, Sternin, & Sternin, 2010; Singhal, Buscell, & Lindberg, 2010; Suchman, Sluyter, & Williamson, 2011). Those solutions are “discovered” by people within their own contexts, rather than imposed from the outside, such that implementing and sustaining the solutions are more likely. Positive deviance was first used to address childhood undernutrition in Vietnam, with remarkable success, and has been applied to a variety of other settings around the world. CONCLUSION Public health leadership benefits from a strong knowledge base in public health science and an understanding of people and complex systems and how to change them. Public health science knowledge is evidencebased, dynamic, prevention-focused, transdisciplinary, and value-laden, and those characteristics shape the nature of public health leadership. As the evidence base in public health science and understanding of people and complex systems improves, leaders will integrate it into their work in order to most effectively mobilize people, organizations, and communities to effectively tackle tough public health challenges.

part iii

Competencies for Public Health Leadership

In each of the next five chapters we cluster five related competencies into leadership “competency sets.” The five competency sets are invigorate bold(er) pursuit of population health; engage diverse others; effectively wield power; prepare for surprise; and drive for execution and continuous improvement. The umbrella framing of the five clusters is our way of trying to “go upstream” in public health fashion to identify common leadership roots that apply to the longer, more granular lists of skills and practices often found in competency frameworks. In each chapter we apply the framework introduced in Chapter 2, first highlighting the public health leadership values, traits, and knowledge that contribute particularly to effective performance of the competency set. Then each of the five competencies in the competency set is examined in turn. While many of the 25 competencies covered in this section certainly apply more generally across sectors other than public health, we suggest dimensions or applications that are specific or at least especially important to public health leaders. Multiple experiences of the authors and of public health leaders and programs are featured to demonstrate application of the competencies in the field.

chapter 51

Invigorate Bold(er) Pursuit of Population Health

key terms 100,000 Lives Campaign Affordable Care Act autonomy brand competencies courage credibility flow flywheel Healthy People 2020 hedgehog concept intrinsic motivation

mission persistence Prevention and Public Health  Fund reliance on evidence social justice Triple Aim United Nations Millennium  Project vision Winnable Battles

A

s expressed in Chapter 1, a fundamental premise of this book is that there are critical gaps between public health’s potential and its current performance that leaders can address. Public health leaders have been pursuing an agenda of improvement for decades. The field of public health has a broad agenda with a wealth of aspirational goals,



107

108

III  Competencies for Public Health Leadership

including those articulated by the United Nations and in the Healthy People 2020 document in the United States. The United Nations Millennium Project, for example, delineated eight aspirational goals to pursue from 2000 to 2015, including reductions in child mortality, improvements in maternal health, and combating HIV/AIDs, malaria, and other disease (United Nations, 2013). Eighteen targets and 48 indicators were selected to monitor progress. A sample target is to reduce the under-age-5 mortality rate by two-thirds between 1990 and 2015. The rate dropped by 41% between 1990 and 2011, but is falling short of the two-thirds goal. Success stories include a reduction in mortality rates from malaria by more than 25% between 2000 and 2010 and substantial declines in tuberculosis mortality. In the United States, public health leaders have articulated core functions and essential services and forged consensus on performance standards for public health agencies and programs. Healthy People 2020 provides a set of goals and objectives with 10-year targets designed to guide national health promotion and disease prevention efforts to improve the health of all people in the United States (U.S. DHHS, 2010, p. 2). It aims to enable “healthy people in healthy communities” through a small set of high-priority health issues such as access to health services, clinical preventive services, mental health, oral health, and social determinants. Within 12 areas, 26 leading health indicators are identified to support the vision of “a society in which all people live longer, healthy lives” and assessed across four broad, cross-cutting foundational health measures including general health status, disparities and inequity, social determinants of health, and health-related quality of life and well-being (U.S. DHHS, 2010, p. 5). The Centers for Disease Control and Prevention (CDC) has identified high-priority “Winnable Battles,” based on the magnitude of problems and the ability to address them, in the areas of food safety, teen pregnancy, motor vehicle injuries, and seven other areas (CDC, 2013a). In the area of teen pregnancy, for example, a baseline rate of 37.9 births per 1,000 females aged 15 to 19 in 2009 is targeted for a 20% reduction by 2015. Public health leaders don’t lack knowledge of what drives population health, or ideas for what to do to improve it. However, given the historic marginalization of the field, leaders may tend to declare victory when they win even minor funding increases or policy victories, despite what the evidence suggests is really needed (usually multiples of what gets funded). The field needs a more seismic shift in health policy and public health practice—a bolder agenda—and more success at turning knowledge and ideas into sustained action.



5  Invigorate Bold(er) Pursuit of Population Health

109

There are particular opportunities for public health to play a more central role in the nation’s health policy in the United States. At the federal level, the Affordable Care Act (ACA) of 2010 finally begins to frame the objectives of the health system in a more holistic and costeffective way, linking health care access and quality with a more robust prevention agenda to focus on health outcomes for individuals and the public. Beyond the ongoing political drama around the ACA, state-level reforms and changes already underway in the private market also seek to reward those activities that most cost-effectively improve health— emphasizing not only value-based care, but also the broader perspective of community health, including social determinants. In what should be a friendlier policy climate, public health has critical tools to show the way to the Triple Aim of better care for individuals, better health for populations, and lower per capita costs. But there are no guarantees that this time will be different. Early experience with the ACA’s Prevention and Public Health Fund (PPHF) is all too familiar—it’s last to be funded, and first to be cut. The PPHF started as an $18.75B (billion) mandatory funding stream dedicated to improving U.S. public health between the fiscal years (FYs) 2010 and 2022, with $2B annual amounts planned beyond 2022. In February 2012, President Obama reduced the PPHF by $6.25B between FYs 2013 and 2021, with further reductions in March and April 2013. Those reductions brought the PPHF down to less than 50% of the planned FY 2013 amount of $1.25B, with reductions to public health programs and services such as community prevention, mental health, and health equity (American Public Health Association [APHA], 2013). “Defund, repeal, and replace ObamaCare” continues to be a rallying cry for many in the conservative political sphere. Deficit reduction proposals from both sides of the aisle almost invariably include cuts to the PPHF, even complete elimination in some cases. Why is it that public health leaders haven’t been able to more effectively sell prevention as a core, bipartisan strategy to reduce health care spending and therefore the budget deficit? What can public health leaders do differently to take best advantage of these opportunities and avoid repeating a disappointing history? This first group of competencies is about setting or resetting the fundamental direction for a public health activity or an enterprise. Successful leaders don’t just wish their way to action. They envision a different future, rally the troops, develop a sound plan, and assure the capacity exists to execute it. Whether at the level of a community, an organization, or an initiative, setting the agenda is something leaders have a unique ability and responsibility to do. Ineffective leadership also has a particular ability to derail a project or an entire organization.

110

III  Competencies for Public Health Leadership

In this chapter, we explore the leader’s work in setting the agenda— including articulating vision and mission—and inspiring and supporting others to pursue it. VALUES AND TRAITS Several values and traits of public health leaders are especially relevant to invigorating the pursuit of bolder agendas for public health efforts. Social Justice As discussed in Chapter 3, social justice means different things to different people, but its essence, according to Gostin and Powers (2006), is to focus attention on “the fair disbursement of common advantages and the sharing of common burdens.” By working to achieve overall improved well-being through health while prioritizing those with the greatest need—the “twin moral impulses” in the language of Gostin and Powers—public health is executed through the lens of social justice. This value is basic to the public health agenda and to a bolder public health vision. Strong action to pursue social justice drives the passion of many in the field of public health. U.S. culture particularly celebrates individual rights, responsibilities, and achievements. U.S. health policy reflects this with an almost singular focus on outcomes at the individual level. The social justice value recognizes that community outcomes are an equal concern, and compels a leader to keep pushing for a different balance between individual and population perspectives. Reliance on Evidence Reliance on evidence drives a leader to critique what’s working and not working, and to challenge entrenched practices rather than accepting the way things have always been done. This is particularly important given the resource constraints with which leaders always deal. The need to focus on priorities is obvious in times of budget deficits, which are predicted to challenge all levels of government for the foreseeable future. But it’s equally true even in good budget times, since there are always more ideas of what could be done than there are resources to do them effectively. Author JM was fortunate to work in state government at a time of economic surplus and ability to invest. Her boss, Governor



5  Invigorate Bold(er) Pursuit of Population Health

111

Ventura, often said he thought it was harder to figure out where to spend more money than where to cut it, since long-funded programs tend to go on autopilot and may lose impact.

Courage and Persistence To pursue bolder agendas, leaders need to think bigger and not accept limits. Some leaders in public health have evolved low expectations for achieving respect and power. This may be understandable given how little credit the field gets for its many accomplishments, but it’s not particularly effective. Leaders can acknowledge the long odds that the culture and economic incentives array against public health, but they also need to believe that very different policy and programmatic outcomes are possible. The very definition of “bold” connotes willingness to try new and unproven things, to take unpopular stands, and to risk failure. This is a common trait among successful public health leaders, in part because failure in a political sense is often dramatic and fast, while success in population-based improvements is often invisible or materializes years after the leader has left the stage. The willingness to hang in there when the heat is on is one of the characteristics that separate the memorable leaders from the forgettable ones. The changes needed to have healthier people in healthier communities are deeply cultural, likely multigenerational, and require policy and political changes that are not fast and often frustratingly impermanent. This means leaders must be able and prepared to take the long view in setting agendas. We see examples of those who have done so and persevered through ups and downs, including political swings, featured in many of the In Practice cases throughout this book. As a case in point of several of these values and traits, consider New  York City (NYC) Mayor Michael Bloomberg (see Chapter 7, In Practice 7.2 for a profile of this public health leader’s work). During his tenure, Mayor Bloomberg received national attention—and often significant political pushback locally and nationally—for his intense focus to reduce preventable diseases through ordinance-based community health initiatives, including public smoking bans, trans fat bans and required display of calorie counts in restaurants, size limits on the sale of sweetened beverages, building code changes to encourage people to take the stairs, and the first-ever proposed surveillance system for chronic and infectious diseases. Interestingly, NYC residents now live almost 3 years longer compared with national averages and prior

112

III  Competencies for Public Health Leadership

local measures. Although not solely attributed to aggressive efforts by the Mayor and the NYC Board of Health (including Commissioners Dr. Thomas Frieden and Dr. Thomas Farley), there is food for thought in Mayor Bloomberg’s sentiment that they “must be doing something right” (El-Naggar, 2013). KNOWLEDGE Public Health Science We commented above on the importance of using evidence on the effects of public health interventions to embolden leaders to push for bolder agendas. Use of evidence draws on the basic science of public health, which includes studies of the social determinants of disease and health outcomes. The evidence is increasingly clear that population health will not be materially improved unless there is significantly greater attention to social determinants. Bolder pursuit of population health includes embracing the social determinants of health perspective laid out in Chapter 2. This broadens both the content of the agenda for public health organizations and the range of stakeholders and partners beyond the more familiar territory of detection and containment of infectious diseases or environmental risks, or education on health behaviors. As the evidence becomes clearer and stronger on the value of public health interventions, leaders should be empowered to reach further. Therefore, current knowledge of public health science is critical to this competency set. Understanding People The knowledge base of understanding people is also directly related to invigorating pursuit of a bolder agenda for public health organizations, particularly as it relates to inspiring others and enrolling them in a common purpose. Reliance on intrinsic motivation is a key to this inspiration, as is knowledge of best practices in building and leading teams. The “science of teams” is a young field that is drawing more attention as clinical care and management decisions are increasingly made by groups of diverse professionals and patients, rather than by individuals. Most health care teams underperform, and leaders can benefit from the growing knowledge base on teamwork competencies and the role that leaders can play in promoting cultures of teamwork, supplying key resources to support teams, and engraining teamwork in organizational structure and strategy (Mosser & Begun, 2013).



5  Invigorate Bold(er) Pursuit of Population Health

113

Understanding Complex Systems The understanding of complex systems gives leaders an appreciation of the need for both planning and continuous adaptation to environmental changes. The systems-thinking archetypes introduced in Chapter 4, for example, allow leaders to visualize long-term consequences of their organization’s actions. Planning under conditions of uncertainty requires preparing for different scenarios and building flexibility into the means of achieving a given mission or vision, and even reconceiving the mission and vision. In rapidly changing environments, bold leadership is needed to push organizations out of their traditional paths (Brown & Eisenhardt, 1998). Scholarship on complex systems is providing a greater understanding of how to balance the wish for certainty with the reality of uncertainty. FIVE COMPETENCIES FOR INVIGORATING BOLD(ER) PURSUIT OF POPULATION HEALTH To invigorate a bolder public health agenda, what must a leader do well? We emphasize five competencies, summarized in Table 5.1. Table 5.1 Five Competencies for Invigorating Bold(er) Pursuit of Population Health 1 Critically assess the current state of your organization or program •  Understand stakeholders’ needs •  Objectively assess the organization •  Clarify core competencies 2 Articulate a more compelling agenda •  Listen first •  Make vision and mission concrete, in powerful words 3 Enlist others in the vision and invigorate them to drive toward it •  Leverage intrinsic motivation •  Build credibility •  Speak and write effectively •  Turn the work over 4 Pursue the vision with rigor and flexibility •  Meet the tests of a solid plan •  Learn and adapt 5 Marshal the needed resources •  Resources include funding, people, technology, political support, and brand •  Use partnerships

114

III  Competencies for Public Health Leadership

Critically assess the current state of your program or organization Stated more bluntly, leaders must first “face reality.” It’s not unique to public health, but leaders have a tendency to believe their own press releases and to talk mostly to others who see the world the same way they do. Leadership author and organizational consultant Jim Collins cites this as one of the critical steps in the transformation of “good” organizations to “great” ones. He writes that you must “confront the brutal facts, yet never lose faith” (Collins, 2001a, p. 65). Heifetz and colleagues state that the leader’s job is to confront reality, and make the organization and its people do so, creating and managing a productive level of tension required to make change (Heifetz et al., 2009). Whether leading an organization, a team, a community, or an initiative, a leader must understand stakeholder needs; objectively assess the organization (or team, program, or community); and clarify the organization’s core competencies. We examine each of these in turn. Understand Stakeholders’ Needs Before launching initiatives, leaders need to spend time developing or updating their understanding of stakeholders’ needs, whether these stakeholders are those served by a particular program or are a whole community. Especially in the context of the social determinants of health, a leader needs to cast the net increasingly broadly to first identify and then engage with the issues and potential contributions of an expanding range of stakeholders, a competency further explored in Chapter 6. Objectively Assess the Organization Objectively looking at the performance of one’s organization in comparison with benchmarks and best practices, and assessing strengths and weaknesses, is a second step in confronting reality. This can be really tough, especially given the pride that organizations develop in what they are currently doing. Objectively examining performance entails several steps: 1. Discerning the most critical outcomes, based on mission and current stakeholder needs 2. Identifying benchmarks and best practices, or where to find them 3. Taking a clear-eyed view of not only current performance but also the likelihood of being able to attract and apply the necessary resources to improve performance if it is lacking



5  Invigorate Bold(er) Pursuit of Population Health

115

Clarify Core Competencies A third and equally difficult step is pushing to clarify and perhaps narrow the core competencies of the organization or program. Clarifying core competencies is hard because it tends to be easier for the component parts or programs of an organization to define their identity and purpose by the unit rather than by the overall organization and its mission. For example, as further described in In Practice 5.2, at Courage Center in Golden Valley, Minnesota, an expansive mission—“Courage Center encourages people with disabilities to realize their full potential in every aspect of life”—gave rise to the creation of 70 different programs over the years, and the very breadth of the programs became part of the Courage Center “brand.” But it also became a weakness, in that the Center had many small, niche programs that lacked the critical mass for economic viability and made technical excellence hard to maintain. The competency of critically assessing the current state is similar to Collins’ (2001a) advice to find an organization’s or team’s “hedgehog concept.” The rather odd name comes from the parable of the crafty fox and the simple hedgehog. The fox keeps coming up with new ideas to eat the hedgehog, but the hedgehog handily defeats the fox every time by doing its one trick: rolling into a thorny ball. An organization’s hedgehog is described by Collins as the intersection of three circles in a Venn diagram: what it is deeply passionate about, what it can be the best in the world at, and what drives its economic or resource engine (a notion beyond “profit” in the public and nonprofit sectors). Collins stresses that figuring out the hedgehog is enormously hard work and usually takes a lot of time to get right—perhaps after several false starts, and that it is fundamentally a process of discovering what each of the three circles is at their essence, and what happens at the intersection. He is clear that the hedgehog concept itself isn’t a strategy or a plan to succeed; rather it is an understanding of what an organization can ­succeed at. An example of a public health organization wrestling with “defining its hedgehog” is Casa de Esperanza (House of Hope), St. Paul, Minnesota (Sandfort, 2006). Founded in 1982 as a shelter for battered women of Latina descent, the organization quickly attracted large proportions of its clientele from Anglo, African American, and Hmong women seeking a safe haven. Over time, its identity shifted from a Latina organization to a multicultural battered women’s organization. Its 1987 mission statement read: “Casa de Esperanza is committed to providing a safe, supportive environment in which women and their children can heal, affirm their own strengths, regain control of their lives, examine their situation and make their own decisions.” As the organization grew and matured, it continued to face questions over whether to serve a general public or to focus on Latinas.

116

III  Competencies for Public Health Leadership

Eventually, the organization settled on its Latina focus, as reflected in the 2002 mission: “Mobilize Latinas and Latino communities to end domestic violence.” Its website stresses that “We are a Latina organization—in both staffing and approach. Our Board of Directors is 80% Latina, and our staff is 72% Latina. All our work is grounded in Latina realities” (Casa de Esperanza, 2013). Casa de Esperanza found its hedgehog. Chapter 9 returns to the theme of rigorously focusing one’s agenda in order to achieve excellence. In particular, the accreditation movement for public health departments in the United States aims to make agencies figure out whether they really have the essentials to assure basic public health protections, or whether they need to make changes, including considering other organizational forms. Articulate a more compelling agenda The first competency for invigorating pursuit of a bolder agenda speaks to the process of assessing the current state to identify what may need to change in the way an organization’s goals and plans are defined and executed. This second competency is about setting a new, bolder agenda— starting with mission and vision—in a context that inspires action. Listen First Vision doesn’t just spring from the head of the leader and get imposed on the followers through force of will. In order to take hold and last, mission and vision must be grounded in the shared values and aspirations of an organization and its people. A new leader is well advised to take time to listen and learn where the passions and strengths of a community, organization, or team lie, not come in and declare a new plan in the first 30 days. As a newly appointed state health commissioner who had never worked in governmental public health, author JM knew she had a lot to learn. Despite being asked almost immediately by agency staff and outside partners, “What’s your agenda,” her response was, “We need to figure out what our agenda is, but I do know we want to build the visibility and influence of the Department.” Agency staff told her later that they were engaged and heartened by that approach. Make Vision and Mission Concrete, in Powerful Words While the process of generating concrete mission and vision statements feels like a proverbial “sausage-making” exercise to many, its importance cannot be downplayed. Vision relates to the high-level values



5  Invigorate Bold(er) Pursuit of Population Health

117

and goals of the organization—in essence, what the organization hopes to accomplish through its efforts. Vision should focus on the future in terms that are broad enough to capture what the organization believes in and seeks to achieve, yet are concise and clear. Mission has an outcomes orientation that speaks to what, how, and for whom the organization does its work, again presented in concise and clear language (Foundation Center, 2013; Nagy & Fawcett, 2013). Kevin Starr (2012) of the Mulago Foundation challenges social sector organizations to “cut to the chase” and develop an eight-word mission statement, including “a verb, a target population, and an outcome that implies something to measure” or, as Nagy and Fawcett (2013) recommend, vision and mission statements should be “short enough to fit on a T-shirt.” Most literature on the subject speaks to a collaborative process, often facilitated, with input from the organization and those whom the organization serves. Nagy and Fawcett (2013) outline a simple framework that provides a good baseline for public health leaders: learn what is important to the beneficiaries of your organization’s work; determine the primary focus of your organization; develop your vision and mission statements; confirm your statements with your organization and its beneficiaries; and share your statements within and outside your organization. While admittedly an oversimplification of the effort, a key point is that vision and mission statements are intrinsic to an organization’s values, purpose, and goals— the challenge is to distill those elements into clear and compelling words and communicate them succinctly and repeatedly. At another extreme, though, organizations can become fixated on refining and fine-tuning their mission and vision statements, time that would be better spent living the mission and vision (Crutchfield & Grant, 2012, p. 34). Enlist others in the vision and invigorate them to drive toward it Are you leading if nobody follows? A vision is compelling only if people want to go there. Constituents seek visions that reflect their own aspirations and portray how their hopes will be fulfilled (Kouzes & Posner, 2009). Inspiring people to want to go in a given direction takes effective communication, an underlying skill embedded in this and many other leadership competencies. Leverage Intrinsic Motivation Communicating effectively requires knowing your audience and speaking to what matters to them. Anchoring the content of your messages and delivery in values and purpose is key. In public health, leveraging

118

III  Competencies for Public Health Leadership

intrinsic motivation is important. Daniel Pink (2009, p. 10) speaks to our deeply human, “ . . . innate need to direct our own lives, to learn and create new things, and to do better by ourselves and our world” as “Motivation 3.0.” Pink posits that the 21st-century world has moved beyond extrinsic (“carrot and stick”) motivation for most activities and now requires us to find intrinsic rewards, an approach supported by evidence-based science. This requires a reliance on three core elements: autonomy over time, task, team, and technique; mastery in one’s work that provides challenges matched to our abilities; and purpose as an aspiration and guiding principle of our work. Pink’s transformational approach to improving our own and others’ satisfaction and performance offers great promise for public health leaders. As discussed in Chapter 4, significant monetary or similar extrinsic rewards are not usually available to motivate people who do public health work. “Motivation 3.0,” based on intrinsic rewards, draws upon what Csikeszentmihalyi calls “autotelic experiences” (Greek for “self” and “goal or purpose”) or, more simply, “flow” (Pink, 2009, p. 111). Csikeszentmihalyi’s research shows that people’s most satisfying experiences occur during the mental state of flow, in which they are simultaneously autonomous and engaged, with a balance of focus and satisfaction that provides its own rewards. Flow requires that the challenge a person faces is neither too easy nor too difficult. Smart organizations, Pink explains, can use the concept of flow to provide employees with the balanced, “Goldilocks tasks”—neither too difficult nor too simple—and create a work environment that “affords employees the freedom to sculpt” their own jobs to add flow to everyday duties (Pink, 2009, p. 113), including in the social sectors. This form of intrinsic motivation works well in the people-oriented, budget-constrained world of public health. More broadly, leaders can work to create meaningful experiences not only for those within their organizations, but for supporters of the organizations, converting them to “evangelists for the cause” (Crutchfield & Grant, 2012). They can do so by telling compelling stories, creating experiential opportunities for supporters, recruiting well-known individuals, and creating connections among supporters. Build Credibility Acting in accord with personal values makes you genuine—it creates credibility. Credibility can’t be faked, at least not for long, or through the predictable duress that comes with leadership. Kouzes and Posner (2012b) argue that credibility is the key to leadership. Covey (2004) bases



5  Invigorate Bold(er) Pursuit of Population Health

119

his personal improvement program on developing individual credibility as well. This is why we suggest in Chapter 3 that if you aren’t personally in tune with the values of public health as a field, it will be hard to lead successfully. Building credibility and trust is a skill. You do it by taking time to learn, admitting mistakes, taking responsibility, and demonstrating that you have lines you will not cross. Many leaders seem to fear that admitting mistakes creates vulnerability for their ability to direct others. However, the reverse seems more often to be true—people are more willing to accept feedback and course corrections from leaders who have demonstrated the humility to benefit from that themselves. The proverbial “line in the sand” can be about organizational values, regulatory responsibilities, and personal and professional behavior. Particularly in politically appointed jobs, if a situation arises in which you as the appointee are asked to alter your position on a public health issue to better align with that of an elected official, it can be very useful for you to let your boss know, respectfully and first privately, that you will not compromise on science or the agency’s duty to protect p ­ ublic health, even if that means your resignation or firing. Your agency should know that you are willing to take such a stand if necessary as a general rule. Public health professionals value science and technical competence, so a leader needs to be credible in these domains. If not an expert yourself, you must at least be respectful of the expertise of those you hope to lead, and demonstrate to them your interest in learning. Author JM found that going into the field with the public health sanitarians, laboratorians, epidemiologists, and others to observe their work first-hand was not only fascinating, but essential to building relationships and credibility with the agency. JM not only came from outside the field but also was not a physician or scientist. Still, the staff knew she was truly interested in their work and eager to understand it. What she lacked in academic preparation, JM tried to supplement with learning from them. Speak and Write Effectively Leaders benefit from developing skills in persuasive communications. Verbal and written communications with impact are clear, illustrative, and tend to convey and evoke emotion. According to Anderson (2013, p. 125), “presentations rise and fall on the quality of the idea, the narrative, and the passion of the speaker. It’s about the substance, not speaking style or multimedia pyrotechnics.” Similar guidance applies to written

120

III  Competencies for Public Health Leadership

communications: convey ideas through strong and substantive narrative that demonstrates your passion for the subject. This is especially true in the social sector: “ . . . who sets the narrative and how they set it has great power. It impacts who cares about an issue, what they hear, and what they are willing to do” (Friedenwald-Fishman, 2012, para. 1). Remember to frame the message and tell a story through your communications. Most audiences connect better with a story told as a journey with a beginning and an end (Anderson, 2013), as well as one in which core elements such as plot, theme, and moral are evident (FriedenwaldFishman, 2012). Above all, be sure to keep at it—whether written or oral communications—because most people do improve with practice. That means write and speak often to learn what tone and content are most effective with various audiences and subjects. For speeches, if you have the sufficient time to practice, memorize the material by rehearsing sufficiently so that the flow of words becomes second nature—without underestimating the amount of time and work required to reach this point (Anderson, 2013, p. 123). Turn the Work Over We end the discussion of enlisting others in the vision by highlighting the need to engage and inspire teams to be willing to own the plan, make or endure often uncomfortable change, and go through the extra work usually entailed in switching from one path to another. The competencies embedded in adaptive leadership, described in Chapter 2, are critical here. Koh and McCormack (2006) use medical and public health examples to contrast technical and adaptive work. A physician setting a broken bone is applying a technical fix to a technical problem, where both are clear. In adaptive work, neither the problem nor the solution is clear, and new learning is required if something other than a temporary band-aid is to be offered. Covering the uninsured, dealing with violence, or ending homelessness are offered as examples. They posit that public health usually deals with adaptive challenges. Indeed, their premise holds given that health disparities, childhood obesity, and other current public health priorities require adaptive work in a social determinants framework. Heifetz and Linsky (2002, p. 6) call out the need for those leading adaptive change to resist the urge to do too much, but rather to “place the work where it belongs.” In the case of public health, the work of making sustainable changes in people’s health behaviors and the community conditions that influence them is clearly adaptive in nature, and belongs with the sectors and groups that make up the community itself.



5  Invigorate Bold(er) Pursuit of Population Health

121

The competencies in this and subsequent chapters bolster this kind of leadership. In Practice 5.1 details the development of the 100,000 Lives Campaign, led by Dr. Donald Berwick. Berwick succeeded in articulating a more compelling mission and vision around quality in care delivery (Competency 2), and enlisted and invigorated others to drive that vision forward (Competency 3)—a model for public health leaders to follow.

in practice 5.1 100,000 LIVES CAMPAIGN MAKING THE CASE FOR QUALITY Widespread quality improvement has been elusive in health care. Despite groundbreaking efforts by the Institute of Medicine (IOM) in the late 1990s and early 2000s to advance the cause of health care safety and quality, by 2004, the state of quality improvements in the United States fell short of expectations by leading health care quality advocates, including the Institute of Healthcare Improvement (IHI); the Centers for Medicare & Medicaid Services (CMS); the Agency for Healthcare Research and Quality; the Veterans Administration; The Leapfrog Group; and related governmental, professional, and quality improvement organizations (Berwick, Calkins, McCannon, & Hackbarth, 2006). Donald M. Berwick, MD, MPP, FRCP, the former head of CMS, used his leadership position as President and CEO of IHI to undertake a bold initiative modeled after a political campaign and adopted, “Some is not a number; soon is not a time” (Berwick et al., 2006)—like a standard political campaign slogan—to communicate the vision of an accelerated rate of quality improvement gains in health care. On December 14, 2004, Dr. Berwick announced his organization’s goal to realize his vision of a healthier, safer patient population in 18 months: improve safety and effectiveness of key hospital interventions to save the lives of 100,000 patients who would not have survived their hospital stay without changes to the current health care system (Berwick et al., 2006). This goal of 100,000 lives was based on IOM estimates of approximately 98,000 deaths annually caused by medical injuries in U.S. hospitals, with another 2 million patients annually suffering from hospitalacquired infections (IHI, n.d.). Despite the health care industry’s extensive efforts and occasional successes to reverse the troubling outcomes, a more concerted campaign was necessary in the eyes of Dr. Berwick and his colleagues pushing for national quality standards and goals.

Six Core Interventions The IHI invited hospitals and other health care providers to actively work to implement one or more of a set of six evidence-based standards set by leading ­quality-improvement and government entities and adopted by the 100,000 Lives

122

III  Competencies for Public Health Leadership

Campaign. With a goal to reduce harm and eliminate unnecessary deaths, the following standards were promoted (Berwick et al., 2006; Governance Institute, 2006; IHI, n.d.): • Deploy Rapid Response Teams—use critical care personnel who normally staff the code teams, such as physicians, nurses, and respiratory therapists, to drive care changes to prevent the need for their critical interventions when patients suffer cardiac arrest. • Deliver Reliable Evidence-Based Care for Acute Myocardial Infarction (MI)— apply well-known cardiology guidelines to prevent deaths from acute MIs. • Prevent Adverse Drug Events (ADEs) Through Medication Reconciliation— acknowledge that ADEs are most common during patient transitions, such as transfers between care units or discharge to home, and implement the process of intentional clinical review of patients’ medication orders before and after transition to prevent or immediately correct any errors or discrepancies. • Prevent Central Line Infections—use evidence-based guidelines from the CDC to reduce infections through a five-step “bundle” of central line care practices. • Prevent Surgical Site Infections—follow comprehensive CDC guidelines for pre- and postoperative care and surveillance to reduce the risk of surgical site infections. • Prevent Ventilator-Associated Pneumonia—implement evidence-based guidelines for a “bundle” of services to reduce serious complications for patients receiving mechanical ventilation. These recommendations were drawn from and expanded upon quality improvement and care guidelines from partner organizations, specialty medical societies, and relevant government agencies, providing participating providers with six “highly feasible interventions” (Berwick et al., 2006; McCannon, Schall, Calkins, & Nazem, 2006) to improve patient safety and outcomes.

Sharing the Vision Communication of the vision of the 100,000 Lives Campaign was framed around the concept of a successful political campaign that sets goals and deadlines to ensure the election is won: “Some is not a number; soon is not a time.” The campaign model allowed the IHI to drive thousands of U.S. health care facilities toward the common goal of improved patient care, rather than rely on the incremental and isolated improvements that characterized the uptake of the IOM’s earlier recommendations (McCannon et al., 2006). By establishing a numeric target and specific (albeit arbitrary) timeline for the IHI campaign, Dr. Berwick challenged health care organizations across the United States to join him in setting a bolder agenda of quality improvement (Berwick et al., 2006; IHI, n.d.). Over 3,000 of the 5,759 U.S. hospitals participated voluntarily, representing 75% of available beds and 80% of hospital discharges in the United States during the period (Berwick et al., 2006; Governance Institute, 2006).



5  Invigorate Bold(er) Pursuit of Population Health

123

The Results and the Path Forward On June 14, 2006, Dr. Berwick announced at the IHI’s annual international summit that “the hospitals reduced mortality rates and saved more than 122,000 lives in many different ways and the Campaign is a player in that process.” Estimated lives saved ranged from 115,363 to 148,758, based on three independent data analysis groups, with 122,300 (±2,074) lives the reported final number. Data were reported by 86% of hospitals, with 33% of these participants adopting and reporting all six interventions (Governance Institute, 2006). Dr. Berwick cautioned that the six interventions of the 100,000 Lives Campaign were not the only reason for the reduced mortality, measured by a comparison of monthly deaths during the campaign period to the same month in 2004 (Berwick et al., 2006; Governance Institute, 2006). Yet he credited the Campaign as a major contributor to “a big change in the country in terms of safety and outcomes in health care,” with several ingredients for a successful campaign outlined in Dr. Berwick’s speech (Governance Institute, 2006): get goals; get bold; get together; get the facts; get to the field; get a clock; get the numbers; and get the stories. These factors provide a framework for a public health leader to successfully set a bolder vision and invigorate others to drive toward it.

Pursue the vision with rigor and flexibility An old proverb declares, “A vision without a plan is just a dream. A plan without a vision is just drudgery. But a vision with a plan can change the world.” Planning is a specialized skill set and many people make careers out of the process. While it’s not necessary for a leader to be an expert in planning processes, leaders should know what makes a good plan versus a poor one. Good plans have some key characteristics, as follows: ■■ ■■ ■■

■■

■■

Good plans include goals, objectives, assignments, and measures. Good plans are internally aligned—the consequences for units and subunits are recognized, resourced, measured, and monitored. Good plans have been vetted with key stakeholders, beginning with the members of the organization or team who are responsible for carrying it out. Good plans are dynamic—they are periodically revisited and altered with changing times and changing circumstances (Begun & Heatwole, 1999). Under some conditions, good plans are quite fluid, because “overplanning” locks into place decisions that may hold back the organization or program as its new future reveals itself. Good plans are believable—the team can see a path to get to the shared bold vision, and it’s clear how you’ll know if you’re succeeding. Clear measurements also help guide course corrections when needed.

124

III  Competencies for Public Health Leadership

Chapter 9 deals further with related competencies to drive for execution and continuous improvement as plans are pursued. It’s important to reiterate that good plans are not rigid plans, but those that encourage learning and adaptation. One characteristic of flywheels, used by Collins (2001a) to visualize the process of going from good to great, is that they are initially hard to turn. It takes significant and sustained effort to get the crank turning. But once it does, the flywheel gathers momentum that builds upon itself. In an organizational context, sustained effort behind initial success fuels further success to catapult the organization to a new level of performance. Those organizations lacking the clarity of the hedgehog or a good plan to pursue it instead experience a “doom loop,” where the initial resistance of the flywheel provokes frequent changes in direction, or fruitless searches for a “home run” or a miracle to change the organization’s trajectory all of a sudden. As we have stated, much of the leader’s task is facilitating others to take ownership of setting and achieving a bolder agenda. However, the responsibility of avoiding the doom loop—making hard choices among priorities—does rest primarily with the leader, working with either the elected officials or board of directors to whom he or she reports. There are a range of styles leaders can use in making such decisions, and the most effective style will be tailored to the situation—whether the organization is facing an emergency or is simply in a period of reflection and renewal. In Practice 5.2 illustrates a hard choice made in the case of the Courage Center, Golden Valley, Minnesota, during the tenure of author JM as its CEO.

in practice 5.2 COURAGE CENTER’S DIFFICULT CHOICE OF A NEW PATH For decades, the Courage Center has been one of Minnesota’s largest providers of medical rehabilitation and social services for people with disabilities. Author JM was privileged to serve as its CEO from 2005 until its merger in June 2013 with the Sister Kenny Rehabilitation Institute. This case describes how a venerable community institution confronted an unsustainable business model and made a decision driven by its mission and vision to trade organizational independence for the prospect of greater impact in a different structural form.

A History of Innovation and Success The Courage Center story began in 1928 when a group of parents concerned with educational access formed the Minnesota Society for Crippled Children. The words “and Adults” were subsequently added to the name. From its advocacy roots, the



5  Invigorate Bold(er) Pursuit of Population Health

125

Minnesota Society for Crippled Children and Adults (MSCCA) expanded into programs and services to fill the unmet needs of children and adults with disabilities who previously had very little chance to participate fully in school, work, or civic life. The signature program of the MSCCA from the 1940s through the 1960s was Camp Courage, thought to be one of if not the first accessible residential camps in the United States where children and adults with disabilities could come for an experience that for many redefined expectations for their lives. The impact the organization observed from working with campers for a week challenged it to develop programming to serve people in many other ways—from adaptive sports and recreation programs offered year-round, to a preschool for special needs; inpatient and outpatient physical, occupational, and speech therapies; a variety of supports for independent living; and vocational rehabilitation. When the MSCCA built a major facility to house its expanded programming in the early 1970s, the organization’s legal name was changed to Courage Center. This breadth of programming intentionally went well beyond medical care and embraced a much fuller agenda to improve the quality of life. With this expansive purpose and its commitment to innovation on behalf of a historically underserved population, Courage Center became a trusted and critical resource for people with disabilities, their families, community advocates, and policy makers. It was a catalyst in changing community norms and building a whole network of services with other organizations that have substantially reduced the barriers faced by people with disabilities in “realizing their full potential in every aspect of life”—which has for many years characterized the organization’s mission. It earned a great reputation and became a “fixture” in Minnesota’s social service fabric. The corporations, foundations, and citizens of Minnesota generously supported this work through their philanthropic gifts. Courage Center was one of the first and largest charitable organizations in the region, and it pioneered many strategies for raising funds that have since been emulated and expanded upon by nonprofits that have started since.

Confronting an Unsustainable Economic Model In the beginning and for many years, Courage Center’s work was funded entirely by philanthropy since its services predated Medicare, Medicaid, and the rise of comprehensive health insurance models. Although more recently the majority of the organization’s funding did come from reimbursement for services from public and private health insurance plans and other sources, virtually none of its programs were financially viable without continued philanthropy. This was due to a combination of factors: the underfunding of these basic services in health care financing models (a problem all too familiar to most social services agencies and primary care providers); the organization’s service mix—it historically offered only underreimbursed therapy and primary care services and none of the profitable services like high-technology imaging or surgeries; and a mission-driven zeal to offer services and programming beyond the reimbursable services in order to produce more fundamental and longer-term gains in health and independence. The underlying financial structure of the organization fell shorter over time, both through growth in numbers of people served and stagnant or falling payment rates. The pressure

126

III  Competencies for Public Health Leadership

on philanthropy increased, with the need to fundraise for a larger and larger share of the budget each year. That became increasingly difficult, given the proliferation of nonprofits in the environment and as disability came to be seen as “yesterday’s priority,” or even ironically as a “solved” societal issue given the progress generated by the good work of Courage Center and its many community colleagues. The multiyear recession that began in late 2008 was almost the perfect storm, causing a simultaneous drop in the value of the organization’s invested assets; a big drop in annual charitable giving; and significant cuts in eligibility, covered services, and payment rates from public and private health plans and state and county contracts.

A Strategic Framework for Needed Decisions Against this backdrop, the CEO suggested that the organization was at a critical “fork in the road” and needed to deliberately chart a new course. The Board of Directors engaged in a deep review of the organization’s mission, vision, and strategies. Literally everything was debated. The mission and vision were endorsed as enduring, but clarity was added on how the vision would be “operationalized.” Values were refreshed. The board adopted four strategic pillars for the organization’s work and set outcome targets it would review over time. Management’s role was then to propose annual priorities and budgets within that framework. The ­single-page strategic framework adopted in 2009 (portrayed in Figure 5.1) replaced the more traditional lengthy strategic plan document, and it served the organization well by more sharply defining aspirations and methods.

Calling the Question Just having a new strategic framework, however, did not solve the conundrum of the Center’s financial model. Over the next several years, it did help the board and management ask the right questions about how the goals could best be achieved in a challenging and rapidly changing health care and social services environment. The board decided to tolerate annual operating losses but set a timeframe for fundamentally changing the business model. In late 2011, the management team brought forward an analysis that suggested that the only way to do so in a reasonable period of time was to choose between two distinct courses: (a) spin off the health care services to another larger provider and go forward as an independent entity with a focus on only the nonmedical quality-of-life programs, plus policy and advocacy (essentially, this would be going back to the organization’s earlier roots); or (b) seek a merger partner who would commit to keeping the full continuum of services intact, and in so doing give up independence and control. Very soon after this fundamental choice was posed by the CEO to the board, Sister Kenny Rehabilitation Institute’s system parent, Allina Health, approached Courage Center to discuss a merger. Allina’s reasoning was that the competencies of the two leading rehabilitation organizations in the Twin Cities area were highly complementary—with Sister Kenny’s strengths in the more acute phases of rehabilitation immediately postinjury or postillness, and Courage Center’s strengths in ongoing rehabilitation and a broader set of health and wellness programming to



5  Invigorate Bold(er) Pursuit of Population Health

127

Figure 5.1  Courage Center strategic framework, 2009.

Mission (why we exist) To empower people with disabilities to realize their full potential in every aspect of life Values (what we believe in and how we conduct ourselves) Clients as partners

Integrating Mind/Body/Spirit

Quality and Innovation

Accessibility

Integrity

The Generous Spirit

Financial Stewardship

Diversity

Vision (where we are going and what we want to be) Courage Center’s vision is that one day, all people will live, work, learn, and play in communities based on their abilities, not disabilities. To further this vision, in service to people with functional impairments, by 2020 we will: -Change community norms and public policies to remove physical and attitudinal barriers so that all people can fully participate in community life. -Be nationally recognized as an innovator in rehabilitation and health and wellness services. -Partner with others to build a seamless continuum of services that supports health. health Strategy (our game plan for achieving the vision) Innovate and drive Engage in transformaDeliver best-in-class Lead in public change through tional resource services that result in policy regarding outcomes-based development to attract health care and social research and by optimal health and significantly more independence for our conditions affecting serving as an expert people with functional resource on functional financial resources to clients. pursue these goals. impairments. impairments. Strategic Outcomes and Measures (how we will measure our success—See Dashboard) Client growth, satisfaction, and improved outcomes

Organizational health and sustainability

Improved services and innovation

Learning and growth (internal environment)

Annual goals set by Management

Reprinted with permission of Allina Health, Minneapolis, Minnesota.

help maintain optimal functioning over time. As well, Allina Health was positioning for a future of Accountable Care Organizations, where requirements and rewards will demand a broader continuum of services. After a year of negotiation and due diligence, the CEO and a working group of the board recommended the full merger of Courage Center with Allina Health. While it reflected the best judgment and recommendation of the CEO and top leadership team, it was a decision only the board could make, and that critical distinction of roles between leader and board was vital to respect. As fiduciaries, the board members had to wrestle with the most fundamental questions of how best to safeguard a vital community asset. At the final board meeting, at which they approved the merger, board members spoke eloquently about the importance

128

III  Competencies for Public Health Leadership

of being able to sustain and take to a broader scale the kinds of innovations and impact for which Courage Center has been known, and the potential for this specific merger to serve the community even better. The Courage Center and Courage Foundation boards literally chose the mission over the form of the organization. Their choice was brave and hopeful. Courage Kenny Rehabilitation Institute began operating on June 1, 2013, as the nation’s fifth-largest and most uniquely comprehensive such system.

Marshal the needed resources Funding is of course key to an agency’s or organization’s ability to achieve its mission, but so are people, technology, and “brand.” Funding It’s critical that public health leaders understand the specific and unique funding streams of their own organization or program. The fact that public health activities are funded in such a myriad of inconsistent ways is part of the field’s challenge, a subject that calls for national and global leadership. Our focus here is on marshaling financial resources at a more local level. Each leader needs to understand his or her organization’s particular mix of government appropriations, fee-based revenues, grants, and contracts from other governmental agencies or private health care organizations, and philanthropy from foundations, corporations, and even individuals. Understanding and critically assessing the sustainability of the funding mix is a key part of the “face reality” competency discussed earlier. Developing and executing ­strategies to strengthen the funding picture is a critical task for leaders, further explored in Chapter 9. Crutchfield and Grant (2012) note that fundraising is highly integrated with the mission and strategies of almost all nonprofit organizations that seek to mobilize for social change. Some organizations seek government funding, some seek to build a base of passionate contributors, some go to the business community, and some solicit foundations, depending on their distinctive mission and strategy. Successful organizations are able to diversify their revenue base over time in order to reduce reliance on single sources of funding. They also must be able to raise capital funds to invest in infrastructure, such as information systems and physical space. Crutchfield and Grant (2012) also point out that successful social change organizations can have huge impacts with small budgets. Having a clear and focused vision and mission help



5  Invigorate Bold(er) Pursuit of Population Health

129

keep the needed resource base attainable and manageable. By the same token, financial largesse does not guarantee success. Collins (2006) urges public- and social-sector organizations to be disciplined about to which resources they say “yes” and to which they say “no.” Rejecting resources that drive an organization away from its hedgehog helps assure focus on the main thing. Many a public health leader can tell stories about the tendency for their organizations to try to secure new funding because it’s there, only to be left with an unsustainable program when the funding priority of the federal agency or foundation or private sector partner from whom the original support came shifts to the next new thing. Given the long-term nature of most public health initiatives and the predictable ebbs and flows of political and funding support, effective marshaling of resources also requires continual assessment of effectiveness and reprioritization of money and effort. This is a form of stewardship further discussed in Chapter 9. People Every organization needs people with the right skill sets to do the work well. Note this is predicated on being very clear about what the right work is, as discussed throughout this chapter. Beyond technical skills, a leader also needs to assure that the organization has the right mix of types for effective teams. This is critical for both innovation and execution, as explained in Chapter 4 on the critical knowledge base for leadership. In the governmental and nonprofit social sectors, the leadership imperative to attract and retain exceptional people is sharpened by the fact that they could almost without exception make considerably more money in the for-profit or large nonprofit health care delivery realms. Knowing how to most successfully engage people in a high purpose—a bolder agenda—is essential. Technology Few segments of the needed resource base are changing as fast as technology. A good technology platform is increasingly basic to any organization’s ability to function in today’s world. For public health, there is an added challenge and opportunity: how to best gather, organize, and connect the right information to improve population health, while protecting the information for both data integrity and critical privacy concerns. With all the changes happening in both public health and health

130

III  Competencies for Public Health Leadership

care, this requires a fundamental redesign of information systems and how they interface. Redesign of information systems takes both money and the right people and organizational competencies, much of which is realistically beyond the reach of many governmental and nonprofit public health organizations on their own. The inability of the Courage Center to address its technology gaps on its own was another driver for the merger decision profiled by In Practice 5.2. Political Support As further developed in Chapter 7, political support—both organizational and legislative—is also a resource that leaders have a unique ability and responsibility to build and use effectively to leverage all of the other needed resources. Brand The value of a clear and positive brand is no less important in the public and nonprofit sectors than it is in the commercial world. In fact, a public health organization’s strong brand is absolutely fundamental to the leader’s ability to marshal every type of resource listed above. Protecting and further building that brand equity is another critical role for the leader. In the Courage Center case, the strong brand of the organization was without question one of the key reasons the partner organization initiated the merger conversation in the first place. Use Partnerships Acquiring and sustaining all the needed resources described earlier increasingly requires attracting partners rather than going it alone. Public health leaders especially need to face the reality of structural public sector budget deficits and the depth of political divides at all levels, both of which seem likely to persist for some time. Marshaling resources through partnerships is a competency set unto itself, further explored in the next chapter.

CONCLUSION Effective leadership is hard work. Just having a certain role or title—be it Commissioner, Department Head, Section Chief, hospital or health plan or agency CEO, or Project Leader—does not guarantee impact.



5  Invigorate Bold(er) Pursuit of Population Health

131

Alignment with values gives the leader needed energy and compels him or her to put in extraordinary effort. The leader applies knowledge and skills to read the environment, discern a compelling and clear course that people want to follow, and give them enough of a roadmap while knowing that ownership must fundamentally be the leader’s. “Followers” experience this as the leader supporting them, seizing the moment, and doing what is needed to be done to take an organization/ community/initiative to the next level. They feel invigorated to expend their own extraordinary effort to help set and achieve bigger goals and broader impact. Ed Ehlinger, long-time local public health leader and Minnesota Health Commissioner as this book is written, paraphrasing British industrialist Geoffrey Vickers (1958, p. 600), often says that “Public health is the continual redefinition of the unacceptable” in the human condition. This means that resetting bolder public health agendas is a constant task. That doesn’t happen without skillful and intentional leadership.

chapter 6

Engage Diverse Others in Public Health Work

key terms business organizations Camden Coalition collaboration community health assessments community self-determination complexity science continuum of collaboration cultural competence empathy health inequities Health Impact Assessment (HIA)

hot-spotting integrity interdependence public health partnerships respect reputational risk Roadmaps to Health self-determination social justice strength of weak ties SWOT analysis

I

t’s self-evident that no one agency or sector alone can bring about public health’s broad vision of “healthy people in healthy communities” (U.S. Department of Health and Human Services, 2010). Public health has the unique statutory charge to protect public health, and public health leaders need the broad perspective and skills to act as convener and facilitator to bring together the stakeholders to pursue this and similar expansive visions.

133

134

III  Competencies for Public Health Leadership

Some scholars and practitioners cite the building of coalitions or enlistment of stakeholders as the most important leadership competency in public health (Porter & Baker, 2005a, p. 1). But as much as most public health leaders would agree this is core to their jobs, it is the exceptional leader who truly does it well. The challenges are sometimes obvious and sometimes subtle. Koh and Jacobson (2009, p. 200) refer to the “relentlessly broad and interdisciplinary nature of the field . . . [which] can lend a cacophony of voices to often sensitive and delicate decisions.” As understanding of the interconnectedness of health and community conditions grows, so must our ability to bring together ever-more diverse coalitions. NATURE OF COLLABORATION Collaboration differs from other types of interdependent relationships, which can be imagined as steps along a continuum of “Cs”—like cooperation or coordination. Table 6.1 describes these as five steps, from least involved (communicating) to most involved (collaborating). At the beginning of an attempt to build a collaborative, it’s important to have an accurate sense of where a group of prospective partners is in reality on the continuum from communicating to collaborating. Often, prospective partners will actually be competing—for influence, scarce resources, and credit. If a leader doesn’t understand the realities of the participating organizations, it’s awfully hard to frame a new shared vision compelling enough to move beyond that point. Doing so is perhaps the key to the public health leader’s role in enlisting the needed broad variety of stakeholders in a sustained effort to address the social determinants of health. Table 6.1 The “C” Continuum of Collaborationa 1 Communicating—willing to share information, likely because of shared interests in the external environment and desire to be “good neighbors” 2  Consulting—asking for opinions, advice that may or may not be followed 3  Cooperating—starting to take joint actions, like lobbying together 4 Coordinating—starting to plan and make decisions influenced by each other, like agreeing to increase referrals among programs 5 Collaborating—decisions made by the group; shared ownership and responsibility; mutual risks and rewards a

This table builds on the work of Himmelman (2002).



6  Engage Diverse Others in Public Health Work

135

Across the United States, almost all state and local government budgets have been structurally in deficit for most of the last decade. For most units of government at any level, health and human services spending is a primary driver of spending and is increasing substantially faster than other areas of spending or revenues. The resulting budget cuts year after year have pitted parts of the health care and human services communities against each other—each lobbying to “cut the other guy and spare me”—at the very time they would ideally be rallying together around a social determinants perspective. Unfortunately, the governmental public health sector has taken some of the deepest cuts of all, further eroding its capacity to think bigger and longer term about how to rally the community to a broader vision of health. This is the conundrum public health leaders must face head on. Doing so requires a fundamental shift in approach—the building of broader coalitions with entirely new players, and the embrace of true collaboration. Author JM participated in a public health leadership institute course in which faculty member Arthur Himmelman discussed how misunderstood and overused the term “collaboration” really is. Himmelman made a memorable point—that collaboration at its core is about those who have power giving it up voluntarily, which is very hard (to say the least) when most leaders have spent their careers finally getting power. Giving up power voluntarily is very rarely done. Another fundamental element of collaboration—sharing risk—makes giving up control even more difficult (Himmelman, 2002). An example comes from the study of health disparities. Awareness of health disparities has been growing for many years. More recently, eliminating inequities has emerged as one of the top public health priorities in most states and communities and many countries. As a matter of both efficacy and public health values, addressing inequities requires working with affected communities, as part of the community, not working on them as removed technical “authorities.” An opportunity for public health leaders is in daring to ask, if communities more directly controlled the resources typically spent on their behalf through professional agencies, how might they prioritize investments differently? Minnesota’s Eliminating Health Disparities Initiative (EHDI) was designed by the Minnesota Department of Health (MDH) in 2001 following publication of a groundbreaking report by MDH on the social and economic determinants of health. Because of that report, the EHDI took an unusual approach at the time, giving grant funding directly to community groups for programs they wanted to work on, rather than giving the funds to local public health agencies to design the programs

136

III  Competencies for Public Health Leadership

with community input. One of the earliest grantees, the Cultural Wellness Center (CWC), and its founder Atum Azzahir, are profiled in the In Practice 6.1 case.

in practice 6.1 THE CULTURAL WELLNESS CENTER: RECONNECTING CULTURAL COMMUNITIES WITH HEALTH Demonstrating respect for diverse cultures is important in collaborative public health work. Respecting a culture’s practices to regain and achieve health is a feature of the philosophy of a visionary public health leader, Elder Atum Azzahir. The Cultural Wellness Center (CWC) was founded in 1996 by Elder Atum as President, Executive Director, and Elder Consultant in African Ways of Knowing to serve the Powderhorn and Phillips neighborhoods in South Minneapolis. Each day the CWC lives out its mission “to unleash the power of citizens to heal themselves and to build community” through “cultural approaches for positively impacting health and health care, economic development, and community building” (CWC, n.d.) for the diverse people in its neighborhoods.

A Community Approach to Health With community knowledge positioned at the forefront of these efforts, the CWC encourages individuals to address sickness and disease on the community, cultural, and personal levels, incorporating harmony, health, and heritage for a holistic approach (Azzahir & Barbee, 2004; CWC, n.d.). The People’s Theory of Sickness and Disease, which “identifies and explains the health problems of community members expressed through purposeful, direct and in-depth dialogue” is core to the CWC’s philosophy (Azzahir, 2010, para. 3; CWC, n.d.). According to Elder Atum, “the People’s Theory supports the knowledge, experiences, values, attitudes, meanings, traditions and systems that influence health behavior or how health happens through culture and community” (Azzahir, 2010, para. 4).

Incubating Traditional Ways of Healing in Diverse Communities The CWC is Minnesota’s first nonprofit organization founded to engage cultural communities in reclaiming traditional ways of healing through the process of study and documentation of their unique experiences with sickness and disease. “Cultural communities” or “communities of color” refer to predominantly non-European American (i.e., non-White) neighborhoods; the South Minneapolis neighborhoods served by the CWC historically include African American and Native American people, with increasing populations of Latin Americans, Asian Americans, and new African immigrants. Elder Atum, who refers to herself as an “African in America,” partnered with Janice Barbee, a woman of European



6  Engage Diverse Others in Public Health Work

137

American heritage, to start the CWC, drawing upon a shared recognition that generations of Americans—especially those of non-European American descent— have lost the collective capacity to support each other in community. Loss of traditional ways and support systems contributes significantly to sickness and “dis-ease” in these communities and the CWC “incubates” or nurtures initiatives to help its residents heal from this loss of culture, community, and family connections; overcome barriers; and restore traditional ways as resources for health, such as language and birthing practices (Azzahir, 2010; Azzahir & Barbee, 2004; CWC, n.d.).

Shifting the Focus to Harness the Cultural Knowledge for Health The CWC evolved directly out of Elder Atum’s community organizing efforts in South Minneapolis from 1994 to 1996 that revealed to her that the African American community was not the only cultural group suffering from a deep sense of “disconnectedness and aloneness” (Anderson, 2011, p. 50; Azzahir & Barbee, 2004, p. 49). This awareness encouraged her to provide direction to efforts to alleviate these communal losses for “great people of heritage,” including Native, Mexican, and Hmong American people (Azzahir & Barbee, 2004, p. 49). Internalized and institutional racism were frequent topics during pre-CWC workshops. The CWC, however, took these feelings of “despair and sadness” and emphasized culture and cultural resources instead, focusing on knowledge to build up community members’ healing and recovery (Anderson, 2011, p. 50). Elder Atum recognized that the loss of community and culture made people sick, and she wanted to provide solutions to help people learn how to get and stay well. This awareness led to the creation of a community caregiving system, including “elders, aunts, uncles, friends, neighbors, and cultures” (Anderson, 2011, p.  51) forming “organic care systems” that allow and require people to take personal responsibility for their health (Azzahir & Barbee, 2004, p. 52) in conjunction with Western health systems and practitioners. In this way, Elder Atum believes a community care system can function alongside the health care system to “help redefine research and . . . consider prevention approaches based on cultural knowledge systems” (Anderson, 2011, p. 51).

Giving Voice to Community Members to Remove Barriers A fundamental technique used early in the CWC development and underlying its many successful initiatives is the Community (or Citizen) Health Action Teams or CHATs (Azzahir & Barbee, 2004; CWC, n.d.). Through a highly active process of sharing thoughts and concerns about the barriers within community and society to health and wellness, diverse cultures and people engage together to create solutions through community engagement, dialogue, listening, collaboration, and compromise (Azzahir & Barbee, 2004). These CHATs have evolved into “study groups and cultural community circles who research and organize to work on a particular topic of importance to the whole community’s health and well-being” (CWC, n.d., p. 2).

138

III  Competencies for Public Health Leadership

Another core technique incorporated into the CWC model is respect for community elders and mentors. This traditional approach to social support and knowledge transfer is an effective way to help cultural groups maintain or remake their state of “being-ness,” especially new immigrants to the United States. In addition, the wisdom and networks of those rooted in the community are tapped through elder advice councils, “anchor families” within neighborhoods, and birthing and mothering circles, for example (Azzahir, 2010; Azzahir & Barbee, 2004; CWC, n.d.). Guiding the philosophy and initiatives within her community and creating recognized models of community-initiated health is Elder Atum Azzahir, an “African in America” woman who has used her own people’s adversity and discrimination to bring the power of tradition and collaboration to cultural communities to heal, recover, and care from their own barriers to health and well-being, to “go beyond surviving to thriving, creating, and giving” (Azzahir & Barbee, 2004, p. 60).

VALUES AND TRAITS Engaging diverse others draws on several values that are at the heart of public health practice, particularly social justice, interdependence, respect, and community self-determination. Helpful traits for engaging diverse others are the traits of integrity and empathy. Social Justice As pointed out in Chapter 3, the value of social justice gives fundamental direction to public health work. Given mounting evidence on health disparities, a growing focus of public health leadership must be on assuring equal opportunities for good health across diverse populations, with attendant policy focus on resource distribution. A commitment to social justice drives public health leaders to work outside their own comfort zones to enroll diverse others in pursuit of public health goals. Integrity, Respect, and Empathy All the values and traits that contribute to a leader’s authenticity and ability to engage people—especially integrity, respect, and empathy— are useful in establishing relationships. Empathy encourages the leader to learn about and involve those affected by a public health issue or program. Personal relationships based on integrity and respect are forces



6  Engage Diverse Others in Public Health Work

139

that hold collaborative activities together for the long run, through crises and challenge. Leaders who develop strong personal relationships with their colleagues in partner organizations put the collaborative in a better position for success. Community Self-Determination Appreciation for communities’ rights of self-determination is an “a-ha” moment for many new public health leaders. One of the most profound lessons author JM learned as state health commissioner relates to the importance of communities themselves defining the problems and solutions. For years, public health leaders noted with alarm the fact that Minnesota’s teen pregnancy rate among African American girls was the second highest in the nation, at the same time that the rate among White teens was the lowest in the nation. When the EHDI was passed, teen pregnancy was one of the issues targeted for intervention. Elder Atum Azzahir, profiled above, very gently but firmly said something very close to this: Jan [note: not “Commissioner”], it is not for you to decide whether or not this is a problem in our community. We value having babies at a young age. Only we can decide that this is depriving our children of other important opportunities in life, and only then, what we want to do about it. This exchange powerfully influenced JM’s understanding of the community’s perspective, and the design of the grants program. Similarly, successful engagement and collaboration with tribes on the health of Native Americans in the United States must recognize not only their cultural values (for instance, the sacred use of tobacco in some tribes) but also the status of the tribes as sovereign nations. Respect must be given both to their legal standing and to the centuries of broken legal agreements between the Native nations and the U.S. government.

Interdependence A belief in the value of interdependence as a starting point for accomplishing public health work promotes a collaborative interpersonal and managerial style. Leaders who believe in interdependence proactively

140

III  Competencies for Public Health Leadership

seek out as partners those individuals and organizations who will be influential and who will be influenced by the work at hand. Real interdependence requires that partners respect each other as the starting point in any relationship. Respect for all and for differences leads to embracing diversity not just because it’s a demographic reality and necessary, but as inherently valuable for genuine solutions, and for countering group think. Koh and McCormack (2006, p. 110) call such respect “honoring.” This includes familiarity with working through ethical dilemmas inherent in public health issues and approaches that may be seen very differently by different stakeholders. Values and beliefs about the acceptable balances of rights and responsibilities, and freedoms and limitations, differ among communities, and those differences are surfaced in public health collaboratives. KNOWLEDGE Public Health Science The knowledge base for engaging diverse others includes the basic public health science that establishes the social determinants framework. Such knowledge drives the leader to encompass the range of interdependent, multiple upstream causes of public health problems. As Gostin et al. (2004, p. 104) point out, more traditional discrete public health interventions “cannot create the conditions to promote and protect the public’s health because they do not attend to the underlying causes.” In this sense, following the emerging evidence on social determinants continues the best tradition of public health by always searching for root causes and working further and further upstream. Understanding People The importance of understanding people, particularly their diversity and motivation, cannot be overestimated as a basis for this competency set. Appreciation of the differences among individuals is a basis for listening, empathizing, and engaging others. Knowledge about the cultural affiliations of individuals is another key area of knowledge, where culture refers to the common values, beliefs, and experiences that shape the way that individuals in the culture understand the world. In that sense, individuals belong to many different cultures, including those based on race, ethnicity, religion, gender, sexual identity, national origin, illness and disability, age, and profession. Knowledge about the beliefs,



6  Engage Diverse Others in Public Health Work

141

values, and practices of different cultures strengthens one’s ability to understand others. Similar knowledge about different occupations and professions strengthens the leader’s ability to work with diverse professionals in collaboratives. Simply put, knowledge is a powerful force for the appreciation of diversity. Understanding Complex Systems The science of complex systems reveals the importance of relationships among agents in a system, in the emergence and evolution of those systems. Complexity science has been described as the science of relationships, because it is the interaction among agents in a system (relationships) that creates new system properties that cannot be predicted by knowledge of the independent agents alone. “The whole is more than the sum of its parts” is a straightforward expression of the importance and dynamic nature of relationships. One relevant finding about relationships in complex systems is labeled “the strength of weak ties,” which denotes that weak relationships among individuals or organizations can still have strong causal effects (Granovetter, 1973). Being connected to potential partner organizations, however superficially, can provide an opening for working with those partner organizations in deeper ways. Being aware of and having contact with potential partners is a first step in engaging diverse others. Public health collaboratives are complex systems that share some common characteristics (e.g., relatively diverse membership, highly motivated by common purpose, often resource-poor), and evidence on the best practices of public health collaboratives is accumulating. We refer to some of that evidence in identifying principal competencies below. As that science develops, it will be another important arena for public health leaders to follow. FIVE COMPETENCIES FOR ENGAGING DIVERSE OTHERS The competency set for engaging diverse others covers broad ground— from deep engagement with geographic, cultural, racial, and ethnic communities, to cross-sector collaboration to confront classical p ­ ublic health issues in new ways as well as to broaden our approach to addressing the social determinants of health. We identify five specific competencies required to practice the kind of collaborative and integrative leadership described in Chapter 2 in a public health context. The competencies are listed in Table 6.2. As noted above, the public health

142

III  Competencies for Public Health Leadership Table 6.2 Five Competencies for Engaging Diverse Others in Public Health Work

1 Assess local conditions in ways relevant and credible to the local stakeholders •  Devote attention to variation and diversity in addition to central tendencies •  Make sure data sources are seen as valid by the community 2  Search widely for the right partners •  Who has a stake •  Who can help •  Who is likely to work against the initiative •  How to handle “reputational risks” 3  Apply a social determinants perspective to planning •  Let go of control over the plan 4  Take time to build relationships, teamwork, and common understanding •  Listening and dialogue •  Skill building and training 5  Clarify roles and governance •  Assure mutual accountability •  Balance equality and equity

leader’s task is made more challenging by the scope and variety of the stakeholders that must be engaged, especially when their interests are not only diverse but divergent. Assess local conditions in ways relevant and credible to the local stakeholders A starting point for engaging in work with another individual, organization, or community is an understanding of the situation or context of the other party—its history, uniqueness, strengths, and challenges. Leaders can use community health assessments to help assess local conditions for public health action. In the United States, availability of standardized data sources such as the Community Commons, the UnitedHealth state rankings, and University of Wisconsin county rankings makes such assessment more feasible (Community Commons, 2013; United Health Foundation, 2013; University of Wisconsin Population Health Institute, 2013). Another potential source of community assessments in the United States is that of hospitals under the Affordable Care Act; these can be useful as both a source of data and a way of inviting hospitals into public health partnerships. Assessments should include asset maps of community



6  Engage Diverse Others in Public Health Work

143

resources, including local citizens’ associations, private and nonprofit associations, physical spaces where people can gather and meet, business organizations, individuals affected by the issue being studied, and businesses and business organizations (Kretzmann & McKnight, 2005). In assessing summary data, it is important to devote attention to variation and diversity in addition to central tendencies. Dig for the disparities, and don’t be lulled by averages. Author JM remembers the surprise it was in the early 2000s for Minnesota health and political leaders to begin to appreciate the pervasiveness and size of the disparity gaps in a state that long prided itself on the excellence of its medical care and public health systems and its top national rankings on health measures. Governor Jesse Ventura’s willingness to confront this “uncomfortable truth” and to push for action by establishing one of the first statewide health disparities initiatives in the nation was one way in which he was an effective public health leader. (This story continues in Chapter 7.) Health inequities affect groups beyond racial and ethnic or income characteristics, and “digging into the data,” examining data from different viewpoints, is critical in developing more valid views of health outcomes. For example, at 19% of the U.S. population, people with disabilities have been described as the largest group suffering disparities in the nation, somewhat off the radar screen. A health disparities report by Drum, McClain, Horner-Johnson, and Taitano (2011) examines the health status of working-age (18 to 64 years) people with disabilities, as reported in the Behavioral Risk Factor Surveillance System. Among the key findings in the report are the following: ■■

■■

The highest proportion of people who say their health is fair or poor is found in people with disabilities (40%, compared with 23% of Hispanics, 22% of American Indian/Alaska Natives, 18% of Blacks, and 8% of Asians). People with disabilities have the highest prevalence rates for 10 selected health indicators, including cardiovascular disease and diabetes.

Iezzoni (2011) reports disparities in treatment and outcomes for breast and lung cancer for people with disabilities. Women with disabilities are less likely to get mammography and Pap tests. While 74% of nondisabled women get a mammogram, 66% of women with movement difficulties get a mammogram. Women with disabilities who get breast cancer are more likely to die than women without disabilities (with an adjusted hazard ratio of 1.31). In seeking and using data, it is important to ascertain what makes data credible (or not) in the eyes of members of the community. Does it

144

III  Competencies for Public Health Leadership

reflect their daily reality? Are the data sources seen as valid? Does its presentation acknowledge their concerns? Often, communities and cultures that have suffered a history of discrimination and abuse, such as Native American communities, do not trust information supplied by outside agencies that purports to represent their interests and their reality. Realizing the importance of going to the community for trusted data is a starting point. Organizations that have not typically been included as key partners in public health initiatives (e.g., businesses focusing on cost control, profit, and competitiveness) may legitimately feel that their concerns are not important to the leaders of the initiative. Acknowledgment of differing interests at the beginning of an undertaking, and reflecting that in the “assessment of local conditions,” is crucial to building a strong foundation. Assessing local conditions in ways relevant and credible to local stakeholders is another way of pursuing the practice of “cultural competence” in the building of a collaborative. Cultural competence refers to the ability to build effective relationships with diverse cultures. It requires that leaders recognize the importance of including affected groups at the beginning of a program or activity, in the interests of social justice and the long-term effectiveness of the program.

Search widely for the right partners Reflecting on the step of selecting partners, Porter and Baker (2005b, p. 369) emphasize connecting with those whose “resources, expertise, political connections, [and] past experiences” complement yours and those of your organization. They advise that we make sure that the selected partners are credible and that we try to avoid “derailers” who diminish the likelihood of success, such as those lacking credibility or energy for the task ahead of the partnership (Porter & Baker, 2005b, p. 370). Identifying the right partners means thinking broadly, particularly considering the following potential sources of partners: 1. Citizens and community groups affected by an issue, including but broader than groups identified by geography or race/ethnicity, also including self-definitions like gay men, people with AIDS, and people with disabilities. 2. Cross-sector interdisciplinary groups. Potential partners include those in public safety and policing, corrections, education, transportation, faith communities, business, philanthropy, and entertainment.



6  Engage Diverse Others in Public Health Work

145

The list of potential partners is generally longer than one first assumes. For example, in considering partners who influence the local economy, Healey and Lesneski (2011, p. 185) list 14 categories: business owners, advertising companies, government and academic economic institutes, rural and urban development councils, chambers of commerce, art councils, banks, major community employers, mass-media outlets, extension services, ecotourism centers, pharmaceutical companies, veterinarians, and health care providers. In the public policy arena, one of the long-standing big challenges to public health infrastructure is that so much of public health funding is issue-specific or “silo-based.” In the United States, until passage of the Affordable Care Act, virtually the only flexible federal funding for public health agencies was through the Prevention Block Grant (PBG). Increasing the federal appropriation for the PBG was high on all the public health trade associations’ legislative priorities for years, almost always to no avail. Holding off further cuts to the program was usually the only “success” to be claimed. During one annual lobbying visit, a Congressional staffer essentially told a group of public health officials, including author JM, “Well, we’ve never heard of anyone dying of Prevention Block Grant Disease. Next?” This illustrates the importance of getting other stakeholders besides the governmental public health community to understand the value of flexible prevention funding and help to advocate for it. Clearly it was too predictable, and too easy to dismiss, if the advocacy was coming only from health departments. “Thinking outside the box” is a guideline that applies in the search for partner organizations. Think about: 1. Who has a stake, especially if the issue is framed in new ways (as in the example later in this chapter of a faith community interested in health equity taking a strong stance on light rail-routing questions). 2. Who can help, with expertise, resources, or influence? 3. Who is likely to work against the initiative? Is there a way to counter likely opponents, perhaps by bringing in other groups from the same sector that have a different view? (For example, all business groups don’t necessarily see health issues the same way.) 4. How to handle the “reputational risk” of the baggage some partners may bring. Note there can be debate about how broadly to cast the net for partners. For example, while it seems obvious to many public health leaders that health care delivery systems in the United States should be

146

III  Competencies for Public Health Leadership

engaged in community prevention efforts, others actively question that presumption. Why shouldn’t hospitals and clinics just concentrate on improving clinical care? After all, that’s their distinctive competency. Can they ever be good at population health promotion? As a fundamental matter of the missions and ethics of health care organizations, however, as well as the profound shift in incentives as the U.S. payment system moves away from fee-for-service to outcomebased measures of value, the growing interest in population health on the part of most health systems and insurers is real and valuable. There is also a very pragmatic issue—that’s where the money is. Increasingly, politicians as well as policy experts understand the fundamental mismatch between the real determinants of health and where the money goes, and as a matter of global competitiveness many in the United States are apt to care about why other countries can spend so much less on medical care yet have such better health status for their people. Only by making it the business of the health care delivery and insurance sectors to “win” by helping to tackle the true determinants of health can we change this trajectory, especially in the United States. Business organizations are sometimes a controversial partner because their interests may include many that are counter to improvements in population health (Wiist, 2010). Businesses have traditionally focused on improving the health of their employees, but expectations that companies extend their focus to population health are growing. One global network of companies has urged that companies “view stakeholders as key partners in addressing the larger, systemic challenge of population health,” and the involvement of business partners is crucial to reducing many root causes of poor health (Business for Social Responsibility, 2013). Crutchfield and Grant (2012, p. 18) advise that nonprofit organizations work to “harness market forces and see business as a powerful partner, not as an enemy to be disdained or ignored.” A recent example of a partnership is the $50 million investment by the for-profit insurance company UnitedHealth Group Inc. into a new program of the Greater Minnesota Housing Fund, a 17-year-old nonprofit. A UnitedHealth spokesperson noted that “It’s a way to build healthier communities and healthier lives . . . It fits with our mission perfectly” (Crosby, 2013, p. D1). In Practice cases 6.2 and 6.3 describe some very creative coalitionbuilding efforts in Alameda County, California, and Camden, New Jersey. Public health leaders Alex Briscoe and Jeffrey Brenner assessed local conditions in ways relevant to stakeholders (Competency 1) and identified the right partners for those responses (Competency 2).



6  Engage Diverse Others in Public Health Work

147

in practice 6.2 CHANGING LIVES THROUGH THE RIGHT COALITION PARTNERS Described as someone driven by the unique combination of “the spirit of innovation and a dedication to service” (Marks, 2012), Alex Briscoe is a public health pioneer who has shown that developing effective relationships with unconventional partners is a winning population health strategy. Coupling expertise in counseling psychology with a passion to address the social determinants of health, Mr. Briscoe leads the Alameda County Health Services Agency that oversees physical, behavioral, and environmental health activities in Oakland, California (California Pan-Ethnic Health Network [CPEHN], 2011; Kaiser Commission on Medicaid and the Uninsured [KCMU], 2013). Mr. Briscoe creates impactful coalitions to improve the lives and health of Bay Area residents through “bold collaboration within and outside of the health sector” (Marks, 2012, para. 11).

Drawn to Issues Needing Collective Attention As discussed in Chapter 1, some public health leaders bring backgrounds in other professions to their public health work. A case in point is Alex Briscoe, who has a bachelor’s degree in sociology and a master’s degree in counseling psychology (CPEHN, 2011; KCMU, 2013). Past work in school reform and charter school development, social justice programming and grant making, and youth and crisis counseling (KCMU, 2013) all contribute to Mr. Briscoe’s unique perspectives on where to focus change efforts in communities as the head of Alameda County’s agency for health care services. A wrong turn during a visit to Oakland from Philadelphia literally brought Mr. Briscoe to the Bay Area and led him to develop a nationally replicated model of school-based physical and mental health services in poor neighborhoods (Freedman, 2005; Marks, 2012). McClymonds High School was ranked as one of the worst high schools in California in 2000, when Mr. Briscoe found himself parked in front of its razorwire perimeter. Only about a fifth of students entering ninth grade would go on to graduate, with almost none qualified for admission to the University of California system. But Mr. Briscoe felt that his experience in school counseling and youth development, as well as a fundamental desire to overcome poor socioeconomic conditions where they hit hardest, drew him to this school; he used these attributes to become the school’s dropout prevention counselor (Freedman, 2005; KCMU, 2013). Mr. Briscoe soon found out that mental health issues were a significant part of the realities facing students without much hope in a depressed and depressing neighborhood. His partnership with Dr. Barbara Staggers, an adolescent medicine specialist at Children’s Hospital of Oakland, grew out of their mutual commitment to improve students’ health and lives. This collaboration manifested into the first of a network of federally qualified health centers across Alameda County delivering

148

III  Competencies for Public Health Leadership

adolescent health and youth development services in schools, as well as a youth center in a former supermarket that allows students to meet, learn, perform, and receive care (Freedman, 2005; KCMU, 2013; Marks, 2012).

New Paths to Overcome Social Barriers to Health Optimizing this “intersection of public health and public education” (CPEHN, 2011) is only one example of the expansive thinking behind this collaborative effort. As the Agency Director for Alameda County since 2010, Mr. Briscoe continues to seek new avenues to overcome the persistent and significant barriers to health in those with the greatest need (CPEHN, 2011). Recognizing the need for health clinics within neighborhoods—and the fact that fire stations are located in every neighborhood—he launched a project in 2012 to develop health clinics in fire stations (Marks, 2012). He also created a community-based program to develop local emergency medical service (EMS) providers called EMS Corps, expanding the number of first-line medical personnel while offering real jobs to local students, often young men of color facing dim prospects of graduation and employment. In neighborhoods that notoriously distrust public officials, firefighters are popular and respected, and they welcome representation in their ranks from the communities they serve (Briscoe, 2010, 2012; Marks, 2012). Other cross-sector initiatives involve banking and education. Marks (2012) reported on Mr. Briscoe’s work to improve health through local partnerships that attract reputable lenders into underserved neighborhoods to protect residents from predatory lenders. As a leading Bay Area expert in the design and delivery of services for youth health and development, Mr. Briscoe is involved with First 5 Alameda County, an early childhood care and education program for children between 0 and 5 years that is funded by a cigarette tax surcharge (First 5 Alameda County, 2013). Additional projects include establishing integrated behavioral and physical health in primary and secondary clinics, offering clinical services in foster care and juvenile justice settings, and providing programmatic and technical assistance to several U.S. foundations. Bringing the “unique, individual qualities of a boundary-spanning leader” (Marks, 2012, para. 14), Alex Briscoe describes best in his own words what drives him: “[The] problems facing our communities have been made by human hands, and only human hands wielding our collective will and intelligence can unmake them” (Briscoe, 2010, para. 1). This joining of diverse and dedicated hands is helping Alex Briscoe bring better health to Alameda County.

in practice 6.3 A BETTER WAY OF DELIVERING HEALTH CARE SERVICES FOR POPULATION HEALTH “Innovative collaboration” is not just a buzzword for Jeffrey Brenner; it is the basis of the care model that he pioneered in Camden, New Jersey. The Camden model brings together a public safety technique applied to health care service utilization



6  Engage Diverse Others in Public Health Work

149

tracking and a diverse team of health and human service professionals directly supporting the city’s sickest patients (Camden Coalition of Healthcare Professionals [CCHP], 2013; Gawande, 2011). That the patients cared for by the Camden Coalition of Healthcare Professionals (Coalition) comprised 1% of the population and 30% of the health care costs in one of the poorest urban communities in the United States (O’Byrne, 2011) makes Dr. Brenner’s contributions—and his story— that much more compelling.

“Hot-Spotting” Health Care Service Utilization Jeffrey Brenner is a family medicine physician who believes in the power of data, as well as collaboration. As a practicing primary care provider in Camden in the early 2000s, he participated in multidisciplinary groups to look at the health of his community. One group was a police commission organized to address the growing issues of violence in Camden; the other started as a breakfast meeting that grew into a forum of care providers working together to improve the practice of health care in their dangerous, decaying city (CCHP, 2013; Gawande, 2011). Dr. Brenner’s police task force involvement introduced him to the computerized mapping of data to identify patterns of crime, a concept called “hot-spotting” developed in New York City in the 1990s and used to focus police resources in the worst areas. After local police declined to undertake a data-mapping ­project, Dr.  Brenner convinced Camden’s three main hospitals—Cooper University Hospital, Lourdes Health System, and Virtua Health—to provide their patient ­billing data to create a searchable database of crime victims and locations on a desktop computer. Despite expecting the police to determine coverage using the resulting crime maps, the Camden police union successfully fought against Dr. Brenner and blocked the use of his maps by the public safety sector (Gawande, 2011; O’Byrne, 2011). This potential defeat for Dr. Brenner inspired innovation in public health that has promise to change care delivery in Camden and beyond. Over the next few years, he mapped and analyzed the health care utilization “hot spots,” including identification of which patients and areas of Camden had the most frequent users of different health care services and calculation of the costs of these patients. Cost was important to Dr. Brenner, primarily because patients who continually utilize high-cost health care services are most often receiving the worst care (least effective, and least helpful in changing outcomes). These are the patients that the informal care provider forum was analyzing, which led to the creation of the Coalition founded by Dr. Brenner as its Executive Director (CCHP, 2013; Gawande, 2011; New York State Health Foundation, 2011; O’Byrne, 2011).

Addressing the Complex Needs of the Urban Poor Critical to the Coalition’s mission “to improve the health status of all Camden residents, by increasing the capacity, quality, and access of care in the city” is a diverse team of physicians, nurse practitioners, social workers, health coaches, and community health workers joined together to work directly with patients

150

III  Competencies for Public Health Leadership

wherever they are—at home, in homeless shelters, or in the hospital. This ­collective approach to better care focuses not only on what the care team can do for the patient, but what patients can do for themselves through involvement in and education about their care. The collaborative incorporates a city-wide network of providers, health care facilities, administrators, advocates, policy makers, and other partners. Another core element is the Coalition’s Health Information Exchange, which shares patient data from providers across Camden to enable better tracking of which patients are not receiving proper care, such as medication compliance and primary care follow-up to prevent readmission (CCHP, 2013; Gawande, 2011; O’Byrne, 2011). An equally vital function for highly complex patients is the Coalition’s concerted efforts to address the nonclinical issues that plague the chronically poor and ill. For these patients, the negative consequences of social determinants on their health and well-being are ever-present, including housing, education, employment, transportation, healthy food access, and the built environment. “Super-utilizers” in the health care system want for the basics that so many take for granted, and Dr. Brenner and his team work to connect patients with the fundamental social ­services they need (CCHP, 2013; Gawande, 2011; New York State Health Foundation, 2011).

National Model of Care The 40% reduction in utilization and 50% reduction in bills experienced by the Coalition’s first 36 patients demonstrated the great potential of the Camden model. Concentrating resources on the most expensive, highest utilizing, and sickest patients in the health care system to overcome barriers to their health is a model that may find traction as the focus shifts from procedures to outcomes (CCHP, 2013; Gawande, 2011). The Coalition model brings together a diverse collaborative of providers, advocates, and patients to shine a light on a better way to care for those patients with the greatest health care needs.

Apply a social determinants perspective to planning In developing programs and initiatives, public health leaders need to think broadly, applying a social determinants framework. Starting points for applying best practices and applying evidence include tools like “Roadmaps to Health,” a collaboration of the University of Wisconsin and the Robert Wood Johnson Foundation (University of Wisconsin Population Health Institute, 2013). To begin community health improvement efforts, the Roadmaps to Health tool advises leaders to work together across the public health, business, education, philanthropy and investor, government, and health care sectors with community members, to assess needs and resources, focus on what’s important, and choose effective policies and programs.



6  Engage Diverse Others in Public Health Work

151

Policies and programs are defined broadly, to include those affecting health behaviors, clinical care, social and economic factors, and the physical environment. In considering potential responses, the Roadmaps resource classifies evidence on the effectiveness of interventions into six categories: scientifically supported, some evidence, expert opinion, insufficient evidence, mixed evidence, and evidence of ineffectiveness. Note this planning step can only generate an outline. For others to be genuinely engaged, they need real input into and ownership of the plan. Just like battle plans never entirely survive the first encounter with the enemy, a plan of response to community health needs must start to evolve in the first meeting with the stakeholders. Leadership authors Kouzes and Posner stress how important it is for leaders to “let go of control” over a plan—and that giving team members ownership and freedom to change it builds pride and accountability in the process (Kouzes & Posner, 2012b, p. 222). The way an issue is framed obviously impacts the outline of an action plan. The emerging tools and techniques of Health Impact Assessment (HIA) can be significant, in attracting new partners and in reshaping a plan based on their priorities. HIAs are more prevalent in other western countries, but interest is growing in the United States as well. As an example, informed by their deep understanding of the social determinants of health, the faith-based coalition, ISAIAH, is urging the use of HIAs in contentious debates about expansion of mass transit in Minneapolis–St. Paul, Minnesota. An impressive coalition— including the local foundation community—succeeded in getting additional stops in low-income communities added to the Central Corridor light rail connection between the two downtowns of Minneapolis and St. Paul. The same social determinants sensibility fuels the arguments ISAIAH leaders bring to strong disagreements over the best route for the next proposed light rail train leg in a planned metro-wide system. The opposing views are mostly arguing about land values and disruption of a valued scenic part of the city. In an opinion piece in the local newspaper written as policy makers were struggling with community dissension, the Reverend Paul Slack wrote: “As we move forward, however, it is vital that we place racial and economic equity at the center of the conversation . . . The [proposed] alignment will put three stops in north Minneapolis, making it a game-changer in closing persistent racial equity gaps in our city and region.” Reverend Slack goes on to describe the benefits transit would bring in employment and income, and in the added time parents would have to engage with their kids with greatly reduced commute times (Slack, 2013).

152

III  Competencies for Public Health Leadership

Take time to build relationships, teamwork, and common understanding Collaboratives of diverse partners have succeeded in a variety of public health and social sector settings, and evidence of best practices is cumulating (Chrislip, 2002; Crosby & Bryson, 2005; Johnson, Grossman, & Cassidy, 1996; Mattessich, Murray-Close, & Monsey, 2001; Porter & Baker, 2005b; Ray, 2002; Rosenberg, Hayes, McIntyre, & Neill, 2010). Successful leaders of collaboratives are open to practices that are grounded in other disciplines, areas of expertise, sector, or culture. As we have discussed earlier, they truly engage in sharing power, going beyond “lip service” by showing trust, giving up control, letting others lead, and contributing their expertise. Building relationships requires effective communication among collaborative members, anchored in listening and dialogue. Building relationships starts with rich introductions to different members of the collaborative, including small group get-togethers, and with opportunities for dialogue, particularly around the issue being tackled and the means to tackle it. This too is a critical part of developing “cultural competence.” Understanding the context for the collaborative effort is important and builds a common understanding of the problem. Formal methods such as Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis can be useful in developing a common understanding, as can other methods such as scenario development and appreciative inquiry (Chrislip, 2002; Cooperrider & Whitney, 2005). Kouzes and Posner (2012b) discuss the importance of building a leadership team in the context of an organization, but their points apply equally well to collaboratives. They stress that leaders must be intentional about building a team—in the case of collaboratives, coleaders must work actively to help the leadership team coalesce and work cooperatively together. An essential ingredient is a climate of trust, and one key leadership behavior they cite is to demonstrate trust before asking for it from the group. Another best practice to build teamwork and trust is the intentional sharing of credit and opportunity—for example, trade off which partner is in the spotlight, controls the budget, or does the press release. Partner organizations may need skill building and training not only in teamwork, but in such core practices as running efficient meetings and managing funds and budgets. Successful collaboratives make sure that partners reach a basic skill level that is necessary for the collective to proceed with confidence. This is one area where more richly resourced partners can support those who are closer to the community—not by



6  Engage Diverse Others in Public Health Work

153

taking over these kinds of tasks, but by helping the community’s own organizations to develop these capabilities, which is good not only for the current collaboration but for future ones as well.

Clarify roles and governance Setting the stage for successful partnerships requires establishing and communicating at the outset realistic expectations regarding outcomes and each partner’s role. Public health leaders should be clear about the “scope, scale, and some rough ideas of roles of the partners” and partners are encouraged to ask for these elements from the leader “to understand the depth of the pool before [they] jump in with both feet” (Porter & Baker, 2005b, p. 371). The initiating partner is responsible for proposing a partnership governance structure that creates an “efficient way for the partners to meaningfully participate” with the proper balance of ownership and engagement (Porter & Baker, 2005b, p. 371). Mutual accountability is an important governing principle. Partners must agree to be accountable and to hold each other and the collaborative accountable for moving the process along and fulfilling its purpose. Mutual accountability could be reflected by partners adjusting their own mission statements or goals to reflect involvement in the collaborative, so that their internal evaluations include an assessment of their contribution to the collaborative. Partners should acknowledge mutual accountability in words, roles, and actions. Partnerships should strive for balanced representation of stakeholders on their governing bodies (Wyatt, Brady, & Maynard, 2013). A vexing question is how to apportion power when the resources invested by the partners, or the stakes in the outcome, aren’t equal. Further, how are nonfinancial stakes valued? Alexander and colleagues have observed different models of distributing control depending upon whether the collaboration prioritizes equality or equity as an organizing value (Alexander et al., 2001). This can be particularly challenging in public– private partnerships due to their “voluntary nature . . . diverse membership, and the complex and sometimes ambiguous nature of partnership goals,” which calls for careful balance of conditions. Partnership leaders are most effective when they recognize this need for balance “between power sharing and control, between process and results, between continuity and change, and between interpersonal trust and formalized procedures” (Alexander et al., 2001, p. 174). The public health leader’s role as the conductor of this symphony, or cacophony, is not always to have the answers to these questions, but

154

III  Competencies for Public Health Leadership

to be sensitive to them and skilled at making sure they are addressed in sustainable ways by the group. As will be discussed in Chapter 9, successful execution relies on additional preparation, particularly in the form of setting goals and targets. Those goals and targets are then assessed in terms of accomplishment, with failures addressed and successes celebrated. Communication of progress to participants and stakeholders is important for long-term success as well, and evaluations of the collaborative are more useful if planned early, so that relevant metrics can be collected from the beginning of the effort. CONCLUSION A leader’s role in building collaboration to tackle a tough public health challenge is to think at a systems level, spot the opportunities, strategically recruit the right partners, lead them to come up with a compelling shared vision, and then keep it in front of them through ups and downs, orchestrating the implementation efforts along the way—­ responding flexibly as learning proceeds and the environment shifts. While a tall order, persistence and firm attention to the process of collaboration pay off with innovative and effective public health programs and organizations.

chapter 71

Effectively Wield Power to Increase the Influence and Impact of Public Health

key terms authority, positional campaign core supporters governing board influence integrity issue-specific allies manage “across” manage “down”

manage “up” persistence political opponents power public support requisite role of government strategic agility transparency Turning Point Initiative

P

ower—the word itself evokes strong reactions. Some people see power as its own reward and others see it as something highly suspect and to be resisted. Scholar Jeffrey Pfeffer (2010, p. 87) writes that power is essentially “the ability to have things your way.” When that involves working with and through others who may have different



155

156

III  Competencies for Public Health Leadership

ideas, that means that “you need some basic forms of leverage.” He puts it bluntly: “People who effectively wield influence make it clear that you will get rewards if you help them and problems if you don’t” (Pfeffer, 2010, p. 89). Given the strong mission and social justice orientation of the public health community, combined with a belief in the importance of science and evidence, many in public health are not comfortable talking about ­“politics” and the intentional building and use of power. The very term may feel coercive, unjust, unscientific, and unsavory. But good policy and programs without enough political power to get them enacted, implemented, and sustained is too much the story of public health in recent decades. Changing this dynamic is core to the public leadership challenge today. Building power is especially important whenever there is a mismatch between goals and direct authority to make something happen. That is surely true of public health. Consider the gap between the field’s responsibility and aspirations to improve population health, and the lack of direct control over its determinants. In nonhierarchical situations like the collaboratives discussed in Chapter 6, the effective use of power becomes even more important to keeping a complex agenda moving. Even though true collaboration means giving up individual power in order to build greater collective power, a collaborative leader still needs to understand power, perhaps to an even greater degree when it is distributed. What do we mean by “effective” use of power? In the policy sphere, both public and private, we mean the intentional and respectful building of influence that helps public health win the policy, programmatic, and funding battles it too often loses. Effective use of power doesn’t mean ramming through any piece of legislation or program just because it can be done—both the ends and the means should be consonant with public health values. A measure of good policy is not only that it has the intended impact, but that it is also sustainable. Stories of political overreach abound in public health as in other policy arenas. Important changes stick best when they have broad support and ideally emanate from the ground up rather than the top down. An effective approach taken on a specific issue will ideally also advance support for public health generally, building more political capital to apply to the next issue. Much of the political work of public health leaders occurs in and around government. Working effectively in and with government is critical to advancing public health interests, whether one works in a government agency or in the private or nonprofit sectors. The nature of public health work and the issues are inherently political, since public health is fundamentally about making change in behaviors and societal conditions. That means changing policies and allocation of resources,



7  Effectively Wield Power

157

and it means disrupting the status quo, which never happens without resistance from the interests currently well served by it. It takes power to do that, and to survive the effort. In formal leadership positions, the pursuit of power is made more challenging because the designated leader is pretty much constantly “on stage,” whether in the public sector or a private organization. Bennis (2004, p. 49) makes this aspect of leadership roles sound particularly challenging: “you have to learn to do the job in public, subjected to unsettling scrutiny of your every word and act . . . everything about you is fair game for comment, criticism, and interpretation (or misinterpretation) . . . all will be inspected, dissected, and judged.” In public-sector jobs (and many private-sector jobs), add to that the fact that some political opponents will be hoping and actively working for your failure. To make leadership even more challenging, public health issues very often play out amid visible controversy and intense media interest. Public health issues go to the very core of deeply held beliefs and reveal stark differences in views about the role of government and individual rights and responsibilities. In the government sector, this often makes public health leaders a top target when a president’s or governor’s political opponents want to attack an opponent’s broader agenda. For example, consider the number of U.S. Surgeons General and Health and Human Services Secretaries who have been subject to highly visible and pointed scrutiny by the opposition political party and even driven from office. Leadership is about impact—effectively tackling public health problems. It takes power to successfully navigate the realities and challenges described above, and others facing public health leaders. This includes weathering the inevitable storms and setbacks that are part of any political endeavor. It’s relatively easy for opponents to take down a lone advocate pushing uncomfortable change. It’s much harder when that advocate has built a base of support and is a savvy campaigner. Public health leaders should be aware of how important this is and should build competencies in the acquisition and effective use of power.

VALUES AND TRAITS Effectively using power tests the depth of the values and the traits of public health leaders in ways that the other competency sets may not, because of the emotional “baggage” carried by the exercise of power discussed above, and the potential to abuse and overextend power in the pursuit of one’s goals. In particular, the use of power can bring to the fore conflicts between one’s integrity and other values, such as the pursuit of

158

III  Competencies for Public Health Leadership

social justice and reliance on evidence. The following values and traits are particularly in the forefront when one is building and using power. Integrity and Transparency Except in authoritarian settings, leaders who lack integrity cannot effectively build and use power. They are viewed as untrusted, unpredictable, and unreliable as political partners. By the same token, leaders with a reputation for integrity are taken to be good partners and are more likely to be treated with respect by opponents. It may be surprising to find “transparency” as a fundamental value in the use of power, but effective leaders over the long run find that if their actions cannot stand the light of day, they are unlikely to be successful. In part because public health literally is “public,” leaders in this field are held to a high standard of transparency. Actions must be defended in public, and transparency bolsters the case that public health leaders are acting in the public interest. In addition, because politics is always “the art of the possible,” political alliances often shift issue by issue. The integrity and transparency of a leader are essential ingredients in building coalitions across the political spectrum and across sectors. Requisite Role of Government As explained in Chapter 3, the government has a central role in public health through its constitutional, statutory, and regulatory powers. For most of those who work in public health, this value takes on an added dimension—that government can do good and should be used to that end. We hazard that most public health leaders don’t love politics for its own sake but rather for what it produces. To put up with the rough and tumble it helps if you believe you are having a positive impact. Note this doesn’t mean you have to believe the government solution is always the best solution; just that the government solution isn’t by definition the worst solution! Persistence Given the nature of many public health issues and the number of stakeholders to be brought along, it’s not uncommon for major programmatic and legislative initiatives to take several years, or even decades, to come to fruition. (Examples include tobacco control and universal



7  Effectively Wield Power

159

health insurance in the United States.) Being able to anticipate that reality, take the long view, and not be stopped by the first defeat (or several) are important to maintaining optimism and quality of work life. A particular dimension of persistence has to do with the possession of a “thick skin,” or the ability to tolerate personal attacks. To be able to do battle in the political arena for many years, in the public sector or in private organizations, leaders need to be able to tolerate the personal attacks that come with politics. A politicized environment is definitely not for everyone. Many a smart, caring public servant or private organization leader has left the fray because the personal toll was just too great. This doesn’t mean one can’t lead in this or other environments, just that sustained success in politicized settings is easier for those with a “thick skin.” Most people who enter the field of public health don’t do so because they want a lot of glory. Nor are they likely to know what a charged, contentious atmosphere they are stepping into. But once a leader feels that pressure, staying in that unique environment—much less thriving in it—takes a drive to want to accomplish something, and a belief that you have a unique ability to do so. KNOWLEDGE Public Health Science As discussed in Chapter 4, technical expertise is a source of power for public health. Basic public health science provides much of the evidence that is used in political debate. Also important in public-sector work, and for interacting with the public sector, is an understanding of the legal basis for public health action and of the public policymaking process. Knowledge of public health law can be an essential source of power in much of public health work, including work at the local level. Some of this knowledge is conveyed in public health degree curricula. Beyond those areas, however, public health science knowledge generally does not prepare people for this competency set. Understanding People Understanding people and their motivation is central to this leadership competency set. Understanding sources of power, and who holds them, is knowledge that is useful in putting to work the political competencies

160

III  Competencies for Public Health Leadership

described below. The works by Pfeffer (2010) referenced earlier and Heifetz et al. (2009) noted below are examples of the literature by social scientists that is relevant for public health leaders. Influencing other individuals and organizations is core to building power. Negotiation and persuasion are competencies that are needed in making deals, and research on effective negotiation and persuasion practices is a promising area for knowledge development that is useful for public health leaders (Cialdini, 2001).

Understanding Complex Systems Effective wielders of power in public health settings are systems ­thinkers. They prepare for the long term, think ahead about the consequences of their actions, and predict the effects of their own actions on others. They prepare for political challenges well in advance by soliciting allies and alliances and by recognizing opponents. They “map the terrain” and build networks of support (Bolman & Deal, 2013, p. 211). The tools of systems thinking, specifically including logic models, are useful for leaders to lay out long-term plans for the outcomes of their initiatives. Public health leaders are well served by developing logic models that can help others see the links among early changes in collaboration processes, indicators of increasing community engagement, then behavior change, and eventually changes in risk factors and ultimately health outcomes.

FIVE COMPETENCIES FOR EFFECTIVELY WIELDING POWER In defining the practices of adaptive leadership, Heifetz et al. (2009) underscore the importance of what they call “thinking and acting politically.” As they describe it, “thinking politically” basically means understanding the concerns of the people in a situation and the relationships among them. “Acting politically” means building alliances and finding ways to defuse opposition. They have several practical tips for how to do this. Such concepts and tips are extremely relevant to public health leadership, yet infrequently studied and used. To implement a bolder public health agenda, knowing what should be done and having great policy proposals or out-of-the-box new program ideas are only the first steps. Leaders need to be able to get those policies and programs adopted and funded.



7  Effectively Wield Power

161

In order to get any major change to happen, whether in a legislative context or in a private organization, leaders need to understand—in the context of a given issue, situation, and time—the intersection of their formal authority, their broader circle of influence, and how much support exists. That intersection establishes the feasibility of whatever leaders are hoping to achieve. Technical feasibility also has to be combined with the importance or urgency of the issue in terms of its impact on the health of the ­public, and the availability of effective interventions. This step is critical in setting political priorities. There is only so much political capital to go around in either the public or the private sector. Public agencies have only so much capital, as do mayors, governors, presidents, or leaders of private organizations. Leaders ignore this reality at their peril. Especially with the breadth of public health, it’s incredibly hard to limit the agenda. But at the end of the day, what gets on the “short list” of a leader’s priorities is really important, as some of the stories recounted later in this chapter illustrate. This competency set is presented in five somewhat sequential steps, starting with how leaders can approach their job generally and then delving into how to approach specific public health issues. The competencies are summarized in Table 7.1. Table 7.1 Five Competencies for Effectively Wielding Power 1 Understand and strategically use both positional authority and informal influence •  If you have positional authority, learn to use it •  Intentionally expand your authority through influence –  Manage “up” –  Manage “down” –  Manage “across” 2  Analyze a given public health problem and proposed solution in “campaign” terms •  Clarify the question •  Demonstrate the effectiveness of the intervention •  Accurately gauge public support •  Outline a public campaign •  Does this issue make the short list? 3  Build coalitions of core supporters, new partners, and issue-specific allies 4  Deal effectively with opponents 5  Be strategically agile

162

III  Competencies for Public Health Leadership

Understand and strategically use both positional authority and informal influence Most leaders understand that formal position brings power, but many do not use that power effectively. In addition, many leaders do not take full advantage of their power to influence others to achieve organizational and programmatic goals. Positional Authority Understanding the power of one’s position or office is critical, and it is a major asset in moving one’s agenda forward. In addition to statutory or regulatory powers common to public health leadership positions, leaders should be mindful of the assets a position controls that others value— including resources, access to influential people, and information (Pfeffer, 2010). Many collaborative leaders hesitate to use positional authority, and inexperienced leaders sometimes are reluctant to “step up to the plate” initially. Author JM recounts her own experience as a political newcomer: I found it amusing and almost embarrassing at first when my lead government relations staff person insisted on addressing me as “Commissioner” whenever others were in the room. He was quite intentional in doing that—reminding others (and me) that the position itself was something to be reckoned with. This was a foreign style for me, especially since by and large I was dealing with people I had known previously in other circumstances. My assumption was that those personal relationships would be “enough” to secure support on important issues. But toward the end of my tenure I had a much clearer sense that it took more than friendly relationships to get big things done. Reflecting back on it, it’s one of the things I most wish I had understood earlier. I would use the formal authority more assertively if I had it to do over again. I wouldn’t hesitate to use the office to get people in a room and lay out my expectations. The ability to take things into the public arena is also important. A reporter said to me early on, “You’re the Commissioner; if you call a press conference, we come.” I didn’t intuitively understand that going in, and I could have made better use of that element of power, too. In Practice 7.1 reports actions of a public health leader who aggressively employed the authority of her office to challenge the trafficking of



7  Effectively Wield Power

163

counterfeit pharmaceuticals in her country. The personal traits of courage, integrity, and persistence also shine through in this leader’s story.

in practice 7.1 THE POWER TO SAVE LIVES What would you do if you had to put your life on the line to do your job as a public health leader? Dr. Dora Nkem Akunyili, Nigeria’s former Director General of the National Agency for Food and Drug Administration and Control (NAFDAC), repeatedly faced physical harm to herself and to her family, employees, and NAFDAC facilities (Akunyili, 2006; Princeton University, 2009). Not only did Dr. Akunyili survive a direct attack, but she used the power of her authority to fight to save the lives and futures of her homeland’s populace.

Battling the Invasion of Counterfeit Drugs Dr. Dora Nkem Akunyili is a pharmacist by training who was working as a scientist and scholar prior to entering public service. First appointed Supervisory Councilor for Agriculture in Anambra State, Nigeria, in the mid-1990s, Dr. Akunyili had been working since 1997 as the appointed Zonal Secretary of Petroleum Special Trust Fund. In 2000, her reputation for integrity brought her to the attention of then-President Olusegun Obasanjo, who appointed her to head the country’s food and drug regulatory agency, NAFDAC. In addition to her gender, Dr. Akunyili’s Igbo ethnic heritage created much backlash against her appointment, due to Igbo ties to drug counterfeiting within ­government and criminal ranks alike (Akunyili, 2013; Princeton University, 2009). But President Obasanjo believed Dr. Akunyili was the right person to end the corruption and eliminate Nigeria’s invasion of fake or substandard drugs. The World Health Organization estimated that over 50% of drugs for sale at the time were fake (Frenkiel, 2005); a Time magazine article put the estimate of “deficient” drugs at 80% (Lemonick & Da Costa, 2005), ranging from drugs for malaria and tuberculosis (Frenkiel, 2005) to drug samples, analgesics, and other everyday medicines (Akunyili, 2006; Lemonick & Da Costa, 2005). Widespread food and drug malpractices were “endemic,” according to Dr. Akunyili (2006), when she was appointed Director General of NAFDAC on April 12, 2001, labeling it a “form of terrorism against public health and an act of economic sabotage. It is mass murder.”

A Deadly Price to Pay Issues with counterfeit drugs ranged from prescription drugs that contained inert, substrength, or expired ingredients—including drugs given during surgical ­procedures—to outright poisons used intentionally or inadvertently in lieu of the proper chemicals. In 1990, over 100 Nigerian children died from a toxic substitute included in a painkiller; in 2003, several children died due to ineffective counterfeit adrenaline that could not restart their hearts during surgery. Dr. Akunyili’s own

164

III  Competencies for Public Health Leadership

family suffered the deadly price of fake drugs, when her sister, Vivian, died in 1988 after using counterfeit insulin for diabetes (Frenkiel, 2005; Lemonick & Da Costa, 2005). Tragically, Nigeria’s experience with fake and substandard drugs was not unique among most African countries (Akunyili, 2006).

Advancing a Public Health Agenda Through Collaboration For Dr. Akunyili, fighting the scourge of drug counterfeiting meant aligning allies and creating a network to put the counterfeiters on the run. One early effort involved removing corrupt government officials who took bribes to allow the drugs into the country, replacing inspectors and pharmacists with a team of female professionals, whom Dr. Akunyili believed to be less tempted by drug importers’ bribes. She also prosecuted counterfeit importers, closed open-air medicine markets in Nigeria, restricted imports to controlled airports and seaports staffed with trusted NAFDAC officials, and conducted extensive raids and destruction of tainted drugs (Frenkiel, 2005; Lemonick & Da Costa, 2005; Princeton University, 2009). Recognizing the power of collaboration while engaging within the realities of the situation, Dr. Akunyili put in place the West Africa Drug Regulatory Authority Network, with the goal of interacting with fellow government officials to set up barriers to the counterfeiters’ invasion of the African subregion. She also used persuasive communication through a public education campaign, using a variety of print and electronic media, workshops, seminars, and other training forums for Nigerians of all ages and in all parts of her country to establish a “culture of quality consciousness” (Akunyili, 2006).

The Personal Price of Public Health Authority Although the Nigerian public widely considered their NAFDAC Director General an “uncrowned queen” (Frenkiel, 2005), Dr. Akunyili was fighting a dangerous criminal element that wanted her enforcement efforts stopped, regardless of the cost. She and her family were threatened repeatedly, and her son was nearly kidnapped from school before being sent to live in the United States. The local drug cartels made several attempts on her life and on NAFDAC personnel, culminating with a gunshot wound to Dr. Akunyili’s scalp on December 26, 2003, when gunmen shattered her car’s rear window with bullets. NAFDAC’s facilities, equipment, and records located across Nigeria were destroyed through synchronized fires in early March 2004 in an effort to halt operations. But Dr. Akunyili was undeterred, setting up temporary workspaces that were replaced quickly with the support of President Obansanjo. Despite the physical losses to her team, she insisted on conducting scheduled raids, vowing not to be broken by the psychological terror tactics (Akunyili, 2006; Frenkiel, 2005; Princeton University, 2009).

Continuing in Service to Nigeria Dr. Akunyili served as Director General of NAFDAC until 2008, having brought a new culture of excellence, honesty, and integrity to her office. According to  a newspaper source quoted on her website, “The NAFDAC Director General is



7  Effectively Wield Power

165

a  revolutionary. She has not only changed NAFDAC, she has also changed the pharmaceutical industry in the country” (Akunyili, 2013). She also succeeded in bringing back acceptance of drugs labeled “Made in Nigeria,” and multinational drug manufacturers which had left the country due to the corruption and dangers have returned (Lemonick & Da Costa, 2005). In 2005, Dr. Akunyili was recognized by Time magazine as a “global hero for health” for her unfailing efforts to bring drug safety and regulation back to her country and region (Lemonick & Da Costa, 2005), one of many awards bestowed upon her. After working from 2008 to 2010 as Nigeria’s Honourable Minister of Information and Communications (Akunyili, 2013), Dr. Akunyili serves her country and the world as a scientist and scholar in the study of pharmacy. A public health leader who continues to uphold—by her words and actions—“the importance of never compromising one’s ideals and ‘selling out’ . . . emphasizing the importance of dedicated and honest leadership in the success of any effective institutional reform” (Princeton University, 2009), Dr. Akunyili provides vital lessons from which all public health leaders can learn and benefit.

Influence Leaders who want to get things done should intentionally expand their power through influencing and persuading others. This is equally as important as or even more important than one’s formal authority as a function of position title and job description. Building influence takes strategy and effort too; it doesn’t just happen without conscious planning and effort. Manage “Up” Almost no matter what position one may hold in either the public or private sector, opportunities exist to manage “up”—to make the boss look good whenever possible, and to work your way into the inner circle. Especially in a political setting for individuals reporting to elected officials, this is one of the first “survival skills” to learn. Governmental health leaders need to be sensitive to the pressures of time and the limits of political capital, the need to assess political risk from all angles, the need to be able to boil messages down to their essence, and the importance of making sure elected leaders get the credit when things go well but not the blame if things go wrong. The same lessons apply to working with elected officials at all levels, including the federal top of the pyramid, and to private sector bosses as well. Managing up includes building personal relationships, which enhances one’s ability to persuade (Cialdini, 2001). Developing personal relationships with legislators, county or city board members, or leaders in private sector stakeholder groups is time consuming (especially

166

III  Competencies for Public Health Leadership

if there are a lot of them), but important. Persuasion works better in person (Conger, 1998). You don’t want to have to introduce yourself to them for the first time when you are coming to ask for their support on an important issue. Author JM describes a colleague who excelled at this political skill: One colleague of mine was tireless about having dinner with every single legislator on the committees he would be working with. As somewhat of an introvert, I found that prospect daunting and remember wondering if that level of schmoozing was really necessary. But my friend had an extremely successful tenure in his state and went on to a number of high-level federal positions. He was a master at the relationship-building part of the job. It is increasingly common for people to have multiple “dotted-line” reporting relationships in addition to a direct reporting relationship to their boss. The dotted-line supervisors provide direction on various projects or other segments of the job. These arrangements can either be perceived as adding bureaucracy and limitations to one’s freedom, or as creating built-in access to more people to influence. As a leader, you can take advantage of these indirect reporting relationships by building political capital throughout the organization. In the private or nonprofit sectors, working with and through a governing board is an important competency. This starts with understanding and appreciating the difference between the governing board’s role and your administrative role. A governing board has a fiduciary duty to protect the interest of shareholders in a for-profit company and of the community in a nonprofit organization. How the board members interpret that duty is a profound responsibility that must be respected by the leader the board selects and supervises. The board fundamentally sets policy and strategy, often upon the recommendation of administrative leaders. However, at the end of the day the decision on whether or not to accept what administration recommends is the board’s to make, not the administration’s. Providing the administrative support to help a board select and engage excellent board members is another principal responsibility of an organizational leader. It is an opportunity to leverage the power these board members can bring to the mission of an organization and to particular strategic initiatives. Board members not only represent the community or investors in assuring an organization stays true to its purpose; they are also ambassadors back to the community in



7  Effectively Wield Power

167

disseminating strategic decisions and seeking the community’s support. The case presented in Chapter 5 (In Practice 5.2) about author JM’s former organization, the Courage Center, illustrates the importance of a leader working with and for a governing board to set and achieve a bolder agenda. Heifetz et al. (2009) remind us that managing up includes respecting that the boss is juggling multiple priorities, not just yours, and sees a bigger picture than you do. That can be really annoying, but it’s probably true. Take your best shot at getting your top issue to be on your boss’s short list of priorities. If you succeed, great. If the boss doesn’t adopt your issue, sometimes you can proceed on your own, as long as it doesn’t conflict with or distract from the boss’s higher priorities. But sometimes you’re asked not to go ahead, or even without that direct request you know you’re unlikely to prevail without the boss’s explicit support. In that circumstance, being a good team player and waiting until the time is right from the boss’s point of view may be the best move. Author JM comments from her experience: There are examples from every part of my career—in private health care, state government, and in the nonprofit social services sector, where either my colleagues or I have misjudged our independent clout to get something done without enough help. I have spent and watched friends spend a lot of energy and time pushing things without enough support from above. By contrast, when I came to the Minnesota Department of Health the issue of health disparities had been on the agency’s agenda for a number of years, with challenges in getting enough funding or attention to get traction. The awareness and the concern certainly predated me. My contribution was to succeed in getting a major long-term initiative on eliminating health disparities onto Governor Ventura’s short list of priorities in one of his biennial budget proposals and to work with him to keep it there throughout the legislative horse trading that year. We ended up with a significant level of funding and the start to an innovative grant program that has been in place for over a decade at this writing. Giving your boss sound, trustworthy advice, respecting your boss’s broader perspective, being a team player, keeping your boss informed, and delivering beyond the boss’s expectations—all are means to getting into and staying in the inner circle.

168

III  Competencies for Public Health Leadership

Manage “Down” Building strong relationships with those who report to you increases your ability to influence others, because they know you speak for the larger unit rather than just for yourself. Being an effective manager of people means including them appropriately in decision making, sharing information, and giving them autonomy and responsibility. In politically appointed jobs, public health leaders also have to influence civil service staff in their agency. Civil service employees know that their tenure likely will exceed that of the political appointee. This makes the management work of the political appointee even tougher, as illustrated in this instance by author JM: As I quickly learned at the Minnesota Department of Health, those of us in politically appointed leadership roles were called “the tourists” by the long-time civil servants who are the backbone of the agency. Those long-term professionals are the ones whose excellence has earned the Minnesota Department of Health its reputation as one of the strongest public health agencies in the nation. As in other public agencies, they know that appointed leaders come and go, and that part of their job is to protect the core functions of the agency from the whip-saw of sometimes drastically changing political agendas set by successive administrations. One of my first impressions of the agency, besides the professionalism and dedication of the staff, was the degree to which everyone seemed to be “hunkered down” in their programmatic silos. There was a lot of activity, but not great evidence of large-scale impact. It was very clear early on that I needed to earn their trust in order to take on larger strategic issues that required the whole agency to work together and to make collective decisions about priorities. As discussed earlier in Chapter 5, doing so was critical to raising the visibility and influence of the entire agency, and turned out to be rewarding for both the “tourists” and the long-time staff. Manage “Across” Managing “across” means extending your influence by effectively working with and through peers. Both in general and on specific issues, it’s important to figure out who can help (or hurt) you in your job overall and on a given issue. Developing relationships with those who can



7  Effectively Wield Power

169

advance your agenda is well worth it, as illustrated by this experience of author JM: When Governor Ventura was elected, he came into office without the usual preparation in the mechanisms of state government, and without much knowledge of the state budget he would have to propose to the legislature within about eight weeks of his election. One of his first cabinet appointments was the commissioner of finance—the budget guru. The Governor made clear early on that he would rely on this leader, not only in her subject matter expertise but as his overall negotiator with the legislature. It became a good idea then for me to develop a good relationship with her, to get her input early on for budget proposals affecting the state health department, and to work very closely with her throughout the legislative session. Happily for me, this was not only effective, but it was also highly enjoyable, as she was both knowledgeable about and supportive of public health. At the end of our terms of office, I gave a lot of public credit to my colleague and friend for the gains public health made under Governor Ventura. She in turn said I had earned her trust by delivering results. As with managing up, managing across doesn’t happen without intentional action. You can’t just assume you’ll get along because the organization chart says you’re supposed to be teammates. You also can’t let personal chemistry define the whole relationship. Whether you like one colleague and dislike another one is not terribly relevant when it comes to figuring out how to accumulate power. In building alliances with peers, it helps if you can get some quick wins to draw their attention and respect. (This is about building power after all, so don’t be shy about it.) It helps even more if you can help peers get some quick wins, too. Spend some of your time and energy to help peers with their agenda, especially when you can see the connection to your agenda. And with the social determinants framework that is at the heart of our bolder public health agenda, what issues aren’t connected? Author JM practiced managing across in the following state government experience: In the first budget proposed by Governor Ventura in 1999, immediately after he came into office, there were federal dollars available in the Temporary Assistance for Needy Families program (formerly known as Aid to Families

170

III  Competencies for Public Health Leadership

with Dependent Children). With funding from the Robert Wood Johnson Foundation’s Turning Point Initiative, the Minnesota Department of Health had already been working to build understanding of the social determinants of health. With awareness of the link between housing and health outcomes, it fit our public health agenda to help lobby for the Governor’s plan to spend some of the money on housing that could have gone to health care access instead. This issue was on his short list that year. It was a major win for the Governor and the Housing Finance Commissioner in the final budget package. As the session came to a close, a capitol reporter asked me if I was upset that the Department of Health didn’t get any of that federal money. I tried to explain how housing is public health, but I think I lost him. The message was a bit ahead of its time, but the Governor and Housing Finance Commissioner remembered for the rest of the term that I had helped work for their priority, and thought differently about the public health agenda as a result. In a large organization—whether public, private, or nonprofit—there are many layers to navigate in order to “manage across.” Finding those with influence is not always obvious. Who are the people everyone wants on their project team, or through whom all decisions ultimately have to go? These might be people at various levels in finance or human resources, strategic planning, or marketing and communications. It differs in every organization.

Analyze a given public health problem and proposed solution in “campaign” terms The agenda of a public health leader will include addressing specific issues, like decreasing tobacco use, decreasing childhood obesity, or improving access to safe water. Whatever the issue, promoting it can benefit from a structured approach, including the following elements. Clarify the Question Getting the definition of the problem right helps frame the solution to the problem. It also isn’t as easy as it may sound. Experts including public health leaders can have a tendency to think of issues in specific, technical terms that may not be compelling to community stakeholders



7  Effectively Wield Power

171

or policymakers. A broader systemic view as outlined in Chapter 4 can frame an issue in new ways and open different approaches. For example, former U.S. Food and Drug Administration (FDA) Commissioner David Kessler came to Minnesota for a meeting on Minnesota’s allocation of its tobacco lawsuit settlement funds. He spoke about how it took a long time for his agency to “get the question right” in terms of the FDA’s role in tobacco control. As soon as the FDA stopped focusing only on the ingredients in tobacco—especially nicotine—and reframed the issue by labeling cigarettes themselves as a drug delivery device for nicotine, the FDA’s regulatory authority and approach became much more broad and proactive. In a related example, in Minnesota, efforts to extend prohibition of indoor smoking to bars and restaurants took on new momentum and finally passed after years of being stalled once the question was framed as a workplace safety issue under the banner “Freedom to Breathe.” Demonstrate the Effectiveness of the Intervention As part of campaigning for a public health intervention, leaders should be prepared to demonstrate the effectiveness of the intervention in a meaningful time frame. Harvey Fineberg (2013a), President of the Institute of Medicine, offers a thorough diagnosis of why it’s so hard to make prevention a higher funding priority in the public or private sectors. Among other observations, he notes the invisibility of success in much of public health, the lack of drama associated with prevention, and the fact that the financial (or political) benefits of prevention rarely accrue to the payer (or policymaker) who is being asked to fund it. It’s important to be able to make success visible, even in the short term. Leaders need to develop compelling logic models for long-term, multifaceted initiatives, and help people see what follows from early success. For example, risk factor reductions can likely be observed within a relatively short time and tied to reduced disease prevalence and severity over a longer period of time. Leaders should be inclusive in projecting benefits—including not only premature deaths that are reduced but also illness and disabilities that are avoided. Public health leaders can often take more credit than they do for near-term cost savings on the illness and injury front. They can also build new economic models that factor in the impact of prevention on costs outside of health care—for example, avoiding absenteeism and turnover for employers, broader social services costs related to disability elsewhere in state and federal budgets, and housing and corrections costs for problems that have mental health, substance abuse, or brain injury components.

172

III  Competencies for Public Health Leadership

When it comes to arguing for the cost-effectiveness of prevention, some public health leaders seem reluctant to engage. They don’t believe that cost savings should be the only measure of prevention’s worth, so they resist the question at all. They also understand better than most that most problems and solutions are multifaceted and causality is hard if not impossible to determine. While measurement of cost-­effectiveness may need to be improved, it is counterproductive to argue that it is irrelevant. By comparison, proponents of medical care solutions don’t hesitate to argue the clinical or cost savings benefit of interventions at a very early stage, and they don’t hesitate to extrapolate from pilot successes to the impact of broader implementation. For that matter, proponents in many sectors of government (education and public safety come to mind) often seem more comfortable than do those in public health in arguing the cost-effectiveness of their functions. In the real world of limited budgets and political decisions, public health needs to compete. At the same time, leaders must also be honest with themselves about the quality of the evidence on which programmatic decisions and policy arguments are based and work to improve it if it is not up to the task. This is further explored in Chapter 9. Accurately Gauge Public Support Effective leaders don’t assume that they know what the public thinks about an issue. They do the research to find out. When they discover distinct pockets of concern, they take them seriously. As an example, the impact of individuals who oppose vaccinations despite overwhelming evidence of their safety and effectiveness has been a vexation to just about every public health leader. Similarly, those who fear all forms of data reporting, including health behavior surveys and disease surveillance, citing privacy concerns, have been effective in blocking the expansion of information sharing systems. They also have succeeded in some places in getting significant restrictions placed on what have long been considered to be core public health functions. It is not effective to dismiss either group of individuals as uninformed. Public health leaders need to work harder to understand their concerns, acknowledge them with respect, try to accommodate reasonable requests, counter concerns with the field’s best evidence, and out-communicate and out-organize them. Another caution regarding public support is to beware of overreach. Change is frequently better supported and sustained when it comes through bottom-up democratic or grassroots processes like



7  Effectively Wield Power

173

local ordinances and legislative deliberations, rather than top-down ­mandates imposed by the courts or by regulations pushing the edge of an agency’s or a leader’s authority. As an example, the difference in the U.S. public’s reaction to the sensitive issues of abortion compared with same-sex marriage is striking. Many legislative and judicial leaders have observed that the public majority was not ready for the sweeping Roe v. Wade abortion rights decision when it was made in 1973. Indeed, the number of state laws restricting abortion has continued to grow in recent years, with many laws passed expressly for the purpose of challenging the Supreme Court’s decision in the hope that another Court would rule very differently. By contrast, the federal Defense of Marriage Act was also overturned by the Supreme Court (in 2013), but that followed a whole series of state legislative campaigns and a well-documented sea change in public opinion on the subject in recent years. The importance of public support—having it, or being able to build it—cannot be overstated. In working to change personal behaviors and the community conditions in which those behaviors are influenced, public health leaders are proposing actions that create new constraints on choices and have economic consequences for many. It’s important for leaders to ask themselves critically: do you believe, do your allies believe, and can you persuade the public to believe that the benefits outweigh the costs? In both financial and ethical terms, leaders should be prepared to make a strong case that the positive impact on the community outweighs the constraints to individuals and the cost to some sectors. Outline a Public Campaign A “campaign plan” will be refined with coalition partners as an initiative evolves, but it’s helpful for a public health leader to lay out the outline of a campaign plan from the start. The goal of the campaign needs to be compelling on the public’s terms. Is there evidence that people will care about it, and can it be packaged well? How will you create some drama where it isn’t obvious? How will you attract more allies to your side? Returning to Fineberg’s (2013a) analysis of resistance to disease prevention, leaders need to find ways to put a face on the statistical lives saved and to help make avoidable harm as unacceptable as the outrage created by “unavoidable” harm. One way to do this may be to enlist as allies those who have lost loved ones to preventable events and who want to do something to help prevent future tragedies.

174

III  Competencies for Public Health Leadership

Any campaign requires resources. Leaders need the funding and know-how on their staff and/or among their partners to manage the media component of the public campaign. Many people underestimate the science and skill needed on the communications end of an effort, thinking that’s just something they can handle themselves. This is no less critical than what is often perceived as the more technically rigorous work of assembling the epidemiological evidence on an issue. Does This Issue Make the Short List? After the initial planning and due diligence is performed to make sure the needed resources are available, leaders should take a final “gut check.” Political capital is finite, no matter how powerful the leader, and it should be expended judiciously. This means taking a hard look at the intersection of the problem’s urgency, the strength of the proposed solution, the leader’s authority and influence, and the strength of public support. Through that lens, is the issue “ripe”—at least enough to take a constructive first step on what could be a long road of change? This fundamental judgment call falls on the leader to make. Build coalitions of core supporters, new partners, and issue-specific allies As elaborated in Chapter 6, public health issues affect an unusually broad and diverse group of stakeholders. This produces a broad pool from which to draw allies, and sometimes an equally broad pool of opponents. In Chapter 6 we discuss the importance of being genuinely inclusive in public health initiatives, and this certainly extends to the political arena. Core Public Health Supporters Public health leaders can cultivate a base of consistent supporters who will stay informed about public health issues in general. These are groups who care about the broad role public health plays, and who can help advocate not just on high-profile campaigns but also on the breadand-butter issues of infrastructure and the scope of public health’s authority. Some groups are natural allies who already understand your issues. These would likely include the local public health organizations, schools of public health, some if not all health care delivery organizations



7  Effectively Wield Power

175

(especially those with a major safety net role), and health advocacy organizations. But the support of such organizations should not be taken for granted—they need to feel important, consulted, and appreciated. They should know that they can count on you to help with their issues, too. It can be easy to take your closest allies for granted. Don’t. They aren’t mind readers, and they have their own battles to fight. Social justice groups are natural allies given the social determinants of health framework. They are discovering the connections among the issues they have historically cared about and health. Public health leaders are finding them and helping them find those connections. ISAIAH, for example, is a national organization of faith groups in the United States who are engaged in public policy issues. The Minnesota chapter had not previously been active in health policy until their members became familiar with the social determinants model and began to see the link between economic and racial justice and health. The organization has become a significant partner for public health organizations in advocating for the use of Health Impact Assessments in economic development projects in Minnesota, as discussed in Chapter 6. Other less “natural” allies may need to be cultivated, but it’s important to help them to understand that they too are part of the public health fabric—both dependent on it and able to contribute to its success. As the Institute of Medicine’s 2003 report, The Future of the Public’s Health in the 21st Century, points out, the larger public health system has many more layers and branches than just public health agencies—including the community, the health care delivery system, employers and businesses, the media, and academia—and is much richer for it (Institute of Medicine, 2003a). Some of these groups have long been public health supporters, or believe themselves to be. But more likely than not, they have a fairly surface-level understanding, or think it’s enough that they support public health goals, do some of their own community health efforts, or sign on to a statewide public health initiative here or there. This might apply, for instance, to most health care delivery and insurance organizations and their trade associations. However, many of the organizations have never really committed much time or many resources to advocating for the larger whole, nor have they even been asked to do so. Have we in public health put much energy into helping them see the interdependency of their interests with ours? It won’t happen automatically and is worth greater attention from public health leaders to make sure the public health “tent” gets a lot bigger and sturdier. Other groups are newer to the public health conversation, and they can bring tremendous assets and new skills and energy to it. Employers

176

III  Competencies for Public Health Leadership

have an interest in the health of their workforce and their customer base, and certainly health care costs are among their most significant challenges. But it’s only fairly recently that employers see public health as an ally, or see themselves as part of the public health system. This opportunity needs to be nurtured and grown. Two other important constituencies noted by Benjamin (2006) are the public and policymakers. We have discussed in the previous chapter the importance of recruiting the public as an ally. Benjamin (2006) emphasizes the need to expand the level and directness of the communication between public health organizations and the public. Persuading the public and policymakers also requires greater attention to the dissemination, not just the accumulation, of public health science and evidence. Even among solid friends there will be disagreements, maybe strong ones, on specific issues. Finding ways to accommodate those issuespecific disagreements while keeping the coalition together broadly is important. Knowing disagreements will happen and being prepared for that prevents overreaction. Allies benefit from constantly noting the issues they agree on, and openly addressing disagreements and explaining them in neutral terms. Trade associations have to do this regularly, and the most effective of them get good at it. The least effective never do; those are the associations that can only ever take “lowest common denominator” positions to avoid internal controversy and as a result rarely have an impact on mobilizing change. Issue-Specific Allies In addition to casting a wide net of invitations to potential allies, being mindful of the political power dynamic means paying particular attention to allies who can help move or solidify public sentiment on a particular issue. This means identifying what groups or individuals have credibility on that issue, and identifying who can help mobilize grassroots support when needed. “Unexpected” allies can be particularly useful, as in this example expressed by author JM: In 2000 many public health practitioners in the Minnesota Department of Health thought the Department could play a constructive role in advancing end-of-life planning in Minnesota. Several leading health care organizations had been working on the issue for a few years, but they felt they were reaching the limits of what they could do without broader community endorsement. I convened a “Commissioner’s Advisory Group” (no legislation or permission needed) that



7  Effectively Wield Power

177

tapped some of the same groups that had been working with the agency through the Robert Wood Johnson Foundation’s Turning Point Initiative, including those core supporters who had always been with us and those we had been cultivating. We also added some new groups, including a more diverse set of leaders from the religious community, and in a rather unusual move, we asked representatives of the main antiabortion or pro-life advocacy organizations to join us. They were surprised to be asked, since our usual relationship was to disagree over family planning, but they came, and their participation added credibility to the group’s report. I can’t say that advisory group or report was a breakthrough in improving end-of-life care in our state, but I do believe it was among many steps in changing the conversation and building readiness in many sectors of our community for a conversation that finally seems to be ripening. That story is a good example of the adage that “in politics, there are no permanent friends and no permanent enemies” if you have your eye on the ultimate goal. Pfeffer (2010, p. 8) advises us to “make important relationships work—no matter what.” His advice speaks to the need to pick your battles, not get distracted by sideshows, and not let the perfect be the enemy of the good.

Deal effectively with opponents Dealing with declared opponents requires tact, understanding, and patience. It is important to seek to understand and respect their point of view, understand what they have to lose, and acknowledge that they may very well find the weak point in your argument. If possible, their concerns should be addressed. Opposition to any public health intervention can and should be anticipated, and leaders can preempt some concerns by addressing them in advance. For example, it is predictable that some groups will oppose public health activities that restrict individual freedom, such as freedom to smoke, avoid vaccinations, eat unhealthy foods, or other personal choices. Their concerns, as noted above, should be understood and respected. It is important to be fact-based and respectful in how opponents’ concerns are countered. As Heifetz and colleagues write, “Authentic empathy has consequences”—if you understand the loss the other

178

III  Competencies for Public Health Leadership

party expresses (e.g., loss of individual freedom), you acknowledge accountability for inflicting it if you win. This is another way of “­ taking responsibility for casualties” when exertion of power hurts others ­ (Heifetz et al., 2009, p. 144).

Be strategically agile Politically effective leaders find a way to get their way. If one strategy doesn’t work, they look for another. This means not relying solely on  one particular ally, or the outcome of one particular meeting, or even one particular strategy. When one strategy stalls, another can keep ­advancing. Another reason to “advance on multiple fronts” (Pfeffer, 2010) is that sustained progress is necessary to keep allies engaged, attract new ones, wear down the opposition, and build momentum. This conveys a sense that success is a matter of time and persistence, and that failure is unacceptable. The battle against tobacco use in the United States over more than half a century is a good example. Public health advocates, significantly supported by the Robert Wood Johnson Foundation, simultaneously pursued health education, development of better clinical cessation programs, local and statewide ordinances to raise the legal age for tobacco use and to prevent smoking indoors, and increases in taxes on tobacco products—while investing in needed research on the effectiveness and optimal mix of these strategies. Strategic agility also means being realistic—knowing what’s possible. In many cases, incremental progress toward a grander vision is likely to be the only practical route. Big ideas may take a long time for public will to form around them. Taking a long-term approach means not giving up at a first defeat. Multiple tactics that can work in changing circumstances are needed to make big changes. Politically astute leaders are always thinking about how to build from one step to the next, or to the next issue—applying the political capital they have just built and being even more politically savvy in the next round. Long-term thinking also means anticipating changes in political winds, particularly in the public sector. Seeing the long term will help public health leaders leverage much greater change. In Minnesota, a successful 1998 lawsuit by the State against the tobacco industry could have been better leveraged for greater long-term change. The lawsuit was successful in part because of extraordinary leadership by the state’s Attorney General, Hubert (Skip) Humphrey, and Blue Cross Blue Shield of Minnesota—the only private plaintiff in the series of state suits against the previously undefeated tobacco industry. When



7  Effectively Wield Power

179

Governor Ventura came into office, dispensation of the proceeds of the settlement was a central issue in his first budget. The use of the Health Commissioner’s formal and informal authority, the use of evidence, and the strength of coalitions built over many years led to the passage of legislation establishing endowments worth over $1 billion, which would fund about $15 million per year in tobacco prevention and an equal amount for health professions education. However, the impact of the victory was wiped out in 2003 when a new governor, from a different political party, insisted on elimination of the tobacco endowment to help eradicate a budget deficit caused by the recession and the failure of the previous legislature to enact a structurally balanced budget. An important lesson from this example is that public health advocates need to think ahead and prepare strategies that can evolve as political and economic circumstances change. While other parts of the state budget also took cuts during the recession, most of them have since mounted efforts—some but not all successful—to restore those cuts. The public health community to date has not mounted any effort to restore funding for prevention efforts from the tobacco lawsuit settlement proceeds, which continue to bring about $200 million per year into the state’s coffers. Sadly, the state has also sold its future proceeds for a number of years to an investment firm in a fiscal move known as “securitization.” Again, due to a surprising lack of political mobilization on the part of the public health community in Minnesota, little protest was registered.

CONCLUSION Public health leaders who use power effectively embrace formal authority and cultivate influence throughout their programs and organizations and with stakeholders. They understand that in public health work, what the public thinks matters, and they respect it, understand it, and influence it through smart campaign tactics. They fit their goals and tactics to the moment, realizing that public health issues are often divisive. They build coalitions and find common ground with opponents where possible. They keep the long term in mind, expecting ups and downs and having a plan to work through both. Successful and significant public health “campaigns” have been waged in a variety of venues. New York City is one of the most notable. Former Mayor Michael Bloomberg and public health advocates aggressively wielded power over many years to implement public health action in New York City, as summarized in the case In Practice 7.2.

180

III  Competencies for Public Health Leadership

in practice 7.2 WIELDING POWER FOR POPULATION HEALTH: NEW YORK CITY New York, New York—New York City, “The Big Apple,” or NYC, for short—is a larger-than-life city in many respects. It is the center of U.S. financial operations, a trendsetter in fashion and the arts, a historic political town that served as the first U.S. capitol, and continues as a national political powerhouse to this day. And, since the election of Michael R. Bloomberg as its 108th Mayor in 2001, NYC has emerged as a hotbed of U.S. public health reform. Driven by Mayor Bloomberg’s passion for public health and its nationally recognized Board of Health (BOH)— including former Commissioner Thomas Frieden, MD, MPH, and his successor, Commissioner Thomas Farley, MD, MPH—the City has implemented a series of “ambitious new health strategies that have become national models” (City of New York, 2013).

Political Forces for Public Health Change NYC has championed several groundbreaking health policies since 2001, many of which have inspired similar initiatives across the United States. Examples include the following: mandates requiring chain restaurants to add calorie labels, ban trans fats, and limit salt in prepared foods; prohibition of smoking in public spaces; increases in cigarette taxes and restrictions on displays of tobacco products; and efforts to increase physical activity, including added miles of bicycle lanes and campaigns to increase the use of stairs over elevators (Alcorn, 2012; City of New York, 2008; El-Naggar, 2013; Hartocollis, 2013). Much credit for implementing healthy policies is given to Mayor Bloomberg, who says his “obligation is to protect the citizens . . . not to have high ratings . . . I believe you do the tough stuff first” (Bennet, 2012, paras. 20, 24). He has also led national public health initiatives, such as Mayors Against Illegal Guns, a coalition of over 1,000 mayors that he cofounded and cochaired (Mayors Against Illegal Guns, 2013a). But Mayor Bloomberg is not alone in the ongoing campaign to promote a healthier NYC through tough, often controversial, policies. Dr. Thomas Frieden, head of the U.S. Centers for Disease Control and Prevention (CDC) since 2009, became NYC’s Health Commissioner in 2002 and the first leader of the newly combined Department of Health and Mental Hygiene (DOH; NYC DOH, 2002). According to the official press release (NYC DOH, 2002, para. 2), Dr. Frieden’s earlier efforts in NYC as Assistant Commissioner and Director of the Tuberculosis (TB) Control Program from 1992 to 1996 effectively “halted the tuberculosis epidemic.” He also impacted global TB during his 5 years as Medical Officer for the World Health Organization; he is credited with helping to develop “one of the most effective tuberculosis programs in the world” (para. 2). Becoming Commissioner shortly



7  Effectively Wield Power

181

after 9/11, Dr. Frieden set out to heal and improve city residents and communities as a way to help both recover and become even healthier. With Dr. Frieden’s 2009 departure to the CDC, Thomas Farley, MD, MPH, was appointed Commissioner, transitioning from Dr. Frieden’s Senior Advisor in 2007 and 2008, and chair of Tulane University’s Department of Community Health Sciences in its School of Public Health and Tropical Medicine (NYC DOH, 2013). Dr. Farley took over one of the oldest and largest public health agencies, with an annual budget of $1.6 billion and more than 6,000 staff, and became Chair of the NYC Board of Health, an 11-member oversight board of appointed, unpaid experts that collectively administer NYC’s Health Code.

Outspoken Champions of the “Nanny State”—With Impressive Results During Dr. Frieden’s tenure as Commissioner, he championed the City’s smoking ban, as well as led the prepared food changes in chain restaurants. Of his contributions, U.S. Senator Kirsten Gillibrand commented, “Dr. Frieden has shown tremendous leadership in New York City,” including reforms which she recommended should be at the federal level (Lombardi & McAuliff, 2009, para. 13). His key political partner in reform, Mayor Bloomberg, credited Dr. Frieden for the NYC smoking ban: “There’s probably nothing any person will ever do to save as many lives as the one act of our Legislature getting together here in the city passing the smoking ban, and Tom deserves the credit” (para. 5). Dr. Farley has continued these health-improving policies during such provocative public health campaigns as requiring cigarette vendors to post graphic images of diseased organs (such as lungs and brains) where tobacco products are sold, promoting reductions in soda drinking with shocking YouTube-based videos (such as someone “drinking” fat from a soda can), and limiting the size of sugar-sweetened beverages sold at the specific retail outlets; the latter initiative was defeated in the state court in March 2013 (Hartocollis, 2010, p. 4, 2013, para. 8). Through all of these efforts, Mayor Bloomberg has been a staunch and outspoken ally of the DOH Commissioners and the BOH, making programs and policies “to improve the general health of New Yorkers a defining feature of his 12-year tenure” (El-Naggar, 2013, para. 5). For example, regarding initiatives to encourage use of the stairs in buildings through promotions, signage, and revised building codes and design, Mayor Bloomberg explained the changes in terms applicable to most of NYC’s public health reforms: “The economic benefit is you will live longer. . . . The whole idea here is not to change what you have to do, but to give the idea or the impetus to do something that is in your own interest” (El-Naggar, 2013, para. 11), in large part by introducing a “series of measures to alter the choices available to residents” (Alcorn, 2012, p. 2037). While critics protest against paternalistic measures that have created what they term a “nanny state,” NYC public health advocates point to quality and quantity of life improvements for residents as evidence of the policies’ benefits (Lombardi & McAuliff, 2009).

182

III  Competencies for Public Health Leadership

Using Scientific Evidence and Structural Change to Enact Policies for Healthier Living Nationally, life expectancy has not improved on the scale seen in NYC, including a 10-year increase between 1987 and 2009 for residents of Manhattan. These findings by Mokdad and colleagues, as cited by Alcorn (2012, p. 2037), are attributed in part to NYC’s DOH, which has aggressively reshaped New York’s social and physical environment to encourage healthier living. The NYC Public Health model is held up as one that the Bloomberg administration, its DOH Commissioners, and the BOH members have based on scientific evidence to “justify and design their policies” and one that has implemented structural changes to support necessary reforms, such as the creation of “a bureau of chronic disease” to ensure “that somebody is paying attention to the issue of chronic disease” (Robert Wood Johnson Foundation, 2013e, paras. 3–4). By continuing in the historic role of large cities as laboratories for health care reform, NYC has shown the way to cities across the United States. Leading the pack has been Mayor Michael Bloomberg, considered the “nation’s first and maybe the world’s first public health mayor, who has made clear that he is willing to take controversial positions to improve the health of his c ­ itizens,” quoting Commissioner Farley (Alcorn, 2012, p. 2038). By combining forces, dedicated scientific and political leaders in NYC have wielded power to reform the public’s health not only in their city, but have become national examples of how to change “the social context” for healthier, longer lives.

chapter 81

Prepare for Surprise in Public Health Work

key terms comfort with ambiguity emergency response plan Emergency Risk Communication   Branch, Centers for Disease   Control and Prevention initiative National Health Security   Preparedness Index

National Incident Management  System power law resilience transparency World Health Organization best   practice guidelines

L

eaders in all types of organizations and in all sectors face surprises and the challenges of leading under pressure (Mitroff, 2004). But public health emergencies have some unique attributes that call for particular leadership competencies, and leading during emergencies is a test almost all public health leaders will face at some point. These can be defining moments for leaders and for the organizations they are leading. Public health surprises come in an impressively broad range of types. In addition to the classic crises of infectious disease or food-borne illness outbreaks, almost any other type of emergency event will have a public health dimension—from natural disasters like hurricanes or tornados to human-made disasters like environmental “accidents” or terrorist

183

184

III  Competencies for Public Health Leadership

attacks. For this reason, public health preparedness has turned largely to an “all-hazards” approach, and it has become critical for leaders to make sure their organizations are at the table in emergency planning led by others as well. Preparation for expected emergencies builds resilience in public health organizations for true “surprises,” as well. Given the broad range of potential public health crises, it’s almost inevitable that leaders in public health will be called on to lead in a crisis, at some level and in some respect. With new and reemerging infections (HIV, severe acute respiratory syndrome [SARS], avian flu, Middle East respiratory syndrome [MERS], and whatever comes next) and our increasingly interconnected planet, emergency preparedness and management are part of public health’s “new normal.” While it can make for some sleepless nights, leaders need to come to grips with the fact that an outbreak across the globe is now less than 24 hours away from being potentially their problem. While public health practitioners and observers used to debate whether it was inappropriate “fear mongering” to call attention to how vulnerable the population is and how urgent is the need for better preparation, it’s now thought to be irresponsible for leaders not to be able to “imagine the unimaginable” and do something to get ready for it. To get ready for surprises, Gebbie et al. (2013) have proposed a set of “preparedness core competencies” for public health workers in the United States, designed to be consistent with the U.S. Department of Homeland Security’s National Response Framework and “target capabilities list.” For leaders, they stress the importance of effective problem solving under emergency conditions, managing one’s emotions and behaviors, facilitating collaboration, and demonstrating respect for all persons and cultures. We build on and around those competencies in this chapter. In an emergency, actions will almost certainly need to be taken on the basis of decidedly imperfect information. Koh and McCormack (2006, p. 107) describe the challenge as follows: “Rarely blessed with the luxury of rigorous studies with defined end points, leaders often find themselves intervening in the midst of public pressure based on minimal and incomplete data.” While that statement applies to “regular” public health challenges, the heat is turned up immeasurably in a crisis where health and lives are at clear risk. In an extensive study of public health agencies’ preparedness, Lurie, Wasserman, and Nelson (2008) noted that leadership is a critical variable in how agencies perform in emergency response exercises. Specifically, the researchers call out the readiness and willingness of leaders to act, even without the comfort of “perfect” knowledge, as if there was such a thing. The fears generated by unknown causation or by communicable outbreaks create a whole other challenge and give rise to a critical competency



8  Prepare for Surprise in Public Health Work

185

of public health leaders—crisis communications. Because of the visibility of many public health crises, how a leader leads in those moments often defines the leader, in the eyes of staff, funders, elected bosses, community partners, and the public. These are also “teachable moments” when everyone is suddenly very aware of what public health organizations do (or at least that they exist!), so leaders have a real opportunity to build support for public health more broadly or lose it, in ways that can last well beyond the end of the event. It’s also important to realize that sometimes a crisis is not a singular event, but rather a growing concern that at some point in its evolution reaches a critical mass of concern and public visibility. For instance, an elevated level of cancer cases in a community can lead to suspicion about some type of environmental exposure, a fear that may not be possible to dispel for years or decades, even if the evidence suggests it is likely a naturally occurring cluster of cases. Sometimes, the elevated community concern compels public health leaders to look more deeply into issues, occasionally breaking new ground in bringing to light suspected causes, or relating previously suspected but undocumented toxins to disease. For instance, such a “long-term crisis” has emerged regarding the exposure of taconite mine workers to asbestos and its potential link to a rare form of cancer, mesothelioma, in northeastern Minnesota (Regents of the University of Minnesota, 2013). It takes many years for the disease to emerge, and years to document evidence of causation. Leaders step to the forefront when the timing is right.

VALUES AND TRAITS Comfort With Ambiguity By definition, surprises open us to the unknown, unpredictable, and uncharted, however well-prepared we are in advance. The ability to “roll with the punches,” adjust, and adapt is rooted in one’s comfort level with ambiguous situations. Those who crave certainty and predictability will be less able to innovate and improvise in response to surprises. Initiative In most of this book, we stress collaborative leadership competencies, but we also highlight the importance of flexibility and versatility in leadership style. Effective leaders need to be willing and able to step

186

III  Competencies for Public Health Leadership

up and take unequivocal responsibility for making decisions when required to protect the public’s health. People look to leaders for guidance and information during surprise events. This form of initiative, though, needs to be coupled with the ability to stay cool in a crisis. Projecting calm and professionalism, even when you yourself are scared and tired, builds confidence in others. Standing up front in a crisis requires self-confidence, initiative, and control over one’s emotions. The utility of the personal traits of comfort with ambiguity and initiative is noted in remarks by Nicole Lurie, Assistant Secretary for Preparedness and Response, U.S. Department of Health and Human Services. In the In Practice 8.1 exhibit, Dr. Lurie discusses the need for leaders to step forward during crises, and she outlines many of the competencies needed from a leader in public health emergencies. She convincingly argues that excellence in public health emergencies is inseparable from the daily operations of protecting public health. The significant federal investment in strengthening public health emergency preparedness over the last decade in the United States can pay big dividends in strengthening the public health system overall. Public health leaders can use improvements in preparing for surprise to leverage further and even more transformative improvements in the future.

in practice 8.1 LEADING IN PUBLIC HEALTH EMERGENCIES* As U.S. Assistant Secretary for Preparedness and Response, Nicole Lurie, MD, MSPH, directs the office leading national preparedness, response, and recovery from public health emergencies. She leads the “go-to” team that coordinates the federal response to public health emergencies ranging from hurricanes to bioterrorism (U.S. Department of Health and Human Services, n.d., para. 1). Dr. Lurie believes that being prepared for such life-altering events “is built on the back of strong day-to-day capabilities: if you can’t do it every day, you can’t do it game day.” The public health leader’s job is to “ensure that you and your organization have sound capabilities and that they are second nature.” Dr. Lurie summed it up like this: “Roughly 80 percent of what you need to do is similar regardless of the emergency. Mastering that 80 percent means that people can be flexible and innovative to address the unpredictable 20 percent.” Being ready for “game day” in the 21st century requires changes in the ­public health infrastructure, according to Dr. Lurie and her colleagues’ findings in a body of work done at the RAND Corporation to study agencies’ preparedness *Quotations not otherwise attributed are from N. Lurie, interview, August 23, 2013.



8  Prepare for Surprise in Public Health Work

187

(Lurie et al., 2008, p. 227). Needed changes include “new partnerships, changes in the workforce, new technologies, and evolving organizational structures.” A central conclusion of the RAND work was that the existing infrastructure has yet to evolve for modern realities. Dr. Lurie urges that the existing public health system be rebuilt to address the fact that diseases are not contained by the borders or jurisdictional boundaries faced by public health authorities (Lurie, 2002). Elements that will contribute to a new public health infrastructure include the following: new and sustained funding streams; operational definitions of public health that clarify roles; accountabilities and expectations between public health entities and partner organizations; development and adoption of standardized measures and metrics supported by a strong evidence base; and improved assessments of the structural elements of preparedness (Lurie et al., 2008, pp. 233–237).

The Public Health Leader’s Role The RAND researchers identified leadership as one critical deficit and challenge in order to better protect population health in an emergency. Presented with tabletop exercises that tested the performance of health departments in a variety of scenarios, the top performers were consistently led by individuals willing to take responsibility and make timely decisions necessary to address the hypothetical situations. Leaders demonstrating strategic thinking, collaboration, and delegation skills also fared ­better overall, highlighting the benefit of leadership training programs for employees to develop skills applicable under routine and crisis conditions (Lurie et al., 2008). Dr. Lurie reported that in the RAND exercises it was striking how often the ­public agency head did not take charge of the situation or make decisions, preferring instead to “co-lead” with others, often regardless of their expertise. Whether this is due to public health’s generally collaborative culture, a lack of ­self-confidence, or a lack of deference from peers, the end result was that these leaders seemed unable to make needed decisions in a timely manner—a critical failing, especially with the public’s health at stake. A public health leader’s obligation is clear to Dr. Lurie: “You make the best possible decision you can make with the information at hand; not to make a decision or not to act is unacceptable.” To do this, a leader needs to draw on certain competencies and needs to have built a capable organization and a healthy learning culture. Situational awareness, decisiveness, and effective communication are competencies for the individual public health leader, while the organization must be capable of high-quality surveillance and situational analysis, in addition to having an overall culture of openness and excellence in order to succeed in times of public health emergencies and disasters. Dr. Lurie provides a succinct process for public health leaders to follow: To make a decision, make it now, and make it on the best available science—you must know what the best science is and it must be available at your fingertips; understand what are the best courses of action and consequences three to four steps down the line of each option—because multiple courses of action are always available—and you may need to change course as additional information becomes

188

III  Competencies for Public Health Leadership available. Make sure you have support around you to always help you be aware of what you don’t know and highlight what you might not be thinking about.

Balancing Command and Collaboration Some emergency management skills can fly in the face public health training. Epidemiological methods require double- and triple-checking results before ­sharing your conclusions. In emergency management, though, you often have to “make a decision, and make it now if it’s needed now.” A public health leader must find the balance between “getting it all right” and “making the best decision with the best information available,” which may result in a decision that is only “directionally correct and may require fine-tuning as the situation evolves.” Another important element in emergency decision making is having ready access to differing views and new ideas in all stages of a crisis, whether preparedness, response, or recovery. This discourse is the result of the routine leadership practice of soliciting and being open to different opinions and perspectives. Leaders must remove the “culture of retribution for those who disagree. It is hard, but critical, to create a culture that ensures people feel safe to take initiative and innovate,” according to Dr. Lurie. It is easy to develop a culture of “group think,” where everyone thinks and feels the same or fears being penalized for thinking differently. But having opposing views and innovative ideas available quickly during times of decision—especially during a crisis—allows the public health leader to consider and select from multiple courses of actions. Soliciting differing opinions builds trust throughout the organization because, in reality, there may be multiple well-grounded courses of action. The leader’s job is to consider these challenges, and sometimes even contradictions, and act in a way that ultimately, she believes, best supports the mission and vision of the organization. Ultimately, from Dr. Lurie’s perspective and experience in emergency preparedness and response, the public health leader must be willing and able to step up and say, “I am in charge,” after providing the opportunity for broad input to define possible courses of action. Often you will come to a consensus decision, but if you don’t, you will at least have knowledge of the consequences of each decision. You need to make the decision today, versus in 3 months—and you must communicate the decision transparently, including what you considered and why. You must be open to questions and judgments, and you will need to explain, under trying circumstances. “The ‘retrospectoscope’ is often harsh,” notes Dr. Lurie. Dr. Lurie’s advocacy of command in crisis decision making coupled with a culture of openness, support, and respect to inspire diverse and innovative solutions to complex challenges provides a powerful guiding principle for public health leaders’ preparedness and response.

Transparency A good bit of effective leadership in a crisis is determined by people’s willingness to trust and to follow. Leaders are more trustworthy when they explain their decisions in the moment. When trying to contain



8  Prepare for Surprise in Public Health Work

189

public panic, this is especially crucial. Furthermore, as explained by Dr.  Lurie in the In Practice exhibit above, leadership decisions and actions taken in an emergency will inevitably be second-guessed, and leaders need to be able to explain what they did and why in an open and nondefensive manner, despite adversarial questioning by the media and public. Author JM presents one episode in which transparency was a guiding principle: Public health practitioners in the United States were doubly challenged by an anthrax attack in Washington, DC, shortly after 9/11/2001. Because of surveillance systems in fairly strong local and state public health agencies distributed throughout the country, it was apparent to the public health community fairly soon that there were not widespread cases of anthrax exposure. The Centers for Disease Control did its detective work to connect the dots between the individuals who got sick and who died and determined quite quickly that the attack came through a specific postal distribution route. Nonetheless, the public was panicked nationwide. Public health agencies all over the nation, along with doctors’ offices and hospital emergency rooms, were swamped by people with respiratory ailments and claimed exposures to all kinds of white powders. The phones rang off the hook and trucks literally appeared 24/7 at the doors of public health laboratories with material to test for anthrax. At the Minnesota Department of Health, we decided to take quite a firm stance against testing all the white powder that showed up at our door, trusting in the evidence that there was no current risk, and in the ability of our systems to detect risk quickly if it were to come to our community. In all the uncertainty of those days, we believed it was important to protect the capacity of the labs and the agency to respond to other emergencies that might very well arise. We were transparent with the media, the politicians, the health care system, and the public about what we were doing and why. We were grateful that in this instance we were right, and the public acceptance was fairly high. Nevertheless, the laboratory system was pressed almost to capacity by fear rather than by widespread illness and death. Just about everyone in governmental public health leadership across the country at that time was shaken by the realization of how precarious our preparedness and response

190

III  Competencies for Public Health Leadership

systems were, which set the stage for extraordinary efforts to improve that began then and continue today. One of the first manifestations of the new national commitment was the plan for widespread smallpox vaccinations in 2002. Even though the smallpox vaccination program never reached the scale initially envisioned by federal authorities, the planning was useful in significantly improving systems for planning and response to annual influenza and preparedness for the inevitable next pandemics.

KNOWLEDGE Public Health Science Basic public health science is quite relevant to the competency of preparing for surprises. Surveillance systems are a backbone of the public health system, and they are critical to early warnings of surprises of many types. Use of social media, in particular, is improving the ability of public health science to study the prediction and evolution of surprising public health events. Knowledge of relevant national and state emergency management systems is fundamental to leading in crises. In the United States, the National Incident Management System provides a starting point, with leaders expected to also know specific state and local division of responsibilities, authorities, protocols, and reporting systems. As the science of emergency response grows, the field will have an even stronger knowledge base to draw upon. Recall the fundamental challenge spelled out in Chapter 3 of balancing public good with protection of individual rights. Particularly in the heat of a public health emergency with extremely high stakes and high emotions, knowing and correctly applying the law is key. It is those laws that delineate authority and assure due process. The laws and procedures on isolation and quarantine are particularly important and sensitive in a crisis involving communicable disease. Other critical laws focus on deploying state resources when local agencies are overwhelmed, or deploying private resources when public resources are overwhelmed. The thick of a crisis is not the time to be trying to determine which statutes are relevant and what they say. For new leaders, this cannot be too far down in the pile of things to learn—the consequences are too great, and leaders have to assume a large-scale emergency could well happen on their watch, probably before they are “ready.” In fact, public health



8  Prepare for Surprise in Public Health Work

191

leaders may often find themselves learning the hard way that the laws and regulations under which they work lack the needed clarity, so pushing for legislative improvements where needed is one way to make a positive and preventive contribution.

Understanding People We noted above the importance of controlling one’s emotions and behavior in leadership activities during a crisis. This is a central part of emotional intelligence, requiring a time-tested awareness of one’s own emotions during stressful events and the ability to control those emotions and project confidence in the ability of individuals and communities to cope with the event. Understanding the response of individuals and social groups to emergencies, and social contagion during panics, is another knowledge area that informs leaders on this competency set.

Understanding Complex Systems The prediction, prevention, and management of emergency events, from natural disasters to bioterrorism, are highly informed by an understanding of complex systems. A simple example comes from mathematical power laws, which express the relationship between the frequency and size of events. The largest events, like powerful earthquakes or typhoons, occur rarely; smaller size events, like small earthquakes and typhoons, occur frequently. The power law seems to be a fundamental property of many natural and social processes, from earthquakes to city sizes. It helps us prepare for the likelihood of extreme events. Complex systems research demonstrates that unpredictability and surprise are fundamental aspects of the world (McDaniel & Driebe, 2005). While the exact nature, timing, and location of surprises cannot be predicted, computational models are becoming more sophisticated in their ability to predict the likelihood of specific types of surprise events and their effects. The sophistication of models will improve in the coming years (Hupert, 2013; Lant & Lurie, 2013). Application of methods from disciplines such as ecology, which focus on long-term ­system ­dynamics, is likely to speed development of the science of preparedness (Smith, Jarris, Inglesby, Hatchett, & Kellermann, 2013). Yet, most surprises indeed will remain unpredictable, with implications for management that are based on an understanding of complex

192

III  Competencies for Public Health Leadership

systems. Such implications include employment of backup and redundant systems, scenario planning, and development of mindfulness and improvisation skills (Begun & Jiang, 2004; McDaniel, Jordan, & Fleeman, 2003). Finally, the knowledge area of quality improvement philosophies and methods is important to preparing for surprises. One of the competencies presented in this chapter is the ability to evaluate emergency responses and learn in order to be ready for the next emergency. This is aided tremendously by having the basic tools of quality improvement in hand.

FIVE COMPETENCIES FOR PREPARING FOR SURPRISE The public health leader’s role in preparing for surprises begins long before the surprise occurs. Preparation for surprise includes building resilience prior to events and developing and testing plans for response. Communicating effectively, executing the plan, and learning after the event round out the competencies for preparing for surprise. They are summarized in Table 8.1. Table 8.1 Five Competencies for Preparing for Surprise in Public Health Work 1  Promote resilience in individuals and communities 2  Develop and test an emergency response plan •  Characteristics of good response plans: comprehensiveness, clarity, and realism •  Practice and test the plan 3  Communicate effectively during surprises •  World Health Organization best practices •  Build trust •  Announce early •  Be transparent •  Respect public concerns •  Plan in advance •  Importance of the message and message delivery •  Collaborate in advance 4  Execute an emergency response plan with flexibility and learning •  Delegate •  Monitor •  Learn fast and adjust 5  Learn and improve after surprises



8  Prepare for Surprise in Public Health Work

193

Promote resilience in individuals and communities Leadership in dealing with surprises incorporates systems thinking about the conditions that create optimal emergency response. Traditional emergency response plans are often limited by their focus on meeting immediate, acute needs. Longer term solutions to dealing with surprise, however, center on building hazard-resistant and resilient individuals, households, and communities. For long-term resilience, communities need robust internal support systems and networks of mutual assistance and solidarity (Dobbs, 2014). Resilient physical structures are created by better building codes, engineering standards, and land use planning. Physical and psychological resilience of individuals is enhanced by better health status. Organizational resilience is enhanced by redundant systems and by investment in training of their workforce and client base. Resilience in communities and organizations is enhanced when conditions for self-organization exist: clear roles, training, connections, and sharing of expertise (Begun & Jiang, 2004). Strong social capital, both in communities and in organizations, is a prerequisite for and a predictor of recovery and may trump both the degree of infrastructure damages and the amount of aid received by an area (Aldrich, 2012; Morton & Lurie, 2013). Develop and test an emergency response plan Given all the attention emergency preparedness has had over the last decade in the United States, most organizations have an all-hazards preparedness plan, and perhaps specific plans for particular types of events built from it. Many public health organizations now have funded staff positions whose responsibility is to create and maintain such plans. Indeed, it may well be part of a public health leader’s political agenda to keep or add to such resources. It’s the job of the leader to look carefully at the response plan and challenge it for c­ omprehensiveness, c­ larity, and realism. The formal leader is the one who will be most ­visible and accountable should it have to be used. Characteristics of Good Response Plans Comprehensiveness: Comprehensive plans anticipate as many dimensions as possible of an emergency and account for the fact that something unforeseen will certainly happen. Different scenarios can address

194

III  Competencies for Public Health Leadership

a range of possible options. Comprehensive plans address the roles of all parts of the agency or organizations. They are careful to consider the needs of various subgroups such as racial and ethnic groups that may face social and economic circumstances that differentially affect their vulnerability, or that may even face different genetic risks; also groups like those with disabilities. Clarity: Clear plans delineate responsibilities and avoid the danger of having great detail on tactics but being dangerously unclear about who exactly does what. Clear plans include backup assignments in case the primary persons or groups are themselves taken out by the emergency or become overwhelmed by volume or unexpected tasks. Realism: Plans need to be realistic in terms of local capabilities. This can be a hard thing for people who are heavily invested in their own history to assess objectively, so it’s critical for the leader to bring this objective view (part of the competency set discussed in Chapter 5). Practice and Test the Plan As the RAND research (Lurie et al., 2008) and the experiences of many a public health leader demonstrate, plans on paper perform very differently in practice. The military saying applies: “no battle plan ever survives its first encounter with the enemy.” Plans need to be tested under a variety of conditions, whether through live simulation or other means. The leader must practice as much or more than anyone. That takes intentional allocation of time. Leaders will get overly busy and may find it easy to assume that everyone else needs to be trained but somehow that the leader’s part will be “natural.” Not so—maybe not ever, but certainly not under the heat of surprise and crisis.

Communicate effectively during surprises While competency in communicating in general is important to public health leadership, with respect to emergency management it is critical. In a crisis, it’s the leader’s job to be out front, take charge, and set a tone of competence, command, and compassion. While good communication skills are needed in daily interactions, they take on particular importance when a public health leader is called upon to inform and direct individuals and groups during times of crisis, disaster, or emergency. Developing these skills before a crisis occurs is the responsibility of public health leaders and their teams.



8  Prepare for Surprise in Public Health Work

195

Extensive resources are available to learn, practice, and strengthen the competency of risk communication, including physical and virtual books, videos, training programs, and best practice guidelines. Best practices from leading organizations, like the World Health Organization (WHO), can also help guide preparation. WHO Best Practices The WHO (2005, p. 1) published best practices guidelines for effective communications in the aftermath of the 2002 to 2003 SARS outbreak, which was labeled “the first severe new disease of the 21st century.” While the primary focus of the guidelines is on the role of communication during an outbreak, the guidelines are straightforward and applicable to communication regarding both daily and extraordinary events in public health practice. The ultimate goal of effective communication is to prevent and control crises and limit the impact on people and their social, economic, and environmental systems, as reflected in the WHO’s recommendations (WHO, 2005, pp. 23–25): 1. Build trust—Trust is the foundation for communication and derives from the public’s perception, confidence, and belief in the involved authorities, including government, agencies, and officials. This is true across cultures, political systems, and levels of economic ­development. 2. Announce early—While this guideline is most applicable to outbreaks and other crisis situations, informing the public about events and activities related to their health and well-being is fundamental to develop and maintain the public’s trust. Having trust in place when an extraordinary event occurs “wins public confidence that authorities are openly reporting what they know when they know it, setting expectations that information will not be concealed.” These sentiments were echoed in remarks by the U.S. Assistant Secretary for Preparedness and Response, Dr. Nicole Lurie, in In Practice 8.1. 3. Be transparent—Communication should be candid, easily understood, complete, and accurate; such features provide a strong incentive for deliberative and accountable decision making. Recognizing the limits of transparency in the public sphere—such as legal and ethical restrictions around private patient information—requires public health leaders to find the appropriate balance between the public’s right and interest in credible, timely information and ­individual rights to privacy.

196

III  Competencies for Public Health Leadership

4. Respect public concerns—Effective risk communications are “a dialogue between technical experts and the public” and must address the rights and interests of the public to receive information that may impact the health and well-being of individuals and their family members. This principle is particularly important to consider in terms of the communities involved and such factors as their culture, language, education, religion, and other demographic and socioeconomic characteristics. Access to information may be impacted by these factors and must be addressed as part of showing respect for all those involved or impacted, especially during times of crisis or emergency. 5. Plan in advance—Establishing the skills, tools, and infrastructure as part of everyday communications will allow for better execution of communication during extraordinary events. The WHO guidelines note that communication cannot be ideally effective “when its principles are considered only at the last minute in the rush to release information.” The old adage “practice makes perfect” applies here. Importance of the Message and Message Delivery Best practice guidelines for effective risk communication frequently speak to the importance of the message. The message must be timely, informative, usable, and accessible to the public at large. Message content and delivery are elements that public health leaders need to plan, practice, and execute on a routine basis, as well as ensure messages are appropriate and available during crisis events. The Centers for Disease Control and Prevention (CDC) and the Emergency Risk Communication Branch (ERCB) address message content and delivery considerations in The Risk Communicator, the ERCB’s online newsletter series. When developing risk communication messages, five key components should be addressed, which align well with the WHO guidelines: reduce uncertainty; increase feelings of control; build trust; communicate transparently; and meet the cognitive needs of people under stress (CDC, 2010a, p. 14). The greatest challenge for risk communicators is crafting messages that drive target audiences to action, which is even more difficult when the audience believes that the emergency or crisis is unlikely to occur, will have little to no impact on them, or that the messages or sources are not credible (CDC, 2008, p. 8). In addition, communicating effectively in a crisis requires calm and confidence, as noted above. Leaders need to be in touch with their emotions and the physical signs of stress, and they may need to apply



8  Prepare for Surprise in Public Health Work

197

stress-reduction techniques. Body language of the leader is important in projecting confidence, so it is important to be aware of one’s appearance. Leaders who communicate high expectations and optimism about people’s ability to rise to the occasion promote positive response on the part of followers (Cabane, 2012, pp. 202–203). A risk communication plan should be developed that addresses the adaptation of health messages for diverse audiences, locations, and circumstances (CDC, 2010a, p. 9). Message mapping is a strong tool to help develop messages appropriate for key audiences and stakeholders who will be experiencing different perceived risks and “mental noise” due to the situation (Hayes, 2002). Being able to communicate clearly, emphatically, compassionately, and credibly is essential to gaining and maintaining the public’s trust before, during, and after a crisis event (Covello, 2003). Hayes (2002, para. 5) uses the analogy of managing drinking water to describe information management: ongoing attention and good sources are required for high quality; established processes are needed to collect, treat, and distribute it; and its flow can be regulated to the point of shutting it off (which can create its own issues). One of the primary tools used to disseminate these messages today is the Internet, which can present challenges in how best to present subject-related content. Important guidelines to follow include use of content from and links to authoritative websites, such as the CDC; regularly refreshed content; presentation in multiple languages; clear, concise, and understandable content; and use of multimedia delivery methods, such as YouTube for video information and instructions. In addition to the Internet, new media channels, such as Twitter, Facebook, and text messages are growing in importance and use as a delivery method to a diverse and technology-dependent culture (CDC, 2010b). Collaborate in Advance Effective risk communication depends on collaborative partnerships and relationships developed in advance of a crisis. These collaborations can and should be extensive: across sectors; with the public, the media, and different levels of government; and even across national boundaries, depending on the scope of one’s duties as a public health leader. Media is an essential partner and audience in risk communication. Covello (2003) advises meeting the needs of the media as a best practice in its own right. Public health leaders need to work with reporters and tailor messages to specific types of media, develop key messages that are repeated during all communications, be truthful and follow up regularly when information is unknown or evolving,

198

III  Competencies for Public Health Leadership

provide the best information available on risks without speculating or over-reassuring, and establish and maintain relationships with editors and ­reporters—while remembering that everything is on the record (Covello, 2003, pp. 5–6). Strong relationships established in advance of emergencies allow for identification and development of roles, communication methods, message content and outlets, and strategic networks (National Center for Food Protection and Defense [NCFPD], n.d.). Developing relationships with key stakeholders and audiences—along with appropriate messages that garner trust and establish empathy with impacted community members—enables public health leaders to be prepared for the times when they need to manage situations and information (Hayes, 2002). Infrastructures can be tested and strengthened, and planning and preparedness can be practiced through local, regional, and system-wide protocols and approaches (CDC, 2010a). Established relationships and collaborations also improve trust and credibility, as well as respect for and understanding what each partner brings to the situation (NCFPD, n.d.). Preparedness is about developing the skills, relationships, tools, and capacity to handle and survive a crisis before that crisis occurs. Remember that there will be a variety of audiences to address at a time when multiple demands will be evolving and changing rapidly (Hayes, 2002). By acknowledging that the unpredictable is a predictable part of public health, leaders can be ready to address both the routine and the extraordinary through risk communication that is established, practiced, and effective.

Execute an emergency response plan with flexibility and learning The competency of executing the plan does not mean doing everything yourself, but making sure the execution is competent. Competent ­execution of the plan requires effective delegation, good monitoring systems, and the ability to learn fast and adjust as events on the ground unfold. Delegate If you know your team and their skills, and if you have a thorough plan that is clear with respect to roles, delegation of responsibilities should be well established in advance. Despite your anxieties, you need to let them do their jobs. Too much “help” from the boss in a crisis is likely to be a problem.



8  Prepare for Surprise in Public Health Work

199

Monitor Even a trusted team needs ways of making sure critical things are being continually checked. Are the steps in the plan being executed? Are there issues, concerned groups, or reactions you didn’t anticipate? Are new facts about the situation emerging? Planning ahead to collect data from the field and establishing performance metrics in advance are important in the monitoring process. Learn Fast and Adjust As explained above, given that the plan cannot have anticipated everything, leaders need to be actively looking for what needs to be changed in the moment, and to be nimble in adapting. Command ­clarity needs to be coupled with simultaneous openness to diverse input. This means listening to all points of view, even and including those not in the mainstream. More generally, direction and control need to be combined with a willingness to change and an ability to learn on the spot. In time-pressured, make-or-break situations, effective leaders take a “two-pronged approach, giving their teams clear direction and, at the same time, enabling rapid innovation” (Rashid, Edmondson, & Leonard, 2013, p. 117). Hupert (2013) gives the example of a hospital evacuation, where knowing the optimal order of evacuation of a critical care unit’s occupants may not be of much use when the pre-event plan calls for elevator use, but the hospital is left without power. Flexibility requires real-time information about the functioning of critical systems and level of threats (monitoring) and flexibility in marshaling resources to maintain continuity of operations of those complex systems (Hupert, 2013). Often, such information and onthe-spot capacity is best handled by self-­organizing of those in the field: “Time and time again, local organizations and networks have proven far more adaptable and responsive than outside agencies in responding to disaster” (Morton & Lurie, 2013, p. 1159). In the aftermath of Hurricane Sandy in the United States in 2012, the grassroots organization Occupy Sandy was credited for its ability to respond with speed and innovation, for example, using social media and its online presence to share critical information with storm victims (Bar-Yam, 2012).

Learn and improve after surprises Taking stock of how things went after a surprise event may sound like it should be automatic—of course everyone should do this—but it takes leadership intention to make it a priority. After the exhaustion of a major

200

III  Competencies for Public Health Leadership

crisis, and the return to the usual busy-ness, it’s harder than one may think to carve out time to systematically assess what went well, what went badly, what to do differently the next time, and even how to generalize some of the learning to improve “routine” daily public health practice. This is an essential component of the preparedness cycle that leaders have a unique duty to make sure happens. The time immediately after a surprise event is also an opportunity for leaders to reinforce the importance of resilience, thus circling back to the first competency in this set (promote resiliency). Surprise events highlight the message that not everything is certain in the future, especially in the public health world, and that the best defense is building a culture and structures and processes that accept uncertainty, expect surprise, and expect to rebound from it stronger than ever. Aggie Leitheiser, a long-time leader at the Minnesota Department of Health, cites several examples of how the agency has learned to improve its capacity to respond to a wide variety of common emergencies such as floods, tornados, and blizzards (A. Leitheiser, personal communication, November 22, 2013). She states, “We have grown considerably in our abilities by having educational materials prepared ahead of time. Having clarified our roles and responsibilities with other state and local agencies, we are more able to respond quickly, can support a broader range of services (like evacuating hospitals and nursing homes safely and quickly), and are better able to manage long-term recovery because of training, exercises, learning from past events, and consistent ­leaders.” A cross-agency group at the agency meets regularly to follow world and national public health events, coordinate testing of possible cases of newly emerging diseases, and develop protocols for immediate management of potentially positive cases. As Assistant Commissioner Leitheiser characterizes it, “We are more willing to prepare for situations, rather than waiting to see what happens and then deciding.” Another example of learning and improving from public health surprises in the United States is the National Health Security Preparedness Index™ (NHSPI™), released in December 2013 by the Association of State and Territorial Health Officials (ASTHO). ASTHO led development of the index, in conjunction with the CDC and a development consortium of 20 public and private health agencies and organizations; the Robert Wood Johnson Foundation will manage and maintain annual index updates (NHSPI.org, 2013a, 2013b; Roos, 2013a). This firstof-its-kind index provides a gauge of the preparedness of the nation and individual states “to prevent, protect against, mitigate, respond to, and recover from public health threats” (NHSPI.org, 2013a, para. 3). The new NHSPI™ will guide and support improvement efforts, inform



8  Prepare for Surprise in Public Health Work

201

policy and resource decisions, encourage collaboration and shared responsibility for preparedness across communities, and advance national readiness to protect people during a disaster through the science of measuring preparedness. The index provides a tool that looks collectively at existing state-level data and includes measures across five domains: health surveillance, incident and information management, countermeasure management, community planning and engagement, and surge management. The 2013 NHSPI™ shows that the nation’s overall health security preparedness score is 7.2 on a scale of 10, with strengths in the domains of health surveillance, incident and information management, and countermeasure management. The community planning and engagement and surge management domains require the greatest work and improvement. Strengths and weaknesses vary from state to state across the domains and subdomains, with limited variability across states on the overall index scores. The index illustrates how public health leaders engaged diverse others—communities, government agencies, policy makers, practitioners, researchers, communicators, and others—to assess, monitor, improve, and sustain health security preparedness capability at the national and state levels. A leader who strives to “learn and improve after surprises” is General Russel Honoré, who led relief efforts in the southeastern United States following Hurricanes Katrina and Rita in 2005. His subsequent focus, based on lessons he learned during his emergency relief work, has been on building an underlying culture of preparedness in the country, as recounted in the profile, In Practice 8.2.

in practice 8.2 A DEDICATED MILITARY LEADER HELPS BUILD AMERICA’S “CULTURE OF PREPAREDNESS” Asked to imagine a contemporary rough-and-tumble military leader, Lieutenant General Russel Honoré may well come to mind. Over 37 years in successively responsible commands in the U.S. Army, General Honoré served with distinction across the globe. Positions included commanding general, 2nd Infantry Division in South Korea; deputy commanding general and assistant commandant at the U.S. Army Infantry Center and U.S. Army Infantry School in Fort Benning, Georgia; and the commander of the Standing Joint Force Headquarters—Homeland Security, U.S. Northern Command (Robison, 2009, para. 2). Yet he is also the man dubbed the “Category 5 General” for successfully commanding Joint Task Force Katrina, the massive poststorm response to Hurricanes Katrina and Rita, which hit the U.S. Gulf Coast only 3 weeks apart in 2005 (Duke, 2005, para. 9). (Category 5 is the

202

III  Competencies for Public Health Leadership

highest rating for hurricane strength.) The job called for an experienced and proven leader, and General Honoré fit the bill.

Strengthened by the Early Example of Hard Work General Honoré’s early experiences on his family’s subsistence farm and the value of hard work he learned in rural Lakeland, Louisiana, had a lasting influence on making him the man and leader he is today (Honoré, 2009). In 2009, General Honoré recounted in his National Public Radio (NPR) “This I Believe” reflection a lesson learned at 12 years old that established his respect for hard work and personal responsibility. After griping about his predawn duties milking a neighbor’s cows, his father said, “Ya know, boy, to work is a blessing. . . . Even having a job you hate is better than not having a job at all.” Looking at his hardworking father and grandfather before him, the General reflected that, “I had a feeling I had been told something really important, but it took many years before it sank in” (Honoré, 2009, paras. 2–4).

Leadership Lessons in the Face of Disasters General Honoré gained national attention in 2005 after being appointed commander over all military branches involved in the extensive storm recovery operations in Louisiana, Mississippi, and Alabama following Hurricanes Katrina and Rita. His training in logistics and human resources management, experience handling national and international disaster responses, and no-nonsense management style made him the perfect candidate for this mission, especially after the unceremonious removal of the Federal Emergency Management Agency (FEMA) administrator assigned to the federal Katrina response (Duke, 2005; History Makers, 2013; Robison, 2009). The General’s job entailed orchestrating a massive response by diverse parties that required both commanding leadership and an openness and adaptability to a dynamic situation. General Honoré demonstrated the “dual imperatives of high-stakes leadership”—directing and enabling—advocated by scholars (Rashid et al., 2013, p. 117). To be successful in complicated and rapidly evolving settings like the postdisaster catastrophe of Katrina, Rashid and colleagues recommend three tasks for leaders to perform: envision—direct a realistic assessment and enable hope; enroll—direct boundary patrolling and enable boundary spanning; and engage—direct execution and enable innovation. General Honoré deftly accomplished these tasks across the Gulf States, receiving respect and praise for getting the job done, as well as for being “the kind of man who’ll cover your back” and ask “for forgiveness rather than permission” (Duke, 2005, paras. 3–30).

Building a National Culture of Preparedness General Honoré retired from the Army in 2008, but not from a life of leadership. He is actively committing the second half of his life to what he refers to as a new mission: creating a “Culture of Preparedness” in America (Honoré, 2013, para. 2), a critical mission indeed in uncertain and changing times. Having witnessed first-hand the



8  Prepare for Surprise in Public Health Work

203

devastating impact on vulnerable people, systems, and structures ­ill-prepared for the catastrophic damage caused by Hurricanes Katrina and Rita, General Honoré believes that Americans have yet to comprehend “the need to be prepared at home and at work for potential disasters” (Honoré, 2013, para. 4). The United States and its citizens, he says, have abandoned a “Culture of Preparedness” that existed during the Cold War in the 1960s, with public and private readiness for an attack. In the wake of large-scale national tragedies in the early 2000s, such as 9/11 and Katrina, the U.S. government reestablished some capabilities through FEMA. But the “new normal” of natural disasters and terrorism demand a new “national preparedness plan, with a local civil defense corps.” Preparedness investment is needed, including education in first aid and pandemics; standards for institutional response to disasters; and infrastructure improvements, such as strategically placed generators and gas stations and flexible communications capabilities (Honoré, 2013, paras. 4–8). Just as important, however, is the need for individuals to assume responsibilities for themselves and their families, communities, and work places, which can be fairly simple. General Honoré provides a three-point plan: develop an evacuation plan; prepare an evacuation kit, including a 3-day supply of food and water at home; and obtain some means of staying informed, such as a weather radio. This emphasis on joint personal and governmental responsibility to move us from an existence “in fear and dependency” to one where we do “the responsible thing and live comfortably in a culture of preparedness” is at the heart of the General’s mission. And, although preparedness is expensive, the Red Cross estimates that for every $1 spent, up to $9 can be saved in the cost of emergency response (Honoré, 2013, para. 5–10). It is a mission that General Russel Honoré is very capable of leading and fulfilling.

CONCLUSION How leaders lead and how their organizations perform during a surprise event reflects how good they are not only at the core competencies needed for good public health practice every day, but also at their orientation to learning, continuous improvement, and the kind of creativity and innovation that can improve the public health system overall for the future. In this sense, being prepared for surprises is a special and distinctive competency that adds value to every public health leader’s portfolio and strengthens public health practice.

chapter 9

Drive for Execution and Continuous Improvement in Public Health Programs and Organizations

key terms accountability accreditation balanced scorecard Consensus Statement on Quality in the Public Health System diffusion theory exploitation exploration financial stewardship Guiding Principles for Health Systems Strengthening initiative integrity lean production

Malcolm Baldrige National Quality Award measurement theory metrics performance measurement Plan-Do-Study-Act rapid process improvement workshop reliance on evidence return on investment Six Sigma social justice transparency

A

fifth and final competency set, driving for execution and continuous improvement in public health programs and organizations, is critical to advancing the field of public health and widening its impact.

205

206

III  Competencies for Public Health Leadership

Execution refers to doing the hard work of following through on commitments and plans. Continuous improvement means constantly searching for ways to add value to and otherwise improve the key processes and outcomes of a public health team, program, organization, or a community. This set consists of five competencies of effective leaders, ranging from holding oneself and others accountable, to taking risks and innovating. Driving for execution and continuous improvement is important for advancing the field of public health because public health knowledge, solutions, and challenges change daily, and continuous learning and change are expected. Advances in the evidence base for root causes and solutions or interventions, in particular, mean that leaders must always be alert for, searching for, and creating better ways to do things. One of our central premises is that public health is undervalued by its constituents, particularly policy makers and citizens. This final competency set is particularly important in turning that around. Like many public services, there is a perception (rightfully or not) that public health programs and organizations lack rigor in execution, tight financial management, and accountability for results. The public and nonprofit sectors are often thought to be lackadaisical in the management of public and philanthropic funds and the performance of their programs and people. This perception must be proven wrong if public health is to thrive. VALUES AND TRAITS Social Justice It may not be obvious how a value of social justice supports a focus on execution and continuous improvement. Allocating more resources to the least advantaged requires that the resources be used with efficiency and effectiveness, to counter the notion that such resources are “handouts” that encourage dependency and maintenance rather than change. Passionate advocates of social justice should be motivated to show that the programs they support are as efficient and effective as programs in the private, for-profit sector. Integrity and Transparency Commitment to one’s integrity as a leader produces honesty in facing the realities of performance metrics. Transparency in financial management and in metrics for performance assures stakeholders that



9  Drive for Execution and Continuous Improvement

207

programs are well-managed or, if problems exist, that they will be recognized and confronted. This is important both to win over skeptics and to strengthen the hand of public health’s supporters. Author JM recalls the critique of a prominent pro-public health state senator in Minnesota, who was concerned about adding significant dollars to a local public health block grant program. The senator said essentially, “the problem with this program is that it’s a black hole—no matter what we add to the funding, there are no measures for what we get out of it.” Reliance on Evidence Evidence-based decision making is important as well in convincing stakeholders that programs and organizations provide value. When a leader commits to using evidence as the arbiter for judging program and organizational effectiveness, and for decision-making, personal and political biases are removed or mitigated. Again, this is particularly important given the perception among many that public health is just so much “do-gooder” social engineering, based more in ideology than in hard science. Initiative Leadership writers Kouzes and Posner (2012b, p. 164) state that “­leaders . . . are fundamentally restless. They don’t like the status quo. They want to make something happen.” Leaders who relentlessly pursue execution and improvement in program outcomes have a certain degree of impatience with the pace of improvement in population health. Leaders who push, set stretch goals, and seek feedback more easily achieve the competencies of driving for execution and improvement. KNOWLEDGE Public Health Science Some concepts, theories, and tools that are basic to executing and improving have been part of public health science for a long time. This includes program evaluation methods, particularly quasi-experimental research design, and evaluation concepts. The concept of logic models is a basic element of the public health science knowledge base that is critical to both execution and improvement, as is evaluation science.

208

III  Competencies for Public Health Leadership

Other relevant concepts, theories, and tools are only recently entering the basic science of public health. Less anchored in public health science, but growing in acceptance, are the knowledge areas of performance improvement, continuous quality improvement, and financial management. Knowledge on performance measurement has improved substantially in the past two decades with wide dissemination of the balanced scorecard method, the Baldrige process, and understanding of the qualities of effective performance measures—measures that are valid, reliable, and understood by users. The methodologies of quality improvement in service settings have become increasingly disseminated, although their customization to public health is relatively new and underdeveloped (Riley et al., 2010). The application of quality improvement methodologies in public health settings is a needed step in cultivating respect for public health organizations and enhancing the impact of public health. Financial management knowledge is even less common in public health science curricula. Working with budgets may be included in basic public health science, but more in-depth financial management knowledge is rarely transmitted. Below we discuss aspects of financial management knowledge that are important for basic public health science. Understanding People To do the hard work of execution and improvement, leaders need to know how to motivate colleagues and workers. The knowledge area of motivating oneself and others, discussed in Chapter 4, is quite relevant to this competency set. A new and growing knowledge area important in improving quality relates to understanding people, specifically how to tap the creativity of individuals. Researchers are learning what stimulates creativity in groups and individuals and what helps drive organizations to be more innovative. For example, rich interaction among diverse individuals, in general, aids innovation. Some corporations are limiting telecommuting because they have learned that it detracts from the face-to-face collaboration necessary for the emergence of organizational innovation. Understanding Complex Systems Much of quality improvement methodology is based on an understanding of systems and applications of systems thinking. Logic models are an example of systems thinking, for example. Systems



9  Drive for Execution and Continuous Improvement

209

thinking archetypes, discussed in Chapter 4, are useful in predicting and avoiding typical performance problems that emerge over time in complex systems. In one sense, an understanding of complex systems challenges an emphasis on driving execution and improvement through metrics and monitoring, since complex processes and outcomes are difficult to measure. This understanding yields an appreciation for that which cannot be measured, and for the limitations of virtually all measures. Effective leaders place metrics in their appropriate context and preserve the right to substitute informed subjective judgment for “management-by-numbers.” Research on change and innovation in complex systems underscores the importance of seeding an innovative culture in programs and organizations. Study of the implementation of innovation is another relatively new area of knowledge that investigates the challenging process of introducing and sustaining innovation in complex programs and organizations.

FIVE COMPETENCIES FOR DRIVING EXECUTION AND CONTINUOUS IMPROVEMENT The extensive use of collaboration in public health work makes execution and continuous improvement more difficult than in the hierarchical corporate organization. Public health leaders have to spend more time and effort on execution and improvement as a result. In this set of competencies, we emphasize the need to hold oneself and others accountable for results. We include a competency drawing on financial management knowledge and skills, another area that has historically received less attention than needed in public health program leadership. Table 9.1 summarizes the five competencies for driving for execution and continuous improvement.

Build accountability into public health teams, programs, and organizations “Accountability” is often mouthed as a basic management principle, but it is equally often downplayed in practice. Yet execution and improvement cannot occur unless individuals and members of teams, programs, and organizations both feel accountable and are held accountable for their promised contributions.

210

III  Competencies for Public Health Leadership Table 9.1 Five Competencies for Driving for Execution and Continuous Improvement in Public Health Programs and Organizations

1  Build accountability into public health teams, programs, and organizations •  Hold yourself accountable •  Hold others accountable •  Program-level accountability •  Accountability in collaborations 2  Establish metrics, set targets, monitor progress, and take action •  Understand measurement theory •  Adopt public health metrics •  Make measures meaningful to stakeholders •  Act on what the metrics tell you 3  Proactively demonstrate financial stewardship of public health funds •  Understand and use external audits and internal controls •  Review and assess financial position •  Develop, present, and manage budgets 4  Employ the methods and tools of quality improvement •  Understand and role model use of quality improvement concepts and methods (Plan-Do-Study-Act, Six Sigma, lean production) •  Support value-adding accreditation 5  Encourage innovation and risk-taking •  Get innovation on the agenda •  Support and reward creativity •  Encourage learning from failure •  Accelerate diffusion of innovation

Hold Yourself Accountable At the individual level, accountability starts with the leader’s own workplace attitudes and behavior. Leaders who do not feel and exhibit accountability in their own work are unlikely to inspire others to do the same. Personal accountability includes being transparent about one’s goals and admitting failure if they are not met. Leaders need to make sure that goals are clear to the team that needs to pursue them, and, if not, the leader needs to assure that the goals are clarified. Note that the first questions might be directed at yourself as the leader—do I really know what this goal means, and how and when can our team achieve it? If you can’t answer that confidently for yourself, what are the chances your team can? Holding yourself accountable also requires that you meet commitments to others. Leaders (as well as others) can easily overcommit due to unrealistic assessment of their own capability and due to their strong



9  Drive for Execution and Continuous Improvement

211

desire to contribute. In public health, as in many fields, the options for additional work are almost endless. The range of issues every public health organization deals with, and the importance of each of them to dedicated staff and passionate community members, pretty much guarantees a constant stream of requests for a leader’s support and personal involvement. It’s hard to disappoint those stakeholders, and it’s easy to assume you have enough time or political capital to take on just one more thing. But overcommitment can yield the same results as undercommitment—failure to meet goals. Setting priorities and focusing on goal attainment are necessary for holding oneself personally accountable. Hold Others Accountable More difficult for many leaders is the task of holding other individuals accountable. In part, this derives from a hope that others will hold themselves accountable. There are two problems with this hope. First, it isn’t always true. Even top performers have “off seasons” or times that they prefer to avoid accountability. Some other individuals make avoiding accountability a habit, being content with getting by and making excuses for their own failings. Second, the information needed to hold others accountable often does not exist or is of suspect reliability and validity. This particularly happens when accountability is not a priority in an organization—leaders in the organization spend little time refining measures and do not allocate their already-scarce resources to collect information to monitor processes and outcomes. Teams, programs, and organizations in public health may simply not have a good idea how they are performing. Addressing this gap is a fundamental goal of the movement to accredit state and local governmental public health agencies that is now taking hold across the United States. Program-Level Accountability As noted above, public health leaders are accountable to a wide range of stakeholders including, at various times, clients and customers, stockholders, regulators, taxpayers, legislators, and private donors. In all cases, program evaluation is one way that public health leaders can demonstrate accountability of their organizations and programs. Evaluations are commonly built into almost every program, but often they receive scant or no resources and attention. In many ways, the evaluation is the most important part of any program, because it contributes to an evidence base and it demonstrates stewardship of

212

III  Competencies for Public Health Leadership

funds, which is the third competency in this competency set. (Other ways to demonstrate stewardship of funds are discussed below.) Public health leaders should understand and support transparent and evidence-based program evaluation. This requires a basic knowledge of program evaluation methods, particularly quasi-experimental research design, and evaluation concepts, such as summative evaluation and formative evaluation. The concept of logic models, which depict program inputs, outputs, and long-term outcomes, is a key knowledge component underlying program evaluation (Taylor-Powell, Jones, & Henert, 2003; Wilder Research, 2010). A logic model for a childhood obesity prevention program in elementary schools, for instance, would list program activities (e.g., the resources needed to supply more nutritious school lunches), immediate goals of the program (e.g., a 20% increase in student intake of vegetables), and long-term outcomes (e.g., a 10% weight loss in the student population). Logic models are a form of systems thinking, because they relate events to each other over time. The chain of reasoning in a system of relationships among inputs, outputs, and long-term outcomes can be explicitly tested. Supporting effective program evaluation also means working harder to get the resources needed to do it. As discussed in Chapter 7, leaders can make sure that funding for evaluation is included in legislative and organizational proposals for new and ongoing initiatives, and they can use their political acumen to make sure it stays in the package. Accountability in Collaborations We have pointed out that much of public health work occurs in collaborations of individuals, programs, and organizations. Accountability is more difficult to enforce in collaboratives because member organizations are rarely hierarchically arranged, but are coequals (Alexander et al., 2001). Yet accountability is a critical feature of successful collaborative activities. Frisina (2011) refers to accountability as the “soul” of collaboration. Collaborators may be reluctant to “call” each other on performance issues (hold each other accountable) because leaders have little formal authority in collaborations. Accountability is sometimes downplayed in implementation of collaborative initiatives, in the hopes of maintaining peace and tranquility. As a result, collaborations may meander in implementation of their work plan and may be hard to terminate or revise because the criteria for performance are not established or are not enforced. This is a mistake. Partner organizations that do not perform should be invited to improve or leave.



9  Drive for Execution and Continuous Improvement

213

Accountability: Summary This initial competency for execution and continuous improvement is strongly attitudinal—at its roots, it is a basic value of individuals, teams, programs, and organizations, related to the traits of integrity and initiative. At the individual level, accountability may be hard to teach and hard to learn in the workplace, but trying to do so is a critical task for leaders. As a start, accountability can be role modeled by leaders for others to see and emulate. Individuals who have not been held accountable may be surprised to learn that being held accountable shows respect for them and their importance to the work, and they may respond positively. Being held accountable communicates to individuals that the organization values their contribution—if their contribution isn’t forthcoming, the organization will suffer. The converse, not being held accountable, communicates that their work is not important enough to monitor and evaluate. It also isn’t fair to those members of a team who hold themselves accountable if those who don’t are left alone. A leader has to be able to remove individuals who can’t be taught accountability in order for the team to succeed. Establish metrics, set targets, monitor progress, and take action Public health programs cannot be rigorously implemented and improved without measurement. The science of performance measurement is an area of knowledge that leaders need to understand and put to use. This does not require that leaders be statisticians, but it requires that they be able to use and understand and critique commonly used statistics and statistical analyses. It is particularly important to understand the limitations of statistical analyses and of many measures, as the analyses are rarely as valid as one would hope, and measures often lack reliability and validity. Most measures of outcomes, for example, do not capture all of the dimensions that are important to different stakeholder groups. Understand Measurement Theory Leaders need a basic understanding of measurement theory, including reliability (consistency of a measure across different conditions) and validity (degree to which a measure reflects the concept it is measuring). This will enable leaders to push for measures that have long-term utility and to avoid measures that may be attractive in the short run because they are easy to collect and communicate. An example comes from the evolving field of measurement of the quality of hospitals.

214

III  Competencies for Public Health Leadership

A first wave of quality measures for hospitals used patient mortality rates. Hospitals that serve urban core populations or elderly populations disproportionately, though, may have higher mortality rates due to the average condition of patients entering the hospital. In the urban core in the United States, victims of gun violence and traffic accidents are more common in hospital admissions. In the case of elderly populations, the elderly patients on average are likely to be less healthy, and more likely to die, than younger patients. Mortality rate is not a valid measure of quality for hospitals unless it is adjusted for the condition of patients entering the hospital, as a result. A second wave of measures of hospital quality accounted for patient severity or complexity, yielding risk-adjusted mortality rates. Those measures, while better, have a host of remaining problems. They do not measure treatment for conditions where mortality is not a likely outcome, such as hospital care for mothers giving birth, or for back surgery patients, or for outpatient services. For chronic conditions or disabilities where “cure” is not the goal, more appropriate quality measures would include the maximization and maintenance of function, such as the ability to work, live independently, and participate in the community. More sophisticated measures that account for diverse services and diverse patients are needed. While perfect measures for performance rarely exist, stakeholders are not sympathetic to the argument that “our outcomes are too hard to measure.” Qualitative measures, including individual stories and collections of anecdotes, are a starting point that can begin to convey outcomes that account for individual diversity and the particular context of each program or intervention. Newer directions in the field of evaluative sciences attempt to recognize the distinctiveness of each intervention and incorporate more understanding of complexity science to the field (e.g., realist or realistic evaluation [Pawson, 2013]; developmental evaluation [Patton, 2010]). Leaders need to use the best tools available to come to terms with the need to measure. Adopt Public Health Metrics Within the field of public health in the United States, a starting point for measurement is the government’s definition of quality in public health services: “the degree to which policies, programs, services, and research for the population increase desired health outcomes and conditions in which the population can be healthy” (U.S. Department of Health and Human Services [DHHS], 2008). Metrics common to public health programs can also be derived from the Public Health Quality Forum’s Consensus Statement on Quality in the Public Health System



9  Drive for Execution and Continuous Improvement

215

(U.S. DHHS, 2008), which offers nine characteristics of quality public health work: ■■ ■■ ■■

■■

■■

■■

■■

■■ ■■

Population-centered: protecting and promoting healthy conditions and the health for the entire population Equitable: working to achieve health equity Proactive: formulating policies and sustainable practices in a timely manner, while mobilizing rapidly to address new and emerging threats and vulnerabilities Health promoting: ensuring policies and strategies that advance safe practices by providers and the population and increase the probability of positive health behaviors and outcomes Risk-reducing: diminishing adverse environmental and social events by implementing policies and strategies to reduce the probability of preventable injuries and illness or other negative outcomes Vigilant: intensifying practices and enacting policies to support enhancements to surveillance activities (e.g., technology, standardization, systems thinking/modeling) Transparent: ensuring openness in the delivery of services and practices with particular emphasis on valid, reliable, accessible, timely, and meaningful data that are readily available to stakeholders, including the public Effective: justifying investments by utilizing evidence, science, and best practices to achieve optimal results in areas of greatest need Efficient: understanding costs and benefits of public health interventions and to facilitate the optimal utilization of resources to achieve desired outcomes

While the nine characteristics vary in their relevance to specific programs and services, they provide a comprehensive starting point for communities and for public health teams, programs, and organizations to consider as they develop indicators of progress and success. The new accreditation standards for U.S. public health agencies described below start to attach externally verifiable quantitative measures to the major domains of public health work. Another useful compendium is the Guiding Principles for Health Systems Strengthening, derived from a global review of literature and frameworks (Swanson et al., 2010). The 10 principles are holism and context, both of which represent systems thinking; social mobilization, which directly links to the definition of leadership in this book; collaboration; capacity enhancement; efficiency; evidence-informed action; equity; financial protection; and satisfaction. Notable in this list of principles are the inclusion of efficiency and financial protection, along with more traditional public health criteria.

216

III  Competencies for Public Health Leadership

Make Measures Meaningful to Stakeholders Performance measures should include outcomes relevant to all stakeholders, not just those stakeholders that are most obvious or prominent. For example, historically, workforce satisfaction was frequently overlooked when many organizations and programs assessed their own performance. The engagement of workers was (mistakenly) taken for granted or assumed to be unimportant. The balanced scorecard and the Baldrige system of performance management are two foundational bodies of work that have promoted a more expansive approach to performance measurement. They encourage leaders to identify stakeholders, including employees; identify stakeholder goals; and ensure that stakeholder interests are reflected in organizational and program performance measurement. The highest level of national recognition for organizational performance excellence in the United States is the Malcolm Baldrige National Quality Award, established by the U.S. Congress in 1987. While the Baldrige Award originally went only to manufacturing and certain types of service organizations, it now includes public health and health care organizations (National Institute of Standards and Technology, 2013). Seven areas of organizational performance are measured by the Baldrige criteria: leadership; strategic planning; customer focus; measurement, analysis, and knowledge management; workforce focus; process management; and results. For leaders seeking guidance for improving their organizations, the Baldrige criteria can provide a place to start. The balanced scorecard derives largely from the work of Kaplan and Norton (1996). A typical balanced scorecard for an organization includes measures in four areas: financial outcomes, efficiency and quality, client satisfaction, and employee engagement. The tracking of multiple, diverse metrics helps communicate to the organization and its stakeholders that progress in one dimension is connected to progress in other dimensions. For example, too much emphasis on financial performance may increase turnover (forced or voluntary) of employees, hurting performance on the workforce engagement dimension (as well as financial performance in the long run). Or, too much (or too little) attention to client satisfaction may create problems for financial performance if disproportionate resources are required to attend to client satisfaction. At the community level, public health leaders have been active in creating better performance indicators for communities. An example is the Community Assessment Project (CAP) of Santa Cruz County, California. The Santa Cruz County CAP was established in 1994 and is



9  Drive for Execution and Continuous Improvement

217

the second-oldest project of its kind in the United States, with leadership from the United Way of Santa Cruz County and the Dominican Hospital working with Applied Survey Research (ASR) as the research partner (ASR, 2012, p. 6). The CAP has been recognized by multiple organizations as a leading U.S. community indicators project, including the Brooking Institute’s 2007 Community Indicators Consortium Innovation Awards and the Robert Wood Johnson Foundation’s (RWJF) inaugural Roadmaps to Health Prize in 2013 (ASR, 2012, p. 6; RWJF, 2013b, p. 1). In recognition of the fact that “we’re all linked to each other,” according to Mary Lou Goeke, Executive Director of United Way of Santa Cruz County (RWJF, 2013b, p. 1), CAP represents a collaborative effort of community members, organizations, and stakeholders to evaluate quality of life in six areas—the economy, education, health, public safety, social environment, and natural environment—using over 100 indicators that are approved collectively (ASR, 2012, p. 6). Community action to set, monitor, and achieve county-wide goals across Santa Cruz County’s diverse socioeconomic, racial, and ethnic population requires crosssector collaboration in the mission to improve health of all residents, including leaders from the business, social services, public safety, faith, education, health care, community health, and environmental communities, as well as the community members (RWJF, 2013b, p. 1). Act on What the Metrics Tell You A final step of the measurement competency is to use the information collected on key measures. Too often, statistics on progress are collected and filed, or are discussed with attention and consternation, but are not acted upon. One important outcome of the use of metrics is that it often forces a confrontation with the reality of a public health problem or opportunity. In the business world, Bossidy and Charan (2002, p. 67) have noted that “many organizations are full of people who are trying to avoid or shade reality” because it makes organizational life for them and others, including their supervisors, uncomfortable. With empirical data on appropriate dimensions of a problem, people are less likely to be able to avoid or shade reality. It is the leader’s job to make the team, program, organization, or community face the realities, which are often unpleasant, about the scope of problems and the impact of public health initiatives on those problems. Frequently, cause-and-effect findings are ambiguous or limited, and there is often a conflict between the interests of various stakeholders. Environmental health is replete with examples of this, for example, where citizens’ fears of harm from potential exposure to

218

III  Competencies for Public Health Leadership

substances either known or suspected of being dangerous collide with economic development interests. Public health is typically asked to weigh in on these issues as part of regulatory permitting processes and is literally always going to anger one side or the other. Building and preserving an organization’s scientific credibility is important, so either overstating or understating the evidence creates a problem for both the organization and its leader. Confronting the reality that important evidence is sometimes too weak should make leaders redouble their efforts to improve the quality of the evidence. This includes advocating for more public health research in national agencies and universities, commensurate with biomedical research. This is another example of rebalancing the health agenda nationally to achieve greater population health. Collecting and putting metrics to use is a strategy used by Cleveland Aligning Forces for Quality (AF4Q), a successful collaboration between public health, community members, and stakeholders to “improve the health and value of health care provided to people with chronic medical conditions in Northeast Ohio” (RWJF, 2013c, p. 2). The program is led by Better Health Greater Cleveland (Better Health), an alliance of providers, patients, purchasers, and health plans that uses public reporting of performance data from electronic medical records to drive improvements in health care delivery and clinical outcomes in primary care in Cuyahoga County. Innovative and collaborative approaches to measuring, monitoring, and acting on health data to improve the community’s health earned Better Health a spot as one of 16 U.S. communities participating in RWJF’s AF4Q initiative (http://forces4quality.org/). Cleveland AF4Q, under the direction of Better Health, participated in an 18-month program focused on establishing national best practices in patient care quality and safety as part of RWJF’s AF4Q (RWJF, 2013d). Founded in 2007, Better Health’s extensive network of clinical partners represents more than 70% of the county’s chronically ill patients (RWJF, 2013c, p. 2), which allows partners to share data for “quality improvement tools, strategies, and lessons learned” using common measures to monitor progress (RWJF, 2013d). Better Health project director, Randall D. Cebul, MD, noted that measurement “is the foundation of continuous improvement, and adoption of common measures helps us to identify successes—and the strategies behind them—so they can be shared” (RWJF, 2013d). By mining data and stratifying results by factors such as race, ethnicity, insurance type, income, and education levels, Better Health is able to analyze patterns and identify both positive and negative outliers that shed light on how best to improve the health of all of its patients (RWJF, 2013c, p. 3).



9  Drive for Execution and Continuous Improvement

219

Proactively demonstrate financial stewardship of public health funds As we noted in Chapter 1, public health programs operate in public, private not-for-profit, and private for-profit settings, or in settings that include organizations of some or all of those types. Accountability for funds in all three settings requires that leaders have more than a passing understanding of financial management. Accountability for funds requires basic financial knowledge, not at the level of expertise, but so that public health leaders can understand how to manage their own program or organization’s finances and can proactively address p ­ ublic and other stakeholder concerns about finances. Knowledge like how to read a balance sheet and income statement in private sector accounting (known as the statements of financial position and financial activities, respectively, in public sector accounting) is important, as are “big-picture” activities, such as comparing actual expenditures to budgeted expenditures. Honoré and Costich (2009) offer a compendium of financial management competencies for senior leaders, denoting each as requiring some familiarity, working knowledge, or expertise. Those identified as requiring the most expertise include assessing the financial status of the organization, assessing budgets, promoting financial accountability and transparency, and complying with federal regulations. Fundamentally the leader’s role is to know enough to ask the right questions and to anticipate the types of questions that public officials, members of an organization’s board of directors, or other stakeholders are likely to ask. Public health programs often rely on philanthropy and legislatively appropriated public funds rather than or in addition to fee-based program revenues. Donors and taxpayers are owed the same level of accountability that stockholders expect in for-profit companies. Funds are scarce resources and should be treated that way. Any suspicion on the part of taxpayers or donors that their money is not well-used is destructive for public health work. Anne Barry, JD, MPH, is a public health leader whose state government public service career in Minnesota spans four administrations, including roles as Deputy Commissioner in the Departments of Human Services and Finance, as well as former Commissioner of Health. As a guideline for fellow public health leaders, she offers a simple yet powerful framework that incorporates three time perspectives: (a) look back through audits, (b) look “right now” through the balance sheet and income statement, and (c) look forward through budgeting (A. Barry, interview, August 30, 2013).

220

III  Competencies for Public Health Leadership

Financial stewardship requires understanding the importance of and using external audits and internal controls, such as proper approval procedures for purchases and policies and procedures for whistleblower protection, conflicts of interest, and control of physical assets (Coe, 2011). In fact, leaders should not be afraid to ask for outside reviews rather than waiting for a hostile legislative committee or another stakeholder group to impose such reviews when they have already concluded something has gone awry. It is important for leaders to “get comfortable about being uncomfortable, because you will be on display in public.” Because leadership isn’t just positional—it is “in the moment” for many involved in public health—individuals must care about and have skills and values aligned with the important work of public health, which often takes place under the “microscope” of the public’s eye (A. Barry, interview, August 30, 2013). External audits also result in improvements in internal controls. Leaders are responsible for assuring that internal controls meet accounting standards. As noted above, leaders need to be able to review and assess financial position as portrayed on balance sheets and income statements (or statements of financial position and financial activities). Honoré and Costich (2009, p. 314) also list financial ratio analysis, benchmarking, and trend analysis as sample practices in this arena that senior leaders should be able to perform. Developing, presenting, and managing budgets is another leadership competency, which relates to the strategic planning competencies presented in Chapter 5. The leader’s primary role is making sure that organizational mission and budget are tightly linked, including both operational budgets and capital (construction and large purchases) budgets (Weikart, Chen, & Sermier, 2013). A useful and commonly used tool for strategic planning and for budgeting is the business plan. Leaders benefit from familiarity with the value and content of business plans, which typically include analysis of the market for a program as well as financial and operational plans. Because one’s program or unit will be competing for funding and resources, leaders need to be able to articulate clearly what the program is doing and why it is doing it. Only then can they develop a budget that supports the business plan, with the organization’s mission as the driver of a budget that “shines a light” on what is important about that mission. Understanding of the concept of return on investment (ROI) and the practice of comparing programs based on their ROI is another common tool of senior leaders. Terms such as breakeven analysis, internal rate of return, and discounted cash flow are among the lexicon of those familiar with ROI analysis (O’Leary, 2012).



9  Drive for Execution and Continuous Improvement

221

One complicating fact of life of financial management in the public sector is that good financial stewardship in the public sector does not generate profits and reserves, since there are no reserves in governmental accounting. Government leaders lack data on reserves (and often, ROI data on their own programs and on competing programs) to highlight their accomplishments as they compete for limited resources. Leaders often need to use performance outcomes other than profit and reserves to make the case for public health investment. As a final note, programs and organizations cannot do good work if they are too lean to accomplish their goals. Stewardship of program funds does not mean starving the program to death in order to meet financial targets. Successful programs get and invest the resources they need, including infrastructure and talent, to accomplish their mission (Crutchfield & Grant, 2012).

Employ the methods and tools of quality improvement Public health leaders should understand the basics and the strengths and weaknesses of quality improvement methods and should role model the utilization of quality improvement (QI) methods in the programs and activities they oversee. Quality improvement methods arrived later on the scene in public health than in many other sectors, and some degree of “catch-up” is required. Riley et al. (2010, p. 5) argue that “unlike many industries that have embraced QI to improve quality and lower costs, the public health field has not developed a set of shared principles and a common definition for QI.” This time lag is undoubtedly related to the complexity of public health interventions, which we detail in Chapters 1 and 2. In particular, applying quality improvement methods to clinical health services is often more straightforward than applying the methods to public health services. For example, the quality of diabetes interventions at the clinical level is often (partially) assessed by achievement of target levels of glucose control in a patient population. Lowering median glucose levels in a patient population is likely to be less complex and shorter term than reducing the disparities in the prevalence and severity of diabetes among different ethnic groups, which is an analogous public health problem. In a report for the Assistant Secretary of Health of the U.S. DHHS, Honoré and Scott (2010) speak to the field of public health as a whole and its priorities for improving quality. For public health leaders in programs and organizations, specific opportunities to improve quality will of course be customized to those settings. But in general, public health

222

III  Competencies for Public Health Leadership

leaders can be guided by the six priority areas reported by Honoré and Scott: we need improvement in population health metrics and information technology; evidence-based practices, research, and evaluation; systems thinking; sustainability and stewardship; policy; and workforce and education. Initiatives and activities in these six arenas will drive improvement in national goals for population health. The focus on metrics, evidence-based evaluation, stewardship, and systems thinking all mirror themes in this chapter and in this book. Leaders benefit from a basic familiarity with the content and the potential and limitations of the methods and tools of quality improvement. Familiarity with the methods and tools enables leaders to engage with those involved in quality improvement and to role model the application of quality improvement. Ideally, leaders should be facile in the application of basic quality improvement concepts such as the distinctions among structures, processes, and outcomes, and the difference between core processes and support processes. They should be comfortable with tools such as fishbone diagrams, process maps, run charts, and control charts (Brassard & Ritter, 2007). Finally, leaders need to understand the formalized programs for quality improvement that are most common in the health sector. These include PDSA, Six Sigma, and lean production (Mosser & Begun, 2013). PDSA refers to Plan-Do-Study-Act, a methodology also known as the Model for Improvement (and Plan-Do-Check-Act, or PDCA). It is the basic approach of the Institute for Healthcare Improvement, Boston, Massachusetts, a leading proponent of quality improvement. To apply the PDSA method, an opportunity for improvement in the quality of a program or activity is identified. For example, waiting times in a public health department vaccination program may be targeted for improvement. The PDSA cycle is then executed as follows: 1. Plan: Gather and analyze relevant data and observations. In the case of waiting times, for example, client waiting times may be recorded over a 1-month period. 2. Do: On a small scale, test the most appropriate or likely solution to the situation. For example, assignment of a float (temporary) nurse during peak hours could be piloted in the vaccination program. 3. Study: Analyze the results of the small-scale intervention to determine whether the test case is representative and whether it resulted in the desired change. 4. Act: Take broader and more lasting action, as appropriate. If the intervention did not meet the expected requirements, go through the PDSA cycle again to test one or more different potential solutions.



9  Drive for Execution and Continuous Improvement

223

The PDSA cycle is easy to understand and disseminate throughout an organization or program. It reinforces the importance of experimentation (which is emphasized in the next competency), as well as the importance of evidence-based change. Six Sigma is a second method of quality improvement practiced by many health care organizations. Six Sigma originated with Motorola in about 1980. It focuses the team, organization, or program on the elimination of errors from internal processes, down to the level of 3.4 errors per 1 million operations (a figure that relates to the derivation of the term “Six Sigma”). For example, delays in hospital admissions from the emergency department can be targeted for reduction, or improved workflow in a service such as the patient visits to a community health clinic. There are five steps in the formal Six Sigma process: 1. Define: Identify the opportunity to improve performance. 2. Measure: Decide what to measure; collect data; establish baseline error rates. 3. Analyze: Study the data that have been collected to determine the root cause(s) of the problem. 4. Improve: Devise potential solutions; test and evaluate different solutions; select solutions to implement. 5. Control: Develop and apply ongoing monitoring measures. The method is applied most readily to systematic processes, such as those found in clinical laboratories or routinized health care delivery. The third common quality improvement method, lean production, is a philosophy and program of quality improvement first piloted by Toyota Corporation. It is focused on eliminating waste from production processes, with seven types of waste targeted: waste of overproduction, waste of time (waiting), waste in transportation, waste of overprocessing, waste of stock (inventory), waste of movement, and waste of making defective products or services. Reducing waste is one way of increasing the value of a service. Methods to eliminate waste have been customized and applied to health care delivery organizations in growing frequency (Spear, 2005). In some applications, rapid process improvement workshops (RPIWs) are held. RPIWs are 3- to 5-day meetings of those responsible for a process. In the meetings, the team identifies sources of and ways to reduce waste. Lean production and Six Sigma can be combined to address issues of both waste and error, and organizations can benefit from any and all of the quality improvement methods. PDSA, lean production, and Six Sigma share a common cycle of performance measurement, problem

224

III  Competencies for Public Health Leadership

identification and clarification, goal setting, process change, and monitoring of the effects of the changes (Mosser & Begun, 2013). Use of quality improvement methods and tools continuously pushes the organization to do better, no matter how well the organization is performing, and it puts to practical use the methods of scientific investigation. Support Value-Adding Accreditation A common form of quality improvement in many organizational sectors is an accreditation process for organizations that share a common purpose. For example, in the United States, organizations delivering clinical health services to individuals in hospitals can receive accreditation by The Joint Commission or alternative accreditors, and such accreditation is required by most third-party payers that reimburse patients and providers for insured hospital services. Academic programs delivering a master of public health degree can seek accreditation from the Council on Education for Public Health. An attempt to upgrade the quality of local and state governmental public health departments is represented by the Public Health Accreditation Board (PHAB), which launched national operations in 2011, following an intensive process supported by the CDC and RWJF over several years, in which public health l­eaders from around the country and at all levels of the public and private ­sectors debated and agreed on the performance improvement ­potential of ­common ­performance standards (Bender, 2013). Among the 12 ­standards is one to “evaluate and continuously improve processes, ­programs, and ­interventions.” In Practice 9.1 portrays the ­example of Comanche County Health Department, Oklahoma, as it strives to meet those accreditation standards.

in practice 9.1 QUALITY IMPROVEMENT THROUGH ACCREDITATION Comanche County Health Department (CCHD), located in southwest Oklahoma, was part of the inaugural group of 11 public health departments that received national accreditation from the Public Health Accreditation Board (PHAB) in March 2013. According to PHAB President and Chief Executive Officer (CEO) Kaye Bender, PhD, RN, FAAN, “With accreditation, we now have national standards that promote continuous quality improvement for public health and a mechanism for recognizing high-performing public health departments” (PHAB, 2013). In preparation for full accreditation, CCHD participated in the 2010 National Voluntary Accreditation Program Beta Test (National Association of County & City Health Officials [NACCHO], 2013a), demonstrating commitment to quality improvement for those it serves (Reed & O’Connor, 2010, p. 1).



9  Drive for Execution and Continuous Improvement

225

Improving Community Engagement At the time of the beta test, CCHD was a department of 58 full-time equivalents serving a population of 112,000 residents in mixed urban and rural settings, including three Native American tribes and a major military post in its service area (NACCHO, 2013b). CCHD recognized that serving as a modern public health department for such a diverse community required a better understanding of the community’s needs (Reed & O’Connor, 2010, p. 1). The starting point of the accreditation process is PHAB’s self-assessment using quality improvement techniques, including the Plan-Do-Check-Act process, root cause analysis, and process storyboards (NACCHO, 2013a, 2013b), which prompted CCHD to assess how well it was serving its community as part of its beta test. For CCHD, this “very revealing” self-assessment highlighted the need “to improve community sector participation in the community health assessment process.” Recognizing deficiencies in its practices “opened CCHD’s eyes to the opportunity for true quality improvement” (Reed & O’Connor, 2010, p. 1). Given these deficits and the accreditation prerequisites to complete a community health assessment (CHA) and develop a Community Health Improvement Plan (CHIP), CCHD selected increased community engagement as the subject of its beta test quality improvement project. Its final aim statement, adopted on September 10, 2010, read: “By December 2010, the Comanche County Health Department will improve community engagement as evidenced by 60 percent of community sectors being represented at meetings, with an average score of 4 on the meeting effectiveness survey.” Ten community health sectors were defined: health, schools/ education, law enforcement/fire, government, business, youth, parents, faith, civic, and media (Reed & O’Connor, 2010, p. 4). Based on CCHD’s analysis of the beta test, average meeting effectiveness measures increased from 3.4 to 4.6 and sector representation increased from 40% to 70% (Reed & O’Connor, 2010, p. 6).

Lessons Learned on the Road to Accreditation CCHD identified numerous “lessons learned” during the beta test. One early example used fishbone analysis to identify potential reasons for community partners’ decreased engagement, with four categories identified: conflicting agendas/­ priorities, time, apathy, and communication (Reed & O’Connor, 2010, p. 5). To improve meeting engagement and effectiveness, CCHD demonstrated respect for its partner’s time and participation by planning meetings based on the partner’s need rather than CCHD’s needs (Reed & O’Connor, 2010, p. 7). Another lesson resulted from the beta test’s required formal quality improvement training, during which CCHD recognized “distinct deficiencies” between its perception and reality of what constitutes a robust quality improvement program, especially in terms of the “continuous and organized process that leads to lasting improvement.” As a result, CCHD applied quality improvement principles “to all areas of their public health practice, including the most vulnerable areas” involving community engagement. These new-found skills and perceptions allowed CCHD to complete the formal accreditation process with a better understanding

226

III  Competencies for Public Health Leadership

and inclusion of quality improvement, including the CHA, CHIP, and strategic plan required for accreditation (Reed & O’Connor, 2010, p. 7). Finally, CCHD learned that “organizational self-awareness is vital when developing a quality public health organization,” calling this its “most valuable” and “most basic” lesson of the process. Acceptance of its successes and deficiencies provided CCHD with “a framework for comprehensive improvement [that] will undoubtedly result in local public health excellence” (Reed & O’Connor, 2010, p. 8). The promise of the accreditation process to bring quality improvement to public health departments and programs—as CCHD experienced—was echoed by PHAB President and CEO Dr. Kaye Bender when announcing the inaugural PHAB-accredited public health departments: “These are the first of many health departments that we look forward to being able to recognize for achieving national standards that foster efficiency and effectiveness, and promote continuous quality improvement” (PHAB, 2013).

Accreditation is not necessarily a panacea, and there are good reasons to question its value (Wholey, White, & Kader, 2010). It can lock in structures and processes and stifle innovation, for example. This was a clear concern expressed in the deliberative process that led up to the creation of PHAB. In fact, the leaders involved in the decision process described above were clear in their view that accreditation is a means to an end—the end being continuously improving public health protection and enhancement—rather than a compliance process that becomes an end unto itself. Leaders should listen to these concerns and work to make accreditation a value-adding rather than value-reducing activity. Encourage innovation and risk-taking A final step in driving for execution and continuous improvement is to search beyond improvement of existing work (e.g., performing existing work with fewer errors and less waste), to discovering new and different ways to accomplish goals. Traditional quality improvement, as described by the previous competency, focuses on maximizing the potential for existing products and services, rather than developing new ones. This contrast is often referred to as exploitation (of existing processes and products) versus exploration (of new processes and products). Organizational scholar James March argued that organizations tend to focus on exploitation to the neglect of exploration (March, 1991). Organizations do so because the benefits of exploitation in the short run are positive and predictable, while exploration is risky and its returns often are negative in the short run. If organizations focus on exploitation while the organization’s environment (e.g., its competitors, donor base, customers, or clients) is changing, the organization risks



9  Drive for Execution and Continuous Improvement

227

becoming obsolete. A single-minded pursuit of efficiency in existing processes means that the organization does not explore products and services based on different technologies and processes, and does not explore new customer, client, or supplier bases. It is relatively “easier” for many leaders to focus on status quo products and services without devoting attention to exploring the unknown. Ideally, the quality improvement and accreditation movements in public health are tools in service to the end goal of improving population health. They are meant to encourage public health leaders to think not just about how to improve on their organizations’ existing functions and programs as a given, but rather to think more broadly and deeply about what is really needed to assure that basic public health protections are in place in every jurisdiction in the country. For example, leaders in the field expect that this will lead to the development of new organizational forms as public health agencies consider collaboration of various types or mergers. Westley and colleagues make the related point that innovation may require moving on from a successful program to changing the broader institutional context to insure impact. While their counsel is directed at those who fund social change, it applies to those involved in programs as well. There is a time for programs to be ended as well as started (Westley et al., 2007, p. 213). How can leaders encourage innovation and risk-taking? A variety of options are available. Leaders can take steps to get innovation on the agenda of the organization, including formally including it as a purpose or goal, and creating metrics to track it. An improvement-driven organization with resource constraints searches for changes that not only are new but also allow the organization to deliver services at lower costs and higher quality (Fallon et al., 2013). Researchers refer to the need to “assert frugality”—keep cost-cutting as an ongoing priority—to produce innovations that create value for consumers (Govindarajan & Ramamurti, 2013). Innovation results from the application of new ideas. The generation of new ideas is stimulated by organizational cultures and structures that support and reward creativity. Creativity is enhanced when individuals share diverse perspectives on a problem or process, so avoidance of “groupthink” (similar thinking produced by the desire for peer acceptance) is important. Leaders can counter groupthink by encouraging challenge and constructive conflict in their own meetings and interactions. They can seek out and praise those who are strong on the creativity dimension. They can make sure that staff members have time to pursue new ideas instead of full-time focus on doing the task at hand. Innovation is more likely to emerge from informed thinkers, so having access to deep knowledge and expertise makes innovation more likely. Sending

228

III  Competencies for Public Health Leadership

employees to continuing education and encouraging learning contribute to that culture. Studying the practices of other similar organizations is another way to open up the eyes of individuals to potential innovations. Learning from failure is another hallmark of the organization that embraces innovation and risk taking. Instead of focusing on the negative consequences of organizational failures, the leader who asks “What can we learn from this?” is role modeling support for risk taking. Dyer, Gregersen, and Christensen (2009) refer to this as experimentation, identifying it as one of four behaviors of innovative people. The others are questioning, observing, and networking. Such behaviors enable people to integrate diverse information into new ideas for programs and initiatives customized to their own setting. Most leaders are well aware that innovation is a long-term process that requires nurturing, listening, and flexibility, as well as attention to dissemination and acceptance of the innovation. Rogers’s (2003) work on diffusion theory suggested that people and organizations typically respond to innovation according to a bell-shaped curve, with early adopters comprising one-sixth of individuals or organizations, m ­ ajority adopters comprising two-thirds, and laggards comprising another ­one-sixth. To accelerate diffusion of an innovation, leaders can seek out those individuals known for their openness to new ideas or those ­organizations or units that have a record of innovation. Listening to and learning from later, more reluctant adopters can accelerate the process, and persistence and political competencies (see Chapter 7) are useful in combating those determined to resist innovation at all costs. The In Practice 9.2 case of Dr. Ken Kizer at the Veterans Health Administration (VHA) is an example of leadership that emphasizes execution and continuous improvement for the benefit of a patient population.

in practice 9.2 CHALLENGING THE STATUS QUO TO ACHIEVE QUALITY IMPROVEMENT When Kenneth Kizer, MD, MPH, was appointed to his post in the Veterans Health Administration (VHA) by the Clinton Administration, the veterans’ health care system was best known for its poor-quality outcomes, bloated bureaucracy, and inpatient care focus (Longman, 2005, p. 3). Dr. Kizer served as Under Secretary for Health of the U.S. Department of Veterans Affairs (VA)—basically, the VHA’s Chief Operating Officer (COO)—from 1994 through 1999. Ken Kizer brought a “forceful leadership and aggressive approach to quality management” (Joint Commission, 2013) as the topranking physician in the federal government and COO of the largest U.S. health care



9  Drive for Execution and Continuous Improvement

229

system (University of California Davis Health System [UCDHS], 2011). He was viewed as an “outsider” at the VHA, having worked as an emergency room physician, an educator and practitioner within the University of California system, and in state public health and medical leadership roles in California, although he did have military credibility as a former Navy diver and adjunct faculty at the Uniformed Services University for the Health Sciences (Medsphere Systems Corporation, 2013; UCDHS, 2011).

Push for Accountability Dr. Kizer brought a unique perspective on health to his VHA efforts, including training in emergency medicine and public health. He introduced accountability and quality into the organization through executive pay-for-performance contracts and by firing incompetent doctors. He also shifted VHA resources to primary- and outpatient care at a time when only 10% of veterans in the VA health system—many with chronic conditions rather than acute-care needs—had a primary care physician (Edmondson, Golden, & Young, 2008, p. 5; Longman, 2005, p. 406). As a result, patient care moved from multiple specialists focused on inpatient treatment to community clinic settings focused on primary care. Dr. Kizer also introduced standardized care protocols, downsized and decentralized management authority, and leveraged the VHA’s purchasing power for better vendor contracts, with savings returned to the VA (Longman, 2005, p. 4; Stires, 2006, p. 1). These efforts laid the foundation to improved care and performance while eliminating waste and inefficiencies in a health care system with a $22 billion budget, over 200,000 employees, and more than 110 care delivery sites (Medsphere Systems Corporation, 2013).

Encouraging Innovation and Exploration By inspiring a culture to innovate and take risks, Dr. Kizer accomplished organizational change aligned with a “new VHA” mission to deliver “a seamless continuum of consistent and predictable high-quality, patient-centered care that is of superior value” (Edmondson et al., 2008, p. 6). This culture diverged from the “zero tolerance for failure” traditional in government; in Dr. Kizer’s opinion, “Innovating means making mistakes. It’s hard to really change without innovating” (Edmondson et al., 2008, p. 6). To fulfill the VHA’s new mission, a system-wide structural reorganization was implemented in late 1995 to create the “veterans integrated service network (VISN),” a referral-based model using “actual and potential patient referral patterns” among its 22 geographic operating units (Edmondson et al., 2008, p. 7). Setting, tracking, and measuring progress were fundamental elements for the VISN model’s success, under which control over budgets, planning, and decision making for each region was moved to the local networks and away from VHA headquarters in Washington, D.C. Employees at all levels had to adjust to this new decentralized model and new programs, accountabilities, and structures, which left some employees “dazed,” but also “stimulated experimentation and entrepreneurial activities” (Edmondson et al., 2008, p. 10). Dr. Kizer provided a new structure that “encouraged innovation” and “the freedom to take reasoned chances” (Edmondson et al., 2008, p. 11) and worked hard during the organizational upheaval

230

III  Competencies for Public Health Leadership

“to find balance between good plans and letting ‘perfect become the enemy of good’” (Edmondson et al., 2008, p. 9). While training programs and best practice sharing were developed to assist leaders through the turnaround and drive for health care value throughout the system, technological innovation proved invaluable to further the new VHA mission.

Technology Backbone for Continuous Quality Improvement and Execution Central to Dr. Kizer’s overhaul of the VHA was the creation of the Veterans Health Information Systems and Technology Architecture (known as VistA), the deployment of which has been called the “largest and most successful implementation of an electronic health record (EHR) ever undertaken” (Kizer, 2010). Dr. Kizer used the savings from renegotiated contracts across the VHA and reengineered formularies and operations at VHA hospital pharmacies (Stires, 2006, p. 2) to develop the “open source and open standards” EHR system (Kizer, 2010). VistA is used to schedule appointments, provide care reminders (such as screening tests or vaccinations due), track lab results, and perform other tasks through a diverse, integrated suite of applications (Stires, 2006, p. 3). Storing all VHA medical records in one EHR greatly improved quality and safety and provided clinical, operational, and technological efficiencies and cost savings. By 1999, VistA was installed at every VA facility (Stires, 2006, p. 3). Because patients remain in the VHA system once they enter it—unlike private medical practices—improvements in cost savings, efficiencies, and continuity of care resulting from the investment in VistA continue to benefit the VA and its patients (Longman, 2005, p. 13). The U.S. health care industry has since adopted a national push toward EHRs, looking to benefit from improved disease management, reduced medical errors, reduced hospital admissions, and better quality (Stires, 2006, p.  12), and national and international entities are using derivative versions of VistA for their EHR needs (Kizer, 2010, p. 1). Dr. Kizer’s willingness to challenge the status quo earned him recognition as “a passionate advocate for performance improvement” who revitalized one of the worst U.S. health care systems into a national model of quality, safety, and integration (Joint Commission, 2013).

CONCLUSION Public health leaders can increase the impact of public health initiatives by driving harder for execution and continuous improvement in their teams, programs, organizations, and communities. This requires establishing accountability for themselves and those they supervise and collaborate with; using metrics to guide performance; using public health funds judiciously; employing quality improvement methods; and innovating and taking risks. The In Practice example of Dr. Kenneth Kizer shows how leaders can energize their organizations by driving hard.

part iv

Sustaining Public Health Leadership

Twenty-five competencies for public health leadership have been presented. A final step in effective leadership is mastering the competencies through experience and lifelong learning. We turn to this topic in the final chapter. Effective leaders enjoy the challenge of learning and growing, because they rarely if ever can rest on their laurels—the world around them is changing too quickly. Learning and growing can be accelerated by conscious decisions to attend to it. Those who know they want a career of leadership can do so from the beginning of their careers; ­others can join at any time, including late in their work lives. Guidance for intentional actions to improve leadership competencies and to sustain effectiveness is presented in this ending chapter.

1 chapter 10

Lifelong Leadership Development

key terms 360-degree feedback celebrating wins coaching development from knowledge development from experience DiSC giving back Insights Discovery leadership development

leadership development, stages of mentoring Level 5 leadership Myers-Briggs Trait Inventory networking self-assessment StrengthsFinder work-life balance

W

hy make leadership development a lifelong priority? In Chapter 1, we listed several reasons why leadership development is important to public health as a field. Evidence-based knowledge for the value of public health interventions has grown significantly, but the share of resources devoted to public health interventions has not. Changing that situation requires that public health practitioners ­perform leadership work—mobilizing people, organizations, and communities to tackle tough challenges—with more intensity and strength. Those committed to furthering population health can build the impact of the field through effective leadership. While leadership development



233

234

IV  Sustaining Public Health Leadership

does not guarantee every individual’s success, without it the field as a whole is much less potent. For every leader who fails, there are many who are succeeding. For one exhausted from the challenge, there are more who are energized. Leadership development will move the field forward, whether it does or does not for any particular individual at any particular time. From an organizational perspective, leadership development improves succession planning and knowledge transfer. Within public health organizations, leadership development should be pursued at all levels of the organization (Czabanowka, Smith, Stankunas, Avery, & Otok, 2013). Strong leaders recognize the value of sharing their experiences and wisdom—through coaching, mentoring, and development of others—which results in increased sharing of knowledge, traits, and values within the organization and with future leaders. Giving back and developing the next generation of leaders is explored in the In Practice cases in this chapter. In addition, leadership development has benefits for individuals. For individuals, leadership development increases the odds of effectiveness and accelerates the trajectory toward effectiveness. A focus on development can help guide decisions, for example, about what optional projects to undertake at work or with one’s leisure time, or what types of jobs to seek. The development process of creating a vision, setting goals, and monitoring progress helps individuals be more effective with their own personal resources in the same way that it helps organizations. As discussed in the previous chapters, leadership is certainly not all about accomplishment and accolades. Done well, leadership is hard work. Devoting attention to ongoing leadership development will increase not only leaders’ effectiveness, but their enjoyment of the work as well, which in turn further increases effectiveness.

LEADERSHIP AS A LIFELONG ENDEAVOR The path to effective leadership is all but linear, all but planned and executed smoothly. Life does not allow that. Individuals hit speed bumps in their own motivation, face personal hardships that detour their progress in careers, fail at some tasks while excelling at others, are variously lucky and unlucky, and work for both effective and ineffective leaders and organizations. There is no foolproof plan or easy path to effective leadership. This reality calls not for abandoning planning, but for realizing the limitations of plans and accepting imperfection. It also calls



10  Lifelong Leadership Development

235

on the traits of passion for the task of development and persistence in its execution. One additional caveat: leadership development cannot succeed without authenticity. As we have noted more than once, there’s a reason that leadership experts spend so much time writing about authenticity as a key attribute of leaders. A mechanistic, “tell-me-what-to-do” fulfillment of leadership competencies does not inspire either the leader or those being led. For this reason, reconsider Chapter 3 on public health values at this point. If you don’t share the public health values and the passion of effective public health leaders, self-development activities seem onerous and may ultimately fall flat.

The Goal Most leadership development for individuals is aimed at mastering competencies of leadership, like the five competency sets presented in this book. At a more abstract level, though, scholars describe a path toward leadership (and management) effectiveness as one that increases or adds complexity to options and increases versatility. For example, emotional intelligence scholar Daniel Goleman views leaders as using six different styles: coercive, authoritative, affiliative, democratic, pacesetting, and coaching. They “use most of them in a given week—seamlessly and in different measure—depending on the . . . situation” (Goleman, 2000, pp. 78, 80). He also argues that the more styles a leader exhibits, the better. Kaplan and Kaiser (2003) see effective leaders as balancing two continuums—forceful versus enabling leadership and strategic versus operational leadership—shifting the balance to suit the circumstances at hand. Bolman and Deal (2013) present effective leadership as the embrace of four alternative mental frames (structural, human resource, political, and symbolic) simultaneously, coupled with a deep commitment to core values. The “master managers” depicted by Quinn, Faerman, Thompson, McGrath, and St. Clair (2011) combine strengths in four diverse quadrants of competencies labeled control, collaborate, compete, and create. Another example comes from the perspective of polarity management (Johnson, 1996). In addressing complex problems, effective leaders are able to embrace opposites (e.g., centralization and decentralization) rather than looking for either–or solutions. Generally, the endpoint of this process of development can be described as increasing our options—options that allow us to appreciate and live with complex challenges, rather than not seeing them, oversimplifying them, or being overwhelmed by them.

236

IV  Sustaining Public Health Leadership

The Journey We stated that the path to leadership is not linear for individuals. Yet when the paths of lots of individuals are examined, aggregate patterns (which do not apply to all individuals) are evident. Bill George, former Chief Executive Officer (CEO) of Medtronic and now a leadership educator, lists three stages of leadership development, with typical age ranges as follows: Preparing for Leadership (age 60). (The age ranges are “typical.” If they don’t fit your situation, ignore them.) Preparing for Leadership includes character formation and “rubbing up against the world.” Leading includes stepping up to lead, including some “crucible” or transformational experiences. Giving Back includes peak leadership and wisdom (George, 2007). These stages are forwarded based on George’s experience and observations; they may or may not be consistent with your own. A general point, though, is that successful leadership is built on years, often decades, of experience. The careers of the two In Practice leaders profiled in this chapter are illustrative. Lowell Kruse, ex-CEO, Heartland Health (HH), St. Joseph, Missouri, has had a distinguished career as a health care administrator and community leader. His experience illustrates stages of leadership and their evolution over time (In Practice 10.1).

in practice 10.1 REFLECTING ON A LIFETIME OF LEADERSHIP: LOWELL KRUSE, MHA Leadership author Bill George (2007) designates three distinct stages through which lifelong leaders pass, as discussed in this chapter: Preparing for Leadership (younger than 30 years); Leading (30–60 years); and Giving Back (beyond 60 years). Despite his retirement in 2009 after a 25-year career as CEO and President at Heartland Health (HH), Lowell Kruse continues to be a recognized, dedicated ­public health leader, one directly living out and even reinventing George’s third stage. By investing in innovative new ideas and training tomorrow’s public health and health care leaders, Mr. Kruse embodies as strong a commitment to the third leadership stage as he did to the first two.

From Hog Farmer to Health Care Executive At a time when a Master of Healthcare Administration (MHA) degree was uncommon, the credential provided “endless opportunities” for those who earned one (Gillard, n.d.), including Lowell Kruse. Instead of pursuing a planned career in hog



10  Lifelong Leadership Development

237

farming on his family’s Iowa farm, he earned undergraduate degrees in business and psychology at Augustana College in Sioux Falls, South Dakota, then his MHA 2 years later at the University of Minnesota (Coventry, 2010; HH, 2009a). He spent the next 10 years in successive leadership roles in health care organizations, landing his first CEO role at age 33 in Rochester, New York. Ultimately, he became the President and CEO of HH in St. Joseph, Missouri, in 1984, spending the remainder of his administrative career building an impressive, award-winning regional rural health care system that serves 16 Northwest Missouri counties and six adjacent counties in Kansas, Nebraska, and Iowa.

Making a Difference for the Community Through Cross-Sector Engagement The importance of addressing the root causes of health struck Mr. Kruse early in his career: We had all these young people starting out poor. They were the future of our community, and I realized running the hospital well wasn’t enough. It just wasn’t even close. We had to do something radically different. As health care leaders, we have a moral obligation to use our leadership capacity to look after the overall health and well-being of the people in our community. (Coventry, 2010, paras. 9, 11) As a result, Mr. Kruse focused on fostering collaboration, integration, and cooperation with “anybody else in the community that was concerned with improving the economic vitality of the community, the health and prosperity of people” (HH, 2009a, p. 2). For example, HH was a major proponent, supporter, and participant in the St. Joseph Alliance, an organization that includes school systems, local government, businesses, and nonprofits. HH joined with the St. Joseph School District in a Youth Health Partnership that focused on the health and well-being of every child in the school district.

Recognition for Excellence in Quality and Providing for Community Needs A fitting tribute was bestowed upon Mr. Kruse and his team of over 3,500 employees and volunteers at the end of his quarter century of service to achieve HH’s vision of making its service area “the best and safest place in America to receive health care and live a healthy and productive life” (National Institute for Standards and Technology [NIST], 2010, p. xii; Wenger et al., 2011, p. 1). The 2009 Malcolm Baldrige National Quality Award recognized the organization’s achievement of health care delivery excellence, while the American Hospital Association’s 2009 Foster McGaw Prize for excellence in Community Service honored HH’s commitment to enhancing the lives of its community members (Coventry, 2010; NIST, 2009).

238

IV  Sustaining Public Health Leadership

Sharing Lessons Learned With Future Leaders A distinguishing characteristic of Mr. Kruse’s leadership style is his commitment to developing the leaders of tomorrow. Like the lessons of farming learned early in life— to paraphrase, if you want to harvest a crop in the fall, you have to plant it in the spring—Mr. Kruse recommends future leaders plan and prepare early for their career (HH, 2009b). He also recommends young people engage in their communities and practice being leaders, advice he followed to great effect. Through active membership and leadership at both the local and national levels of the Jaycees, an organization aimed at developing young leaders, and involvement with cross-sector social and economic development in the communities in which he has lived and worked, Mr. Kruse has engaged in community service throughout his career (HH, 2009a, 2009b). One of his stated goals upon retirement has been to give back and share his wealth of “knowledge and experience . . . with graduate students in health care administration and talking to them about their role as leaders in creating healthy communities.” As examples of the depth of this commitment, Mr. Kruse has continued involvement on the Coordinating Board of Higher Education and The Family and Community Trust in Missouri (HH, 2009a, p. 3) and invested “time and talent to the concept of integrative leadership . . . to achieve improved health, economic and social well-being” in the health care sector (Wenger et al., 2011, p. 5). In addition, Mr. Kruse and his wife fulfilled a shared goal “to raise Americans’ economic, educational, and social well-being to create healthier citizens and healthier communities” by endowing the Lowell and Leslie Kruse Scholarship to Build Healthy Communities for MHA students at his alma mater (Coventry, 2010). Mr. Kruse lives the servant leadership philosophy of contributing to others around him in his professional and civic commitments and embodies the belief that we are all a product of those who support us. Quoting legendary athlete Althea Gibson in his retirement interview, Mr. Kruse noted, “No matter what accomplishments you make, somebody helped you”—one of those key people supporting him has been his wife, Leslie (HH, 2009a, p. 3; 2009b). This philosophy is also reflected in advice shared during the interview (HH, 2009a, p. 4): “Create an environment where outstanding people want to work. Surround yourself with people who can help create the vision— those who have a lot more skills and capacity to get the job done than you have as a leader. . . . Get to know the community and region. . . . Build trust and relationships in the community.” George’s third stage of “giving back” doesn’t mean resting on one’s laurels. In the case of Mr. Kruse, he is hard at work promoting a new initiative, Communities of Excellence 2026, to adapt Baldrige performance criteria to elevate the health and well-being of American communities. These are actions of a lifelong leader who public health leaders of today and tomorrow can strive to emulate.

Warren Bennis (2004), another respected leadership educator, writes of the seven ages of the leader, borrowing from Shakespeare: infant, schoolchild, lover, soldier, general, statesperson, and sage. The leader evolves from dependence on others for guidance, to becoming comfortable in the role, to overcoming arrogance, to passing on wisdom to others. Another acute observer of leadership, Jim Collins (2001b), speaks of “Level 5”



10  Lifelong Leadership Development

239

leadership, at which the most effective leaders combine personal humility with their execution competencies. Level 5 is built on a development hierarchy growing through four levels: highly capable individual, contributing team member, competent manager, and effective leader. Psychologists Kegan and Lahey (2009, p. 9) posit a related pattern in adult mental development through three phases: (a) the socialized mind, where the individual is a team player, reliant, and seeking direction; (b) the self-authoring mind, where the individual learns to lead and set agendas, is problem-solving and independent; and (c) the ­self-transforming mind, where the individual “leads to learn,” holds contradiction, is interdependent, and “problem-finding.” Each stage represents an increase in mental complexity. In the first stage, the socialized mind is shaped by the definitions and expectations of our personal environment. In the second stage, (the self-authoring mind) people take stands, set limits, and step back enough from the social environment to ­generate a personal ­authority. In the final stage, the self-transforming mind, individuals reflect on the ­limits of their own personal authority and ideology and understand that any one system is in some way partial or incomplete. In conclusion, leadership development is a lifelong journey. That fact means deferring gratification for those beginning the journey. On the positive side, it allows room for failure and learning from failure, and it connects the leader to an engaging, lifelong purpose. Accepting the long-term nature of leadership development, how might one approach it? Four stages in the process of learning can be delineated: (a) understanding oneself, (b) planning for development, (c) the development process itself, and (d) sustaining a life of leadership. UNDERSTANDING ONESELF Pursuing personal leadership development begins with a reality assessment, in the same way that assessing reality is a first competency in setting agendas for public health initiatives. For prospective leaders, assessing the starting point is useful in setting feasible goals. If you are beyond the early stages, you likely know yourself fairly well and can skip much of this step. Self-Assessment Self-assessments of leadership values, traits, knowledge, and competencies are a starting point. For example, one can self-assess alignment with or attainment of the knowledge, values, traits, and competencies

240

IV  Sustaining Public Health Leadership

covered in this book. Tables 10.1 to 10.3 provide simple rubrics for doing so. Table 10.1 lists the values of the field of public health and helpful traits of public health leaders that were presented in Chapter 3. In Table 10.2, the key knowledge areas for public health leaders are summarized (drawn from Chapter 4), and the key competencies are listed in Table 10.3 (drawn from Chapters 5 to 9). Table 10.1 Values and Traits for Public Health Leadership: Self-Assessment Aligns Well with My Values/Traits?

Public Health Values 1.  Social justice 2.  Reliance on evidence 3. Interdependence 4. Respect 5.  Community self-determination 6.  Requisite role of government 7.  Transparency Helpful Leader Traits 1.  Integrity 2. Initiative 3. Empathy 4.  Comfort with ambiguity 5. Passion 6. Courage 7.  Persistence

Table 10.2 Knowledge for Public Health Leadership: Self-Assessment Area of Knowledge

1.  Public health science 2.  Understanding people •  Motivation •  Social and emotional intelligence 3.  Understanding complex systems 4. Changing people, organizations, and communities

Needs Development?



10  Lifelong Leadership Development

241

Table 10.3 Competencies for Public Health Leadership: Self-Assessment Competency Set and Competencies

Needs Development?

Invigorate Bold(er) Pursuit of Population Health 1. Critically assess the current state of your program or organization 2.  Articulate a more compelling agenda 3.   Enlist others in the vision and invigorate them to drive toward it 4.  Pursue the vision with rigor and flexibility 5.  Marshal the needed resources Engage Diverse Others in Public Health Initiatives 1. A  ssess local conditions in ways relevant and credible to the local stakeholders 2.  Search widely for the right partners 3.  Apply a social determinants perspective to planning 4.  Take time to build relationships, teamwork, and common understanding 5.  Clarify roles and governance Effectively Wield Power to Increase the Influence and Impact of Public Health 1. Understand and strategically use both positional authority and informal influence 2.  Analyze a given public health problem and proposed solution in “campaign” terms 3.  Build coalitions of core supporters, new partners, and issue-specific allies 4.  Deal effectively with opponents 5.  Be strategically agile Prepare for Surprise in Public Health Work 1.   Promote resilience in individuals and communities 2.  Develop and critique an emergency response plan 3.  Communicate effectively during surprises 4.  Execute an emergency response plan with flexibility and learning 5.  Learn and improve after surprises (continued)

242

IV  Sustaining Public Health Leadership Table 10.3 (continued) Competencies for Public Health Leadership: Self-Assessment

Competency Set and Competencies

Needs Development?

Drive for Execution and Continuous Improvement in Public Health Programs and Organizations 1. Build accountability into public health teams, programs, and organizations 2.  Establish metrics, set targets, monitor progress, and take action 3.   Proactively demonstrate financial stewardship of public health funds 4.   Employ the methods and tools of quality improvement 5.   Encourage innovation and risk-taking

Other leadership development frameworks typically provide selfassessment instruments. (For example, the Turning Point [2006] collaborative leadership framework includes self-assessment instruments for the six practices of assessing the environment, visioning and mobilizing, building trust, sharing power, developing people, and self-reflection.) Greater depth in self-assessment is provided by longer and more detailed surveys of emotions, behavior, and attitudes, most of which are proprietary. For example, emotional intelligence, discussed in Chapter 4, can be assessed by several different proprietary instruments (Consortium for Research on Emotional Intelligence in Organizations, 2013). Appropriate goals for understanding one’s emotions are to be able to recognize your patterns, label your thoughts and emotions, accept them, and take action that aligns with your values (David & Congleton, 2013). The self-assessment instrument StrengthsFinder® (www .gallupstrengthscenter.com) is popular in many educational settings. Leadership consultant and author Marcus Buckingham (2012) argues that you learn best from leaders whose strengths match your own and warns that you lose authenticity if you attempt techniques that don’t fit your strengths. The StrengthsFinder® instrument reveals patterns in thoughts, feelings, and behaviors to identify areas where an individual has the greatest potential for building strengths, from among 34 themes (Rath, 2007). Sample themes are learner, competition, and positivity. DiSC® and Insights Discovery®, popular in many workplaces, use four major categories of temperament or behavior style, matched with colors. Another popular instrument for self-assessment of traits



10  Lifelong Leadership Development

243

is the Myers-Briggs Trait Inventory® (MBTI). The MBTI® summarizes an individual’s preferences for taking in information and then making decisions. The MBTI® classifies individuals into one of 16 types based on the four dimensions of introversion–extroversion, sensing–intuition, ­thinking–feeling, and judging–perception.

Assessment by Others Since self-assessments may be inaccurate, understanding one’s self requires soliciting feedback from others about strengths and weaknesses as a potential leader. Those “others” likely include fellow workers, supervisors, and those who may report to you or provide assistance. They also include clients, patients, or customers whom you serve. The concept of 360-degree feedback refers to feedback from those “around” you in all directions, like a circle. Such feedback can come from performance evaluations, but often must be solicited independently. Many people avoid this step because of the discomfort of receiving suggestions for improvement, which can be taken as criticism. Admitting to weaknesses can evoke feelings of inadequacy and failure. Acknowledging weaknesses requires commitment, energy, and focus. A  first place to start is collecting personal feedback, privately, by keeping track of plans, targets, and performance. A second step is to understand your own typical responses to feedback. Separating the content from the source of the feedback can be helpful, and designing small experiments to test out suggestions is another way to gently begin to put feedback to use (Heen & Stone, 2014). Of course, feedback from others can be biased, skewed, or otherwise inaccurate, complicating the assessment process. Only by listening to several sources, over time and across different situations, and “triangulating” input from diverse sources, does a more complete picture emerge. Simultaneous consideration of self-assessments, assessment by others, and their gap are important in developing a full understanding of oneself (Avolio, 2010, p. 46).

PLANNING FOR DEVELOPMENT A personal leadership development plan specifies strengths and weaknesses, a time-bound mission or vision, and targeted strategies and tactics for achieving the vision or mission. Plans for development can range in timeframe from a few months to a lifetime.

244

IV  Sustaining Public Health Leadership

The need for planning for self-development differs qualitatively from the need for planning in programs and organizations, because it is linked to individual preference. Some individuals prefer to live a more unplanned, emergent life, and too much formalized planning is viewed as intrusive and restrictive. For some, planning may consist of as little as “give me a few tips as I do my thing.” For others, formalizing plans in documents, revisiting and altering the plans, vetting the plans with others, and monitoring progress are both feasible and important. Energy to devote to planning and to pursuing plans may wax and wane for some individuals, too. Some prefer short bursts of commitment to improvement, rather than constant and consistent attention. A related point is that self-development plans should be customized to one’s strengths and personality as they relate to both learning style and expected outcomes. For example, someone strongly anchored in an other-directed, caring personality may choose to eschew the ideal of the “versatile leader” who uses forceful direction when appropriate. Many observers advise a focus on building your strengths, rather than worrying too much about weaknesses (Drucker, 1999; Rath, 2007; Roberts et al., 2005). Or, at least, one should “Put yourself where your strengths can produce results” (Drucker, 1999, p. 166). The basic rationale is that change in your basic traits is unlikely, compared with changing the way you perform. But both building strengths and addressing weaknesses are important, and there is no reason not to do both, while recognizing that some weaknesses and traits are more malleable than others (Zaccaro, 2007). In addition, the possibility that “overdeveloped” strengths can reduce versatility and growth should be considered (Kaplan & Kaiser, 2013). A comprehensive approach (building strengths and addressing weaknesses) is particularly important in public health work, where a wide range of competencies is requisite. Most leadership training programs include self-development planning, and many planning templates are available commercially (e.g., Kouzes & Posner, 2012a). Many organizations assist with leadership development plans if you let it be known that is your goal. Ideally, they are customized to the individual. Griffin (2003) notes one particularly interesting category of individuals, the “reluctant leader,” who require extra encouragement, mentoring, and coaching in order to move into leadership roles. These individuals, who are often technical experts, may never have considered themselves leaders, or leadership “material.” Those with formal leadership roles or who manage leadership development programs in public health should not overlook the “reluctant leaders.” It benefits the field if such individuals can be encouraged to expand their leadership contributions.



10  Lifelong Leadership Development

245

THE DEVELOPMENT PROCESS Development From Knowledge Building knowledge is a small part of leadership development, but it has a definite place. (One maxim asserts that 70% of what you learn about leadership comes from on-the-job experiences, 20% from coaching, and 10% from classroom learning [Zenger, 2013]). Knowledge that summarizes best practices provides a shortcut compared with trial-and-error learning, for example. Knowledge of theories and concepts creates a comfort level with action because it helps place the action in a larger context. This is a form of “sense-making”—knowing that your actions are consistent with larger evidence and guidance (Ancona, 2012). Knowledge is available by observation, reading, watching films, listening to mentors, and a variety of other means. Knowing one’s learning style makes the process much easier. Some prefer hearing from experts, some prefer private study, some prefer joining book or journal clubs, and some prefer personally calling and visiting experts. Professional associations offer education in knowledge areas relevant to leadership, and promote networking, another way to develop discussed below. Participation in specialized leadership training offered by organizations is often a peak experience for aspiring leaders. Small group sessions are particularly useful. At most large public health organizations, training programs for leadership exist. Other organizations support enrollment in related degree programs or attendance at continuing education sessions. Regional and national public health institutes are another source of leadership training (National Network of Public Health Institutes, 2010). Philanthropic organizations such as the Robert Wood Johnson Foundation also support leadership education in public health. The Foundation’s State Health Leadership Initiative (SHLI), mentioned in Chapter 3, offers training, assistance, and mentoring of new State Health Officials. Beyond their tenures as state commissioners or secretaries of health, SHLI participants demonstrate an ongoing commitment to public health leadership through involvement in national organizations, such as the Association of State and Territorial Health Officials, and other national health policy development activities, committees, and roles (Hohl, 2006). Tangible examples of these bonds and purposeful motivations of public health leaders are evident in the ongoing contribution made by SHLI alumni to the field. (Mary Selecky, profiled later in this chapter in In Practice 10.2, is one.)

246

IV  Sustaining Public Health Leadership

“Action learning” conveys knowledge by applying it to real ­problems. Many leadership development programs use action learning, as well as learning in teams, which approximate the realities of l­eadership much more closely than do solo and “book” learning (Ceraso et al., 2011).

Development From Experience Knowledge, skills, values, and traits come together in the world of practice in the form of experience. Experience is by far the best way to “learn” leadership, if experience is used wisely. The utility of experience is affected by “the amount of challenge, the variety of task or assignments, and the quality of feedback that is received by the participants” (Jackson & Parry, 2011). Thus experience must be consciously utilized for learning, as opposed to forgotten or excused or repressed. The practice of periodically reflecting on experience, and getting input from others about the experience and how you handled it, is highly recommended (Hill, 1998). Learning from experience also requires that the experience include new challenges. Stepping outside of one’s comfort zone expands horizons, leads to new interests, and adds to maturity. Leaders interested in growth seek diversity (Yip & Wilson, 2010). Diverse experience includes experiences that cross boundaries, including vertical levels in hierarchical organizations, cross-functional team roles, experiences with different stakeholder groups, and dealing with different demographies and geographies (Ernst, Hannum, & Ruderman, 2010). In public health, diversity includes working with people outside of one’s specialty area and outside of the public health sector. Diversity also includes working with communities and residents impacted by public health programs, partnerships, and policies. To reiterate, “The essence of development is that diversity and adversity beat repetition every time” (McCall, Lombardo, & Morrison, 1988, p. 58). Regarding adversity, some of the most potent development experiences are those that are the most difficult. As one Executive MHA Program student commented to author JB, “I learn from my mistakes. I recommend getting thrown a curve ball every now and then to keep you on your toes.” Ideally, the “curve ball” challenges but does not overwhelm you. Among the most diverse experiences are those crossing the ­public, private nonprofit, and private for-profit sectors, experience which makes particular sense in public health because so many problems and solutions are cross-sector ones. Fellowships or other temporary ­assignments across sectors are likely to proliferate to facilitate such cross-­ sector ­training (Lovegrove & Thomas, 2013).



10  Lifelong Leadership Development

247

Another major development experience is starting a program or organization from scratch. Building a program forces one to develop flexibility and resilience, because failures along the way are inevitable. Teaching, mentoring, and coaching others are learning and growth opportunities as well, as they require deeper understanding of leadership and reflection beyond short-term reaction to events in the workplace.

Development From Networking Networking—cultivating productive personal and professional ­relationships—can be a valuable basis for acquiring new knowledge, in addition to new experiences. New knowledge and the benefits of expertise can be as close as an e-mail or telephone communication with a member of one’s network. A wide breadth of relationships, across fields and disciplines, enables more innovative learning (May, 2013a). Professional associations provide a convenient means for networking within one’s field or specialty. Within the leadership development field itself, there is growing interest in building networks among participants in a given program over time as well as between programs. The goal is to link leaders who may be working on similar issues but who may not typically have the time to search out others. Newer forms of networking involve social media tools, such as LinkedIn and Twitter. While many experienced professionals are less familiar with these tools, their use continues to increase. As part of professional development, leaders may want to seek formal training or tap existing network contacts to expand skills in using these expanding networking tools. Regardless of the tools used, networking is ultimately about connecting with people, sharing information, and respecting the give and take of these relationships. Contacts appreciate helping one another, with the expectation that the exchange flows in both directions. Offering to help others—sometimes before they ask for help—is the mark of a true leader and a savvy networker, which benefits both parties in the networking relationship.

Development From Coaching and Mentoring Formal coaching services are increasingly offered by large organizations and are readily available on the private market. Coaches provide oneon-one analysis of workplace actions as well as long-term planning for

248

IV  Sustaining Public Health Leadership

growth. Coaches can advocate for self-awareness, promote sustainable learning from experience, and generally create a learning environment for one’s experience (Frankovelgia & Riddle, 2010). They are also useful for teams or groups of leaders. Mentors are acquaintances within or outside of one’s organization who provide one-on-one advising, usually over the long term and without compensation. Mentors share the lessons they have learned through experience. Effective mentoring expands one’s opportunities for collaboration with new partners and new ideas for growth. Good mentors help you see your flaws, even when you overlook them during self-assessment. Most people can benefit from having multiple mentors. Large organizations often offer or facilitate access to both mentors and coaches. If you are not in such an organization, proactively developing mentor relationships is particularly important. In this situation, involvement in professional, civic, and other organizations and engagement with a broad network can lead to coaching and mentoring opportunities. Yet just as one seeks a coach and mentor to develop one’s own career and development, it is important to be ready and willing to help others in kind. By supporting others in their professional development, coaches and mentors further develop their own leadership capabilities and add to their knowledge and experiences through those they assist.

SUSTAINING A LIFE OF LEADERSHIP Sustaining a lifetime of “tackling tough public health challenges” requires nurturing oneself along the way, including maintaining work– life balance, and maintaining physical and mental health. While work– life balance decisions are intensely personal, most leaders strive to maintain a satisfying personal life that energizes their work life, and vice versa. Celebrating “wins,” however small, is important to maintaining passion for the challenge. Celebrating with colleagues, peers, and mentors is even more satisfying. Acknowledging the contributions of others can go a long way toward reinforcing an environment of celebrating “wins” and sets a positive example for others to both emulate and strive to achieve. Choosing (and contributing to) workplaces with optimistic, enthusiastic colleagues is another sustaining practice. Use of humor and meditation are others. “Giving back” by mentoring and educating others is practiced by many experienced public health leaders, and is a means of sustaining



10  Lifelong Leadership Development

249

one’s own development. As Koh and Jacobson (2009, p. 201) write, “Those who have successfully navigated these waters can share their insights as experienced change agents and coach those otherwise ­working in ­isolation, thereby providing another service in our service-­ oriented profession.” To paraphrase a Greek proverb, “a field grows great when leaders plant trees whose shade they know they will never sit in.” Mary Selecky, long-time Secretary of Health in the State of Washington profiled in In Practice 10.2, is known as a leader who mentors and contributes to the careers of others.

in practice 10.2 MARY SELECKY, PUBLIC HEALTH “GODMOTHER”* Upon her retirement in 2013, Mary Selecky was hailed by state, local, and federal public health leaders from around the United States. She led a local health department in eastern Washington for 20 years before becoming Secretary of Health for Washington State for 15 years, serving three different governors. That kind of longevity in public health speaks volumes about her commitment to public health, and about her competency as a leader as well. In addition to her service to Washington, Secretary Selecky served two terms as president of the Association of State and Territorial Health Officials (ASTHO), as president of the Washington State Association of Local Public Health Officials, and on the board of the National Association of County and City Health Officials (NACCHO). Throughout her career, she has received multiple awards, including virtually every award ASTHO has to bestow. She has been recognized not only by public health organizations but by the American Medical Association as well, with its Nathan Davis Award for Outstanding Government Service (Faces of Public Health, 2013). Most importantly, under her leadership, among other population health accomplishments, Washington’s adult smoking rate dropped 30%, and youth smoking rates are down by half. Childhood vaccination rates in the state are the highest in years (Allmain, 2013). What has made Mary Selecky such an effective and beloved public health leader? Throughout her career, she has embraced opportunities to learn from others and to learn by doing, to reflect, and to generously share her experience. Mentors have played a big role in her development, and she in turn has been and will continue to be a mentor to others. One of Secretary Selecky’s first and most enduring mentors was Dr. Ed Gray, who was one of the nation’s longest serving local public health officers. He retired in 2012 after over 50 years of service. Dr. Gray helped Secretary Selecky develop her confidence and her approach to local leadership

*Quotations not otherwise attributed are from M. Selecky, interview, December 2, 2013.

250

IV  Sustaining Public Health Leadership

early in her career, and he encouraged her to embrace the new challenge of state leadership when the opportunity came. Mary Selecky distills the essence of what mentors can do: listen and give feedback (a mentor will see the world differently than you do); open minds (a mentor can’t do the task for you, but can make you think about how to approach it); and open doors (but you have to walk through the doors yourself). In addition to individually mentoring public health leaders around the country, she typically speaks to the incoming class of state health officials at ASTHO’s annual orientation sessions. Given the frequent turnover of state public health leadership (75% turnover since the 2010 elections), there is a high need for rapid and effective “onboarding” in these unique jobs. For this purpose she developed what she calls “Selecky’s Baker’s Dozen for Leadership”: 1. Public health is a nonpartisan issue. 2. Know the political circumstances. 3. Collaboration is essential. 4. Relationships are everything. 5. Seek out a mentor. 6. Use your authority wisely. 7. Establish your priorities quickly and stick with them. 8. Ask questions. 9. Jargon is not your friend—put every issue in “plain talk.” 10. Seek out the best information from the most diverse places. 11. Don’t let the PERFECT be the enemy of the GOOD. 12. Make good on promises. 13. Accountability and credibility lead to results. Of these, Secretary Selecky stresses communication and relationships as the underpinnings of everything else. As spokespersons for public health both during emergencies and on everyday health issues, she urges leaders to embrace the Centers for Disease Control and Prevention (CDC) mantra of “Be First, Be Right, Be Credible.” And she might add: “Go everywhere and be relentless about getting out the key messages of public health.” Since her retirement, she notes that it’s not uncommon for citizens she meets to say, “Why do I know you? Oh yeah, you’re the one who kept telling me to wash my hands, cover my cough, and get my shots.” Secretary Selecky says another key lesson she learned along the way was to keep expanding her horizons—getting to know and becoming known by other parts of the health enterprise, and looking for learning from events all over the globe. Based on the strength of its systems and adherence to her Baker’s Dozen, she is rightly proud of how the Washington State Department of Health managed the whooping cough outbreak in 2012, and how its leaders reassured their state and the nation that monitoring and protection systems were in place following the Fukushima nuclear reactor disaster in Japan in 2011. She and her colleagues had



10  Lifelong Leadership Development

251

worked hard to earn their reputations as a trusted, caring voice that would do everything possible to help people protect themselves and their families. Looking back over her career, Secretary Selecky points out important differences in the leadership context between state and local public health. At the local level, leaders are typically able (and required) to “roll up your sleeves” and get more hands-on with various issues, and hopefully often you will have the satisfaction of seeing something get resolved. At the state level, leaders are required to be constantly surveying a much broader landscape, and with eyes on many things simultaneously, there isn’t usually the same opportunity to be personally engaged in the details of the work. With the average tenure of a state health officer still under 4 years, she wisely counsels leaders to pick a very short list of priorities to try to drive, and stay focused on those. Secretary Selecky is not retiring from public health. She is serving on the accreditation subcommittee of the Public Health Accreditation Board (and counts it as “sweet” that Washington State was one of the first state agencies to be accredited, just before her retirement), on a CDC national advisory committee, and on advisory committees on various national projects. She plans to join the board of a major health system in her home state, where she will no doubt continue to advocate for higher impact collaboration between public health and health care. With such a distinguished record of accomplishment, Mary Selecky exemplifies the type of sustained leadership needed to effectively tackle tough public health challenges and to strengthen the field of public health.

CONCLUSION Leadership development is important to public health as a profession, as well as to individuals who consciously chose to build their leadership competencies. Leaders develop self-understanding by assessing themselves and listening to input and advice. Leaders build their knowledge by self-learning and involvement in continuing education and training programs. They reveal their values and traits to themselves and others by testing them in action. They develop skills and competencies through diverse and challenging experiences. They customize their leadership style to their strengths, while working to lessen the negative impact of weaknesses and to expand their versatility. The public health workforce is filled with individuals who want to make a difference. Leadership development will empower the field and will enable those who choose to lead to leave an even greater legacy of improved health for all.

References

Adams, J. S. (1965). Inequity in social exchange. In L. Berkowitz (ed.), Advances in experimental social psychology (Vol. 2, pp. 267–299). New York, NY: Academic Press. Akunyili, D. N. (2006, April 29). Women leadership in emerging democracy—My NAFDAC Experience [Speech]. Washington, DC: Author. Retrieved July 5, 2013, from http://www.wilsoncenter.org/sites/default/files/Akunyili_speech.pdf Akunyili, D. N. (2013). Prof. Dora Nkem Akunyili: The official website [Personal website]. Author. Retrieved July 5, 2013, from http://www.doraakunyilionline.org/ Albrecht, K. (2006). Social intelligence: The new science of success. San Francisco, CA: Jossey-Bass. Alcorn, T. (2012). Redefining public health in New York City. Lancet, 379, 2037–2038. Alderfer, C. (1972). Existence, relatedness, and growth. New York, NY: Free Press. Aldrich, D. P. (2012). Building resilience: Social capital in post-disaster recovery. Chicago, IL: University of Chicago Press. Alexander, J. A., Comfort, M. E., Weiner, B. J., & Bogue, R. (2001). Leadership in collaborative community health partnerships. Nonprofit Management and Leadership, 12(2), 159–175. Allina Health System. (2013a). Engaging communities, improving health: 2012 Community Benefit & Engagement report [Annual report]. Minneapolis, MN: Author. Retrieved October 12, 2013, from http://www.allinahealth .org/ahs/aboutallina.nsf/page/Allina-Health-In-the-Community-2012 .pdf/$FILE/Allina-Health-In-the-Community-2012.pdf



253

254

References

Allina Health System. (2013b). Community health improvement initiatives. Minneapolis, MN: Author. Retrieved October 13, 2013, from http://www .allinahealth.org/ahs/aboutallina.nsf/page/heart_health Allina Health System. (2013c). Center for Healthcare Innovation and Research at Allina Health [Webpage]. Minneapolis, MN: Author. Retrieved October 14, 2013, from http://www.allinahealth.org/ahs/aboutallina.nsf/page/ health_care_innovation Allmain, G. (2013, February 6). State health secretary’s legacy includes fewer smokers. Federal Way Mirror. Retrieved December 15, 2013, from http:// www.federalwaymirror.com/news/190117911.html American Library Association. (2013). Leadership Traits. Document ID: 15c6f4c18c2c-62a4-618d-f02cf93e3d57. Chicago, IL: Author. Retrieved August 18, 2013, from http://www.ala.org/nmrt/initiatives/ladders/traits/traits American Public Health Association (APHA). (2013). Prevention and Public Health Fund: Dedicated to improving our nation’s public health. Washington, DC: Author. Retrieved July 15, 2013, from http://www.apha.org/NR/ rdonlyres/3060CA48-35E3-4F57-B1A5-CA1C1102090C/0/APHA_PPHF_ factsheet_May2013.pdf American Red Cross. (2013). A brief history of the American Red Cross. Washington, DC: Author. Retrieved August 11, 2013, from http://www.redcross.org/ about-us/history Ancona, D. (2012). Sensemaking: Framing and acting in the unknown. In S. Snook, N. Nohria, & R. Khurana (Eds.), The handbook for teaching leadership: Knowing, doing, and being (pp. 3–19). Thousand Oaks, CA: Sage. Anderson, C. (2013). How to give a killer presentation. Harvard Business Review, 91(6), 121–125. Anderson, K. M. (2011). State and local policy initiatives to reduce health disparities: A workshop summary. Washington, DC: Institute of Medicine. Retrieved July 10, 2013, from http://www.nap.edu/catalog.php?record_id=13103 Anderson, L. M., Brownson, R. C., Fullilove, M. T., Teutsch, S. M., Novick, L. F., Fielding J., & Land, G. H. (2005). Evidence-based public health policy and practice: Promises and limits. American Journal of Preventive Medicine, 28(5S), 226–230. Applied Survey Research (ASR). (2012). Santa Cruz County: Community assessment project (Online report). Watsonville, CA: Author. Retrieved August 10, 2013, from http://www.appliedsurveyresearch.org/projects_database/ quality-of-life/santa-cruz-county-community-assessment-project-cap.html Arvey, R. D., Rotundo, M., Johnson, W., Zhang, Z., & McGue, M. (2006). The determinants of leadership role occupancy: Genetic and personality factors. The Leadership Quarterly, 17, 1–20. Association of Schools of Public Health (ASPH). (2006). MPH Core Competency Model 2010. Retrieved August 9, 2013, from http://www.asph.org/document .cfm?page=851



References

255

Association of Schools of Public Health (ASPH). (2009). DrPH Core Competency Model 2009. Retrieved August 9, 2013, from http://www.asph.org/document .cfm?page=1004 Avolio, B. J. (2010). Full range leadership development (2nd ed.). Los Angeles, CA: Sage. Azzahir, A. (2010). Cultural Wellness Center’s response. Unequal distribution of health. Minneapolis, MN: Blue Cross Blue Shield Foundation. Retrieved July 10, 2013, from http://bcbsmnfoundation.com/pages-grantmaking-tier4Unequal_Distribution_of_Health_in_the_Twin_Cities?oid=11931 Azzahir, A., & Barbee, J. (2004). Powderhorn Phillips Cultural Wellness Center: Cultural reconnection and community building for personal and collective health. End of One Way. Minneapolis, MN: McKnight Foundation. Retrieved July 10, 2013, from http://www.mcknight.org/system/asset/ document/101/v-cultural-reconnection-and-community-building284-kb.pdf Barbuto, J. E., & Wheeler, D. W. (2006). Scale development and construct clarification of servant leadership. Group & Organization Management, 3, 300–326. Bar-Yam, Y. (2012, November 15). After Sandy: Preparing for crises. Cambridge, MA: New England Complex Systems Institute. Retrieved November 1, 2013, from http://www.necsi.edu/events/vidlib/SandySeminar1115.mp4 Bass, B. M. (1990). From transactional to transformational leadership: Learning to share the vision. Organizational Dynamics, 18(3), 19–31. Beard, A. (2013). Life’s work: Maya Angelou. Harvard Business Review, 91(5), 152. Begun, J., & Heatwole, K. B. (1999). Strategic cycling: Shaking complacency in healthcare strategic planning. Journal of Healthcare Management, 44, 339–352. Begun, J. W. (2009). Realistic evidence-based management. Health Care Man­ agement Review, 34, 214–215. Begun, J. W., & Jiang, H. J. (2004). Changing organizations for their likely masscasualties future. Advances in Health Care Management, 4, 163–180. Begun, J. W., & Thygeson, M. (2014, forthcoming). Complexity and health care: Tools for engagement. In S. S. Mick and P. Shay (Eds.), Advances in health care organization theory (2nd ed.). San Francisco, CA: Jossey-Bass. Begun, J. W., & White, K. R. (2008). The challenge of change: Inspiring leadership. In Claire Lindberg, S. Nash, & Curt Lindberg (Eds.), On the edge: Nursing in the age of complexity (pp. 239–262). Bordentown, NJ: Plexus Press. Begun, J. W., Zimmerman, B., & Dooley, K. J. (2003). Health care organizations as complex adaptive systems. In S. S. Mick and M. E. Wyttenbach (Eds.), Advances in health care organization theory (pp. 253–288). San Francisco, CA: Jossey-Bass. Bender, K. (2013).National accreditation of public health departments. In J. W. Holsinger, Jr. (Ed.), Contemporary public health: Principles, practice, and policy (pp. 155–169). Lexington, KY: University Press of Kentucky.

256

References

Benjamin, G. C. (2006). Putting the public in public health: New approaches. Health Affairs, 25, 1040–1043. Benjamin, G. C. (2013, January 16). White House plan on gun violence [Press release]. Washington, DC: American Public Health Association. Retrieved June 28, 2013, from http://www.apha.org/about/news/pressreleases/2013/White+ House+plan+on+gun+violence.htm Benkler, Y. (2011). The unselfish gene. Harvard Business Review, 89(7–8), 76–85. Bennet, J. (2012, November). The Bloomberg way. Atlantic Monthly. Retrieved August 16, 2013, from http://www.theatlantic.com/magazine/archive/ 2012/11/the-bloomberg-way/309136/ Bennis, W. G. (2004). The seven ages of the leader. Harvard Business Review, 82(1), 46–53. Berwick, D. M., Calkins, D. R., McCannon, C. J., & Hackbarth, A. D. (2006). The 100,000 lives campaign: Setting a goal and a deadline for improving health care quality. Journal of the American Medical Association, 295(3), 324–327. Blackwell, A. G. (2012, August 8). For prosperity economics to work we must leverage America’s growing diversity as an asset. HuffingtonPost.com. Retrieved July 25, 2013, from http://www.huffingtonpost.com/angelaglover-blackwell/prosperity-economics-for-minorities_b_1749447.html Blackwell, A. G., & Tanden, N. (2013). Preface. In V. Cárdenas & S. Treuhaft (Eds.), All-in nation: An America that works for all (pp. vii–x). Washington, DC: Center for American Progress & PolicyLink. http://allinnation.org/ Block, P. (2008). Community: The structure of belonging. San Francisco: Berrett-Koehler. Bolman, L. G., & Deal, T. E. (2013). Reframing organizations: Artistry, choice, and leadership (5th ed.). San Francisco, CA: Jossey-Bass. Bossidy, L., & Charan, R. (2002). Execution: The discipline of getting things done. New York, NY: Crown Business. Bradley, E. H., Elkins, B. R., Herrin, J., & Ebel, B. (2011). Health and social services expenditures: Associations with health outcomes. BMJ Quality and Safety, 20, 826–831. Brassard, M., & Ritter, D. (2007).The public health memory jogger II. Salem, NH: GOAL/QPC. Braveman, P., Egerter, S., & Williams, D. R. (2011). The social determinants of health: Coming of age. Annual Reviews of Public Health, 32, 381–398. Braveman, P. A., Egerter, S. A., & Mockenhaupt, R. E. (2011). Broadening the focus: The need to address the social determinants of health. American Journal of Preventive Medicine, 40(1S1), S4–S18. Braveman, P. A., Egerter, S. A., Woolf, S. H., & Marks, J. S. (2011). When do we know enough to recommend action on the social determinants of health? American Journal of Preventive Medicine, 40(1S1), S58–S66.



References

257

Briscoe, A. (2010). His health: Alameda County male health status report 2010: Foreword. Alameda County Public Health Department. Retrieved July 10, 2013, from http://www.acphd.org/media/278462/hishealth2.pdf Briscoe, A. (2012, March). Fire station health portals [Video of presentation]. Sausalito, CA: Design Access Summit. Retrieved July 10, 2013, from http:// vimeo.com/44414615 Brown, S. L., & Eisenhardt, K. M. (1998). Competing on the edge: Strategy as structured chaos. Boston, MA: Harvard Business Press. Brunt, B. A. (2010 May 18). Developing a just culture. HealthLeadersMedia [online]. Retrieved August 31, 2013, from http://www.healthleadersmedia .com/print/NRS-251182/Developing-a-Just-Culture Buckingham, M. (2012). Leadership development in the age of the algorithm. Harvard Business Review, 90(6), 86–94. Bunker J. P., Frazier, H. S., & Mosteller, F. (1994). Improving health: Measuring effects of medical care. Milbank Quarterly, 72, 225–258. Business for Social Responsibility. (2013). A new CSR frontier: Business and population health. New York, NY: Author. Retrieved December 4, 2013, from http://www.bsr.org/reports/BSR_A_New_CSR_Frontier_Business_ and_Population_Health.pdf Cabane, O. F. (2012). The charisma myth: How anyone can master the art and science of personal magnetism. New York, NY: Portfolio/Penguin. Cain, S. (2012). Quiet: The power of introverts in a world that can’t stop talking. New York, NY: Crown Publishers. California Pan-Ethnic Health Network (CPEHN). (2011, November 9). Seizing the opportunity: Achieving equity in health reform; Speaker biographies— Oakland. Oakland, CA: Author. Retrieved July 10, 2013, from http://www .cpehn.org/pdfs/Seizing%20the%20Opportunity%20Speaker%20Bios% 20-%20Oakland%2011-11.pdf Callahan, D., & Jennings, B. (2002). Ethics and public health: Forging a strong relationship. American Journal of Public Health, 92(2), 169–176. Camden Coalition of Healthcare Providers (CCHP). (2013). About the Coalition [Organization website]. Camden, NJ: Author. Retrieved July 8, 2013, from http://www.camdenhealth.org/about/about-the-coalition/history/ Casa de Esperanza. (2013). Casa de Esperanza. [website]. Retrieved October 5, 2013, from https://www.casadeesperanza.org/ Center for Infectious Disease Research and Policy (CIDRAP), University of Minnesota. (2012a, October 15). New U of M-led analysis finds urgent need for new influenza vaccines [Press release]. Minneapolis, MN: Author. Retrieved July 7, 2013 from http://www.cidrap.umn.edu/compelling-need-gamechanging-influenza-vaccines Center for Infectious Disease Research and Policy (CIDRAP), University of Minnesota. (2012b, October 15). The compelling need for game-changing influenza Vaccines [Online report]. Minneapolis, MN: Author. Retrieved

258

References

July 7, 2013, from http://www.cidrap.umn.edu/compelling-need-gamechanging-influenza-vaccines Centers for Disease Control and Prevention (CDC). (1999). Ten great public health achievements—United States, 1900–1999. MMWR, Morbidity and Mortality Weekly Report, 48(12), 241–243. Centers for Disease Control and Prevention (CDC). (2011). CDC health disparities and inequalities report: United States, 2011. MMWR, Morbidity and Mortality Weekly Report, 60(Suppl), 1–116. Centers for Disease Control and Prevention (CDC). (2013a). Winnable Battles. [website]. Retrieved December 12, 2013, from http://www.cdc.gov/­ winnablebattles/index.html Centers for Disease Control and Prevention (CDC). (2013b, January 16). Key facts about seasonal flu vaccine. Washington, DC: Author. Retrieved July 7, 2013, from http://www.cdc.gov/flu/protect/keyfacts.htm Centers for Disease Control and Prevention (CDC). (2013c, March 29). 2012– 2013 flu season drawing to a close: Flu vaccine still best way to prevent flu. Washington, DC: Author. Retrieved July 7, 2013, from http://www.cdc .gov/flu/spotlights/2012-2013-flu-season-wrapup.htm Centers for Disease Control and Prevention (CDC). (2013d, May 24). Situation update: Summary of weekly FluView. Washington, DC: Author. Retrieved July 7, 2013, from http://www.cdc.gov/flu/weekly/summary.htm Centers for Disease Control and Prevention (CDC). (2013e). A practitioner’s guide for advancing health equity: Community strategies for preventing chronic disease. Atlanta, GA: U.S. Department of Health and Human Services. Retrieved December 7, 2013, from http://www.cdc.gov/nccdphp/dch/ pdf/HealthEquityGuide.pdf Centers for Disease Control and Prevention (CDC), Emergency Risk Communication Branch. (2008). The risk communicator: Emergency risk communication network, Issue 1. Washington, DC: Author. Retrieved September 16, 2013, from http://www.bt.cdc.gov/ercn/01/ Centers for Disease Control and Prevention (CDC), Emergency Risk Communication Branch. (2010a). The risk communicator: Emergency risk communication network, Issue 2. Washington, DC: Author. Retrieved September 16, 2013, from http://www.bt.cdc.gov/ercn/02/ Centers for Disease Control and Prevention (CDC), Emergency Risk Communication Branch. (2010b). The risk communicator: Emergency risk communication network, Issue 3. Washington, DC: Author. Retrieved September 16, 2013, from http://www.bt.cdc.gov/ercn/03/ Centers for Medicare and Medicaid Services. (2012). National Health Care Expenditures Data, January 2012, Table 1. Retrieved July 29, 2013, from: https://www.cms.gov/Research-Statistics-Data-and-Systems/StatisticsTrends-and-Reports/NationalHealthExpendData/downloads/tables.pdf



References

259

Ceraso, M., Gruebling, K., Layde, P., Remington, P., Hill, B., Morzinski, J., & Ore, P. (2011). Evaluating community-based public health leadership training. Journal of Public Health Management and Practice, 17, 344–349. Children’s Safety Network (CSN). (2013). The cost of gun violence [Online report]. Waltham, MA: Author. Retrieved June 29, 2013, from http:// www.childrenssafetynetwork.org/sites/childrenssafetynetwork.org/ files/TheCostofGunViolence.pdf Chrislip, D. D. (2002). The collaborative leadership fieldbook: A guide for citizens and civic leaders. San Francisco, CA: Jossey-Bass. Cialdini, R. B. (2001). Harnessing the science of persuasion. Harvard Business Review, 79(9), 72–79. City of New Orleans. (2013, February 22). New Orleans Health Department receives Roadmaps to Health prize from the Robert Wood Johnson Foundation [Online press release]. Retrieved August 8, 2013, from http://www.nola.gov/mayor/­ press-releases/2013/ 20130222-new-orleans-health-department-receives-ro/ City of New York. (2008, May 20). City officials unveil new icon to inspire New Yorkers to take the stairs for better health and a greener NYC [Online press release]. New York City, NY: Author. Retrieved November 5, 2013, from http://www.nyc.gov/html/doh/html/pr2008/pr033-08.shtml City of New York. (2013). Mayor’s Bio [Official online biography of Mayor Michael R. Bloomberg]. New York City, NY: Author. Retrieved November 5, 2013, from http://www1.nyc.gov/office-of-the-mayor/bio.page Coe, C.K. (2011). Nonprofit financial management: A practical guide. Hoboken, NJ: Wiley. Collins, J. C. (2001a). Good to great: why some companies make the leap—and others don’t. New York, NY: HarperBusiness. Collins, J. C. (2001b). Level 5 leadership: The triumph of humility and fierce resolve. Harvard Business Review, 79(1), 67–76. Collins, J. C. (2006). Good to great in the social sectors: A monograph to accompany Good to Great. New York, NY: HarperBusiness. Collins, J., & Hansen, M. T. (2011). Great by choice: Uncertainty, chaos, and luck— Why some thrive despite them all. New York, NY: HarperCollins. Community Commons. (2013). Maps & data. Columbia, MO: Author. Retrieved from http://www.communitycommons.org/maps-data/ Conger, J. A. (1998). The necessary art of persuasion. Harvard Business Review, 76(3), 84–95. Consortium for Research on Emotional Intelligence in Organizations. (2013). Emotional intelligence measures. Retrieved November 23, 2013, from http://www.eiconsortium.org/measures/measures.html Cooperrider, D. L., & Whitney, D. (2005). Appreciative inquiry: A positive revolution in change. San Francisco, CA: Berrett-Koehler.

260

References

Covello, V. T. (2003). Best practices in public health risk and crisis communication. Journal of Health Communication, 8, 5–8. Coventry, M. (2010, June 16). Building healthy communities: This public health scholarship might just turn our country around. Giving to medicine and health  [Online article]. Minneapolis, MN: University of Minnesota. Retrieved July 29, 2013, from http://blog.lib.umn.edu/mmf/news/­ giftplanning/2010/building-healthy-communities-this-public-healthscholarship-just-might-turn-our-­country-around.html Covey, S. R. (2004). The 7 habits of highly effective people. New York, NY: Free Press. Crosby, B. C., & Bryson, J. M. (2005). Leadership for the common good: Tackling ­public problems in a shared-power world. San Francisco, CA: Jossey-Bass. Crosby, B. C., & Bryson, J. M. (2010). Integrative leadership and the creation and maintenance of cross-sector collaborations. The Leadership Quarterly, 21, 211–230. Crosby, J. (2013, November 15). United puts $50M into housing. Minneapolis Star Tribune (pp. D1–D2). Crutchfield, L. R., & Grant, H. M. (2012). Forces for good: The six practices of highimpact nonprofits (Rev. ed.). San Francisco, CA: Jossey-Bass. Cultural Wellness Center (CWC). (n.d.). Cultural Wellness Center [Organization Website]. Minneapolis, MN: Author. Retrieved July 10, 2013, from http:// ppcwc.org/home Czabanowka, K., Smith, T., Stankunas, M., Avery, M., & Otok, R. (2013). Transforming public health specialists into public health leaders. Lancet, 382, 449–450. David, S., & Congleton, C. (2013). Emotional agility. Harvard Business Review, 91(11), 125–128. Day, M., Shickle, D., Smith, K., Zakariasen, K., Oliver, T., & Moskol, J. (2012). Time for heroes: Public health leadership in the 21st century. Lancet, 380, 1205–1206. de Savigny, D., & Adam, T. (Eds). (2009). Systems thinking for health systems strengthening. Geneva, Switzerland: WHO Press. Dees, D. E. (2005, October 7). Outrage over Red Cross—why the surprise? Mother Jones. Retrieved August 8, 2013, from http://www.motherjones .com/mojo/2005/10/outrage-over-red-cross-why-surprise DeSalvo, K. (2013, January). Letter from the Health Commissioner. In New Orleans Health Department (Ed.), New Orleans community health improvement report: Community health profile & community health improvement plan. New Orleans, LA. Retrieved August 8, 2013, from http://www.nola .gov/nola/media/Health-Department/Publications/NOLA-CommunityHealth-Improvement-Final-Report.pdf Dobbs, R. A. (2014). Ethics issues in disaster planning. In F. Perry (Ed.), The tracks we leave: Ethics in healthcare management (p. 253). Chicago, IL: AUPHA Press.



References

261

Drath, W. H. (2004a). Leading together: Complex challenges require a new approach. In M. Wilcox & S. Rush (Eds.), The CCL guide to leadership in action (pp. 153–163). San Francisco, CA: Jossey-Bass. Drath, W. H. (2004b). The third way: A new source of leadership. In M. Wilcox & S. Rush (Eds.), The CCL guide to leadership in action (pp. 171–180). San Francisco, CA: Jossey-Bass. Drath, W. H., McCauley, C. D., Palus, C. J., Velsor, E. V., O’Connor, P. M. G., & McGuire, J. B. (2008). Direction, alignment, commitment: Toward a more integrative ontology of leadership. The Leadership Quarterly, 19, 635–653. Drucker, P. (1999). Managing oneself. Harvard Business Review, 77(2), 64–74, 185. Drum, C., McClain, M. R., Horner-Johnson, W., & Taitano, G. (2011). Health disparities chart book on disability and racial and ethnic status in the United States. Durham, NH: Institute on Disability, University of New Hampshire. Duke, L. (2005, September 12). The category 5 general. Washington Post. Retrieved August 22, 2013, from http://www.washingtonpost.com/ wp-dyn/content/article/2005/09/11/ AR2005091101484_pf.html Dye, C. F. (2010). Leadership in healthcare (2nd ed.). Chicago, IL: Health Administration Press. Dyer, J. H., Gregersen, H. B., & Christensen, C. M. (2009). The innovator’s DNA. Harvard Business Review, 87(12), 60–67. Edmondson, A. C., Golden, B. R., & Young, G. J. (2008, January 17). Turnaround at the Veterans Administration (A). Boston, MA: Harvard Business School Publishing. Retrieved from www.hbsp.harvard.edu El-Naggar, M. (2013, July 17). Next steps in Bloomberg’s obesity fight: Up the stairs. New York Times. Retrieved November 5, 2013, from http://www .nytimes.com/2013/07/18/nyregion/next-steps-in-bloombergs-obesityfight-up-the-stairs.html?partner=rss&emc=rss Eoyang, G. H., & Berkas, T. H. (1998). Evaluation in a complex adaptive system. In M. R. Lissack and H. P. Gunz (Eds.), Managing complexity in organizations (pp. 313–335). Westport, CT: Quorum Books. Epstein, R. A. (2003). Let the shoemaker stick to his last: A defense of the “old” public health. Perspectives in Biology and Medicine, 46(3), S138–S159. Ernst, C., Hannum, K. M., & Ruderman, M. N. (2010). Developing intergroup leadership. In E. Van Velsor, C. D. McCauley, & M. M. Ruderman (Eds.), The Center for Creative Leadership handbook of leadership development (3rd ed., pp. 375–404). San Francisco, CA: Jossey-Bass. Evashwick, C. J. (2013). Public health workforce and education in the United States. In J. W. Holsinger, Jr. (Ed.), Contemporary public health: Principles, practice, and policy (pp. 63–83). Lexington, KY: University Press of Kentucky.

262

References

Evashwick, C. J., Begun, J. W., & Finnegan, J. R. (2013.) Public health as a distinct profession: Has it arrived? Journal of Public Health Management and Practice, 19(5), 412–419. Faces of Public Health: Mary Selecky Looks Back. (2013, March 18). NewPublicHealth [website]. Retrieved December 14, 2013, from http://www .rwjf.org/en/blogs/new-public-health/2013/03/faces_of_public_heal.html Fallon, L. F., Begun, J. W., & Riley, W. (2013). Managing health organizations for quality and performance. Burlington, MA: Jones & Bartlett Learning. Fielding, J. E., & Briss, P. A. (2006). Promoting evidence-based public health policy: Can we have better evidence and more action? Health Affairs, 25(4), 969–978. Fielding, J. E., Teutsch, S., & Breslow, L. (2010). A framework for public health in the United States. Public Health Reviews, 32, 174–189. Fineberg, H. C. (2013a). The paradox of disease prevention: Celebrated in principle, resisted in practice. Journal of the American Medical Association, 310, 85–90. Fineberg, H. V. (2013b). The state of health in the United States. Journal of the American Medical Association, 310, 585–586. First 5 Alameda County. (2013). Organization website. Alameda County, CA: Author. Retrieved July 10, 2013, from http://www.first5alameda.org/ Foundation Center. (2013). Establishing a non-profit organization: Develop vision and Mission statements. New York, NY: Author. Retrieved July 17, 2013, from http://foundationcenter.org/getstarted/tutorials/establish/statements.html Frankovelgia, C. C., & Riddle, D. D. (2010). Leadership coaching. In E. Van Velsor, C. D. McCauley, & M. M. Ruderman (Eds.), The Center for Creative Leadership handbook of leadership development (3rd ed., pp. 125–146). San Francisco, CA: Jossey-Bass. Freedman, S. G. (2005, July 6). Easing troubled emotions inside a troubled  school.  New York Times. Retrieved July 10, 2013, from http://www .nytimes.com/2005/07/06/education/06education.html?pagewanted =all&_r=1& Frenkiel, O. (2005, July 12). This world: One woman’s war with fake drugs [Broadcast transcript]. Retrieved July 5, 2013, from http://news.bbc .co.uk/2/hi/programmes/this_world/4656627.stm Frieden, T. R. (2010). A framework for public health action: The health impact pyramid. American Journal of Public Health, 100(4), 590–595. Friedenwald-Fishman, E. (2012, September 12). Tell me a story: Eight tips for creating powerful narratives that drive social impact. Stanford Social Innovation Review. Retrieved August 20, 2013, from http://www.ssireview .org/blog/entry/tell_me_a_story Frisina, M.E. (2011).Influential leadership: Change your behavior, change your organization, change health care. Chicago, IL: Health Forum.



References

263

Gagne, M., & Deci, E. L. (2005). Self-determination theory and work motivation. Journal of Organizational Behavior, 26, 331–362. Gawande, A. (2011, January 24). The hot spotters: Can we lower medical costs by giving the neediest patients better care? New Yorker. Retrieved July 8, 2013, from http://www.newyorker.com/reporting/2011/01/24/ 110124fa_fact_gawande Gebbie, K., Merrill, J., & Tilson, H. H. (2002). The public health workforce. Health Affairs, 21(6), 57–67. Gebbie, K. M., Weist, E. M., McElligott, J. E., Biesiadecki, L. A., Gotsch, A. R., Keck, C. W., & Ablah, E. (2013). Implications of preparedness and response core competencies for public health. Journal of Public Health Management and Practice, 19, 224–230. George, B. (2007). True north: Discover your authentic leadership. San Francisco, CA: Jossey-Bass. Gillard, A. M. (n.d.). Lowell Kruse, CEO. Health Care Compass. Retrieved July 18, 2013, from http://www.healthcare-compass.com/lowell-kruse/ Glouberman, S., & Zimmerman, B. (2002). Complicated and complex systems: What would successful reform of Medicare look like? Discussion Paper No. 8. Commission on the Future of Health Care in Canada. Goldberg, E. (2013, July 17). Red Cross in hot water again for failing to deliver promised aid to Hurricane Sandy victims: Report. Huffington Post. Retrieved August 8, 2013, from http://www.huffingtonpost.com/2013/07/17/redcross-sandy-relief_n_3611534.html Goleman, D. (1998). What makes a leader? Harvard Business Review, 76(6), 93–102. Goleman, D. (2000). Leadership that gets results. Harvard Business Review, 78(2), 78–90. Goleman, D. (2013). The focused leader: How effective executives direct their own—and their organizations’—attention. Harvard Business Review, 91(12), 50–60. Goleman, D., & Boyatzis, R. (2008). Social intelligence and the biology of leadership. Harvard Business Review, 86(9), 74–81. Gostin, L. O. (2010a). Mapping the issues: Public health, law, and ethics. In L. O. Gostin (ed.), Public health and ethics: A reader (pp. 1–19). Berkeley, CA: University of California Press. Gostin, L. O. (2010b). Public health law and ethics: A reader (2nd ed.). Berkeley, CA: University of California Press. Gostin, L. O., Boufford, J. O., & Martinez, R. M. (2004). The future of the public’s health: Vision, values, and strategies. Health Affairs, 23(4), 96–107. Gostin, L. O., & Powers, M. (2006). What does social justice require for the public’s health? Public health ethics and policy imperatives. Health Affairs, 25(4), 1053–1060.

264

References

Governance Institute. (2006). 100,000 lives campaign results. Retrieved June 26, 2013, from http://www.governanceinstitute.com Govindarajan, V., & Ramamurti, R. (2013).Delivering work-class health care, affordably. Harvard Business Review, 91(11), 117–122. Granovetter, M. S. (1973). The strength of weak ties. American Journal of Sociology, 78, 1360–1380. Grant, A. M., Gino, F., & Hofmann, D. A. (2010). The hidden advantages of quiet bosses. Harvard Business Review, 88(12), 28. Green, L. W. (2006). Public health asks of systems science: To advance our evidence-based practice, can you help us get more practice-based evidence? American Journal of Public Health, 96, 406–409. Greenleaf, R. K. (2002; original copyright 1977). Servant leadership. Mahwah, NJ: Paulist Press. Griffin, N. S. (2003). Personalize your management development. Harvard Business Review, 81(3), 113–121. Hackman, J. R., & Oldham, G. R. (1976). Motivation through the design of work: Test of a theory. Organizational Behavior and Human Performance, 16, 250–279. Hanlon, P., Carlisle, S., Hannah, M., & Lyon, A. (2012). The future public health. Maidenhead, Berkshire, England: Open University Press. Hargreaves, M. B. (2013). Using complexity science to improve the effectiveness of public health coalitions. Retrieved from http://www.necsi.edu/events/ iccs7/papers/e839e1bbe9ea54c690072c99a4b1.pdf Hartocollis, A. (2010, November 5). Running for your life. New York Times. Retrieved August 16, 2013, from http://www.nytimes.com/2010/11/07/ nyregion/07farley.html?pagewanted=all&_r=1& Hartocollis, A. (2013, March 18). Bloomberg’s plan would make stores conceal cigarettes. New York Times. Retrieved August 17, 2013, from http://www .nytimes.com/2013/03/19/ nyregion/bloomberg-proposes-anti-cigarettelegislation.html?pagewanted=all&_r=0 Hayes, M. (2002). Crisis communication: To be effective, treat it like water. Northwest Public Health, University of Washington School of Public Health. Retrieved from http://www.nwpublichealth.org/docs/nph/ s2002/hayes_s2002.pdf Healey, B. J., & Lesneski, C. D. (2011). Transforming public health practice: Leadership and management essentials. San Francisco, CA: Jossey-Bass. HealthPartners. (2013). Northwest Metro Alliance year 3 results. Bloomington, MN: Author. Retrieved October 20, 2013, from http://www.healthpartners .com/ucm/groups/public/@hp/@public/documents/documents/ cntrb_037948.pdf HealthPartners and Allina Hospitals & Clinics. (n.d.) HealthPartners and Allina Hospitals and Clinics: Northwest Metro Alliance. Bloomington &



References

265

Minneapolis, MN: Authors. Retrieved October 20, 2013, from http://www .healthpartners.com/ucm/groups/public/@hp/@public/documents/ documents/cntrb_008919.pdf Heartland Health (HH). (2009a, June 22). The road that leads you home . . . a dedication to Lowell C. Kruse. This Week at Heartland [Online newsletter]. Retrieved July 26, 2013, from http://media.heartland-health.com/ webdocs/­lowell/6-22-09.pdf Heartland Health (HH). (2009b). Lowell Kruse retirement celebration [Online video]. St. Joseph, MO: Author. Retrieved July 26, 2013, from http://www .heartland-health.com/body_clinic.cfm?id=2435 Heen, S., & Stone, D. (2014). Find the coaching in criticism. Harvard Business Review, 92(1/2), 108–111. Heifetz, R. (1994). Leadership without easy answers. Cambridge, MA: Harvard University Press. Heifetz, R. A., Grashow, A., & Linsky, M. (2009). The practice of adaptive leadership: Tools and tactics for changing your organization and the world. Boston, MA: Harvard Business Press. Heifetz, R. A., & Linsky, M. (2002, June). A survival guide for leaders. Harvard Business Review, 80(6), 65–74. Hemenway, D. (2010). Why we don’t spend enough on public health. New England Journal of Medicine, 362(18), 1657–1658. Herzberg, F. (1968). One more time: How do you motivate employees? Harvard Business Review, 46(1), 53–62. Hickman, G. R. (2010). Leading change in multiple contexts. Thousand Oaks, CA: Sage. Hill, L. A. (1998). Managing your career. Harvard Business School case 9-494082 (rev. December 15, 1998). Boston, MA: Harvard Business Publishing. Himmelman, A. T. (2002, January). Collaboration for change: Definitions, decisionmaking models, roles, and collaboration process guide. Minneapolis, MN: Himmelman Consulting. Retrieved from http://depts.washington.edu/ ccph/pdf_files/4achange.pdf History Makers. (2013, February 21). Lieutenant General Russel L. Honoré ‘Leadership in the new normal’ [Online speaker’s biography]. Chicago, IL: Author. Retrieved August 21, 2013, from http://www.thehistorymakers.com/program/lieutenantgeneral-russel-l-honore-%E2%80%9Cleadership-new-normal%E2%80%9D Hohl, J. (2006). The State Health Leadership Initiative. Developing ­leaders in the public health workforce. Washington, DC: Association of State and Territorial Health Officials. Retrieved July 19, 2013, from http:// www.astho.org/Programs/Workforce-and-Leadership-Development/ Developing-Leaders-in-the-Public-Health-Workforce-report_2006/ Honoré, P. A., & Costich, J. F. (2009).Public health financial management competencies. Journal of Public Health Management and Practice,15(4), 311–318.

266

References

Honoré, P. A., & Scott, W. (2010).Executive summary of priority areas for improvement of quality in public health. Washington, DC: U.S. Department of Health and Human Services. Honoré, R. (2009, March 1). Work is a blessing. Washington, DC: National Public Radio. Retrieved August 20, 2013, from http://www.npr.org/templates/ story/story.php?storyId=101267379 Honoré, R. (2013). Home [Corporate website]. Retrieved August 21, 2013, from http://www.generalhonore.com/index.html Horton, R. (2011). Offline: Where is public health leadership in England? Lancet, 378, 1060. Hupert, N. (2013). Dynamic analytics: A 21st-century preparedness science. Journal of Public Health Management and Practice, 19(5), S28–S30. Iezzoni, L. I. (2011.) Eliminating health and health care disparities among the growing population of people with disabilities. Health Affairs, 30, 1947–1954. Institute of Healthcare Improvement. (n.d.). Overview of the 100,000 Lives Campaign. Retrieved June 26, 2013, from http://www.ihi.org/offerings/ Initiatives/PastStrategicInitiatives/5MillionLivesCampaign/Documents/ Overview%20of%20the%20100K%20Campaign.pdf Institute of Medicine. (1988). The future of public health. Washington, DC: National Academy Press. Institute of Medicine. (2003a). The future of the public’s health in the 21st century. Washington, DC: National Academies Press. Institute of Medicine. (2003b). Who will keep the public healthy? Educating public health professionals for the 21st century. Washington, DC: National Academies Press. Institute of Medicine. (2011a). For the public’s health: Revitalizing law and policy to meet new challenges. Washington, DC: National Academies Press. Institute of Medicine. (2011b). For the public’s health: The role of measurement in action and accountability. Washington, DC: National Academies Press. Institute of Medicine. (2012). For the public’s health: Investing in a healthier future. Washington, DC: National Academies Press. Isham, G. J., Zimmerman, D. J., Kindig, D. A., & Hornseth, G. W. (2013). HealthPartners adopts community business model to deepen focus on nonclinical factors of health outcomes. Health Affairs, 32(8), 1446–1452. Jackson, B., & Parry, K. (2011). A very short, fairly interesting and reasonably cheap book about studying leadership (2nd ed.). Los Angeles, CA: Sage. Jackson, M. C. (2003). Systems thinking: Creative holism for managers. West Sussex, England: John Wiley & Sons. Jamieson, C. (2013). Gun violence research: History of the federal funding freeze [Online report]. Washington, DC: American Psychological Association.



References

267

Retrieved June 28, 2012, from http://www.apa.org/science/about/ psa/2013/02/gun-violence.aspx Jarris, P. E., & Sellers, K. (2013). Strategies for public health in a transforming health system. Journal of Public Health Management and Practice, 19, 93–96. John Wiley & Sons, Inc. (2013). Our Authors’ Research. Retrieved August 9, 2013, from http://www.leadershipchallenge.com/research-section-ourauthors-research.aspx Johnson, B. (1996). Polarity management: Identifying and managing unsolvable problems. Amherst, MA: HRD Press. Johnson, K., Grossman, W., & Cassidy, A. (Eds.), (1996). Collaborating to improve community health: Workbook and guide to best practices in creating healthier communities and populations. San Francisco, CA: Jossey-Bass. Joint Center for Political and Economic Studies. (2012, June). Place matters for health in Orleans Parish: Policy brief. Washington, DC: Author. Retrieved August 9, 2013, from http://www.jointcenter.org/docs/40532_JCSummary.pdf Joint Commission (2013). 2005 Ernest A. Codman Award recipient: Individual award winner: Kenneth W. Kizer, M.D., M.P.H., President and Chief Executive Officer National Quality Forum (Online recipient profile). Oakbrook Terrace, IL: Author. Retrieved August 6, 2013, from http://www.jointcommission .org/assets/1/6/Kenneth_W._Kizer.pdf Judge, T. A., Piccolo, R. F., & Kosalka, T. (2009). The bright and dark sides of leader traits: A review and theoretical extension of the leader trait paradigm. The Leadership Quarterly, 20, 855–875. Kaiser Commission on Medicaid and the Uninsured (KCMU). (2013). Alex Briscoe [Commission member profiles]. Menlo Park, CA: Henry J. Kaiser Family Foundation. Retrieved July 10, 2013, from http://kff.org/person/ alex-briscoe/ Kaissi, A. A., & Begun, J. W. (2008.) Fads, fashions, and bandwagons in health care strategy. Health Care Management Review, 33(2), 94–102. Kaplan, G. A. (2004). What’s wrong with social epidemiology, and how can we make it better? Epidemiologic Reviews, 26, 124–135. Kaplan, R. E., & Kaiser, R. B. (2003). Developing versatile leadership. MIT Sloan Management Review, 44(4), 19–26. Kaplan, R. E., & Kaiser, R. B. (2013). Fear your strengths: What you are best at could be your biggest problem. San Francisco, CA: Berrett-Koehler Publishers. Kaplan, R. S., & Norton, D.P. (1996). The balanced scorecard: Translating strategy into action. Boston, MA: Harvard Business School Press. Keane, C. (2014). Modeling behavior in complex public health systems: Simulation and games for action and evaluation. New York, NY: Springer Publishing Company. Kegan, R., & Lahey, L. L. (2009). Immunity to change. Boston, MA: Harvard Business Press.

268

References

Kellerman, A. L., Rivara, F. P., Rushforth, N. B., Banton, J. G., Reay, D. T., Francisco, J. T., Locci, A. B., . . . Somes, G. (1993.) Gun ownership as a risk factor for homicide in the home. New England Journal of Medicine, 329(19), 1084–1091. Kindig, D., & Stoddart, G. (2003). What is population health? American Journal of Public Health, 93, 380–383. Kizer, K. W. (2010, October 6). Statement of Kenneth W. Kizer, MD, to the Senate Committee on Veterans Affairs. San Francisco, CA: Medsphere. Retrieved August 7, 2013, from http://www.medsphere.com/news/medsphere-­inthe-news/767-statement-of-kenneth-w-kizer-md-to-the-senate-committeeon-veterans-affairs Koh, H. K., & Jacobson, M. (2009). Fostering public health leadership. Journal of Public Health, 31(2), 199–201. Koh, H. K., & McCormack, M. (2006). Public health leadership in the 21st century. In Kellerman, B. (Ed.). Working papers of the Center for Public Leadership (pp. 101–116). Cambridge, MA: Harvard University Kennedy School of Government. Retrieved from http://hdl.handle .net/1721.1/55951 Komives, S. R., Wagner, W., & Associates. (2009). Leadership for a better world: Understanding the social change model of leadership development. San Francisco, CA: Jossey-Bass. Kouzes, J. M., & Posner, B. Z. (2009). To lead, create a shared vision. Harvard Business Review, 87(1), 20–21. Kouzes, J. M., & Posner, B. Z. (2012a). LPI: Leadership practices inventory development planner (4th ed.). New York, NY: Wiley. Kouzes, J. M., & Posner, B. Z. (2012b). The leadership challenge: How to make extraordinary things happen in organizations (5th ed.). San Francisco, CA: Jossey-Bass. Kovner, A. R., & Rundall, T. G. (2006). Evidence-based management reconsidered. Frontiers of Health Services Management, 22(3), 3–22. Kretzmann, J. P., & McKnight, J. L. (2005). Discovering community power: A guide to mobilizing local assets and your organization’s capacity. AssetBased Community Development Institute, Northwestern University. Retrieved from http://www.abcdinstitute.org/docs/kelloggabcd.pdf LaFronza, V., & Burke, N. (2007, Summer). Katrina and social determinants of health:  Toward a comprehensive community emergency preparedness approach. Washington, DC: CommonHealth ACTION. Retrieved August 8, 2013, from http://commonhealthaction.org/PDF/CHA_KatrinaSocialDet.pdf Lant, T., & Lurie, N. (2013). Science preparedness and science response: Perspectives on the dynamics of preparedness conference. Journal of Public Health Management and Practice, 19(5), S3–S5.



References

269

Lantz, P. M., Lichtenstein, R. L., & Pollack, H. A. (2007). Health policy approaches to population health: The limits of medicalization. Health Affairs, 26, 1253–1257. Latham, G. P. (2007). Work motivation: History, theory, research, and practice. Thousand Oaks, CA: Sage. Latham, G. P., & Locke, E. A. (2002). Building a practically useful theory of goal setting and task motivation. American Psychologist, 57, 705–717. Leischow, S. J., & Milstein, B. (2006). Systems thinking and modeling for public health practice. American Journal of Public Health, 96, 403–405. Leischow, S. J., Best, A., Trochim, W. M., Clark, P. I., Gallagher, R. S., Marcus, S. E., & Matthews, E. (2008). Systems thinking to improve the public’s health. American Journal of Preventive Medicine, 35(2S), S196–S203. Lemonick, M. D., & Da Costa, G. (2005, October 31). Drug warrior. Time.org. Retrieved July 6, 2013, from http://www.time.com/time/magazine/ article/0,9171,1124289,00.html Lombardi, F., & McAuliff, M. (2009, May 15). President Obama taps NYC health commissioner Thomas Frieden to head CDC. NY Daily News. Retrieved August 16, 2013, from http://www.nydailynews.com/news/politics/ president-obama-taps-nyc-health-commissioner-thomas-frieden-headcdc-article-1.409935 Longman, P. (2005, January/February). The best care anywhere. Washington Monthly. Retrieved August 7, 2013, from http://www.washingtonmonthly .com/features/2005/0501.longman.html Lovegrove, N., & Thomas, M. (2013). Triple-threat leadership. Harvard Business Review, 91(9), 46–56. Luo, M. (2011, January 25). N.R.A. stymies firearms research, scientists say. New York Times. Retrieved June 28, 2013, from http://www.nytimes.com/ 2011/01/26/us/26guns.html/?pagewanted=all&_r=1& Lurie, N. (2002). The public health infrastructure: Rebuild or redesign? Health Affairs, 21(6), 28–30. Lurie, N., & Fremont, A. (2009). Building bridges between medical care and public health. Journal of the American Medical Association, 302, 84–86. Lurie, N., Wasserman, J., & Nelson, C. D. (2008). Public health preparedness: Evolution or revolution? In J. Colgrove, G. Markowitz, & D. Rosner (Eds.), The contested boundaries of American public health (pp. 226–238). New Brunswick, NJ: Rutgers University Press. Management Sciences for Health. (2013). Leadership, Management & Gov­ ernance Project. Retrieved August 15, 2013, from http://www.­lmgforhealth .org/ March, J. G. (1991).Exploration and exploitation in organizational learning. Organization Science, 2, 71–87.

270

References

Marion, R., & Uhl-Bien, M. (2001). Leadership in complex organizations. The Leadership Quarterly, 12, 389–418. Marks, J. S. (2012, October 25). Community health: taking smart steps [Online opinion report]. SFGate.com. San Francisco Chronicle. Retrieved July 10, 2013, from http://www.sfgate.com/opinion/openforum/article/Communityhealth-taking-smart-steps-3982459.php Marmot, M. (2005). Social determinants of health inequalities. Lancet, 365, 1099–1104. Marshall, E. (2013, January 16). Obama lifts ban on funding gun violence research [Online report]. Washington, DC: ScienceInsider. Retrieved June 28, 2013,  from http://news.sciencemag.org/scienceinsider/2013/01/obamalifts-ban-on-funding-gun-v.html Martin, W., Wiebe, R., Hermansen, A., Beveridge, R., Carroll, S., & McDonald, M. (2012). Complexity Science Knowledge Synthesis: Resources. Core Public Health Functions Research Initiative. Retrieved September 3, 2013, from http://www.uvic.ca/research/groups/cphfri/assets/docs/Complexity_ Science_Resources_July_2012.pdf Maslow, A. (1954). Motivation and personality. New York, NY: Harper. Mattessich, P. W., Murray-Close, M., & Monsey, B. R. (2001). Collaboration: What makes it work (2nd ed.). St. Paul, MN: Wilder Foundation. May, E. L. (2013a). Managing your career in transformative times. Healthcare Executive, 28(6), 10–12, 14–16, 18. May, E. L. (2013b). Population health management: Defining the provider’s role. Healthcare Executive, 28(4), 20–29. Mayors Against Illegal Guns. (2013a). About the coalition: Message from the ­co-chairs. New York, NY & Boston, MA: Author. Retrieved August 15, 2013, from http://www.mayorsagainstillegalguns.org/html/about/about.shtml Mayors Against Illegal Guns. (2013b, January). Access denied: How the gun lobby is depriving police, policy makers, and the public of data we need to p­ revent gun violence [Online report]. New York, NY: Author. Retrieved June 28, 2013, from http://libcloud.s3.amazonaws.com/9/c1/6/1017/3/access_ denied.pdf McCall, M. W., Lombardo, M. M., & Morrison, A. M. (1988). The lessons of experience. Lexington, MA: Lexington Books. McCannon, C. J., Schall, M. W., Calkins, D. R., & Nazem, A. G. (2006). Saving 100,000 lives in U.S. hospitals. British Medical Journal, 332, 1328. McDaniel, R. R., & Driebe, D. J. (Eds.) (2005). Uncertainty and surprise in complex systems: Questions on working with the unexpected. Heidelberg, Germany: Springer. McDaniel, R. R., Jordan, M. E., & Fleeman, B. F. (2003). Surprise, surprise, surprise! A complexity science view of the unexpected. Health Care Management Review, 28, 266–278.



References

271

Meadows, D. H. (2008). Thinking in systems: A primer. White River Junction, VT: Chelsea Green Publishing. Meadows, D. H., Randers, J., & Meadows, D. L. (2004). Limits to growth: The 30-year update. White River Junction, VT: Chelsea Green Publishing. Medsphere Systems Corporation. (2013). Kenneth W. Kizer, MD, MPH— Chairman  (Lead Independent Director) (Online biography). Retrieved August 7, 2013, from http://www.medsphere.com/company/leadership/ board-of-directors/303-kenneth-w-kizer-md-mph Meindl, J. R., Ehrlich, S. B., & Dukerich, J. M. (1985). The romance of leadership. Administrative Science Quarterly, 30(1), 78–102. Melchar, D. E., & Bosco, S. M. (2010). Achieving high organization performance through servant leadership. Journal of Business Inquiry, 9(1), 74–88. Miller, D., Hartwick, J., & Breton-Miller, I. L. (2004). How to detect a management fad—and distinguish it from a classic. Business Horizons, 47(4), 7–16. Mitroff, I. I. (2004). Crisis leadership: Planning for the unthinkable. Hoboken, NJ: John Wiley & Sons. Morell, J. (2013). A rolling conversation about the “agreement x certainty” space.  [Blog, Surprises in Programs and their Evaluations]. Retrieved September 3, 2013, from http://evaluationuncertainty.com/2013/05/05/ a-rolling-conversation-about-the-agreement-x-certainty-space/ Morrissey, T. W. (2011). The Affordable Care Act’s public health workforce provisions: Opportunities and challenges. Issue Brief, June 2011. Washington, DC: American Public Health Association. Retrieved July 27, 2013, from http:// www.apha.org/ Morton, M. J., & Lurie, N. (2013). Community resilience and public health practice. American Journal of Public Health, 103, 1158–1160. Mosser, G., & Begun, J. W. (2013). Understanding teamwork in health care. New York, NY: McGraw-Hill. Moyers, B. (2013). Angela Glover Blackwell: Social justice advocate [Online biography]. Public Affairs Television, Inc. Retrieved July 28, 2013, from http:// billmoyers.com/guest/angela-glover-blackwell/ Nagy, J., & Fawcett, S. (2013). Proclaiming your dream: Developing vision and mission statements. Washington, DC: The Community Tool Box. Retrieved July  17, 2013, from http://ctb.ku.edu/en/tablecontents/sub_section_main_1086.aspx National Association of County & City Health Officials (NACCHO). (2013a). Accreditation best test QI efforts (2009–2010). Washington, DC: Author.  Retrieved July 29, 2013, from http://www.naccho.org/topics/ infrastructure/accreditation/beta-test-qi-projects.cfm National Association of County & City Health Officials (NACCHO). (2013b). Comanche County Health Department (OK). Washington, DC: Author.  Retrieved July 29, 2013, from http://www.naccho.org/topics/ infrastructure/accreditation/ok-comanche-county.cfm

272

References

National Association of County & City Health Officials (NACCHO). (2013c). Health in all policies. Retrieved July 27, 2013, from http://www.naccho .org/topics/environmental/HiAP/ National Association of County & City Health Officials (NACCHO). (2013d). New Orleans Health Department (LA). Washington, DC: Author. Retrieved August 8, 2013, from http://www.naccho.org/topics/infrastructure/ accreditation/neworleans-la.cfm National Cancer Institute. (2007). Greater than the sum: Systems thinking in tobacco control. Tobacco Control Monograph No. 18. Bethesda, MD: U.S. Department of Health and Human Services. National Center for Food Protection and Defense (NCFPD). (n.d.). Best practices in risk communication. Minneapolis, MN: Author. Retrieved September 16, 2013, from http://www.ncfpd.umn.edu/Ncfpd/assets/ File/pdf/NCFPDRiskCommBestPractices.pdf National Health Security Preparedness Index (NHSPI.org). (2013a December 4). First-of-its-kind U.S. preparedness index shows great strengths and challenges in protecting nation’s health during disasters [Press release]. Washington, DC: Author. Retrieved December 8, 2013, from www.nhspi.org/content/press-releases National Health Security Preparedness Index (NHSPI.org). (2013b). 2013 National NHSPI results summary. Washington, DC: Author. Retrieved December 8, 2013, from http://www.nhspi.org/content/2013-­nationalnhspi-results-summary#summary National Institute of Standards and Technology (NIST). (2009, December  7). Five U.S. organizations honored for innovation and performance excellence with the 2009 Baldrige National Quality Award (Press release). Washington, DC: Author. Retrieved July 27, 2013, from http://www.nist.gov/baldrige/ baldrige_recipients2009.cfm National Institute of Standards and Technology (NIST). (2010). Heartland Health: 2009 National Baldrige application summary. Washington, DC: Author. Retrieved July 22, 2013, from http://www.baldrige.nist.gov/PDF_files/ Heartland_Award_Application_ Summary.pdf National Institute of Standards and Technology (NIST). (2013.) Baldrige performance excellence program. Retrieved September 9, 2013, from http:// www.nist.gov/baldrige/ National Network of Public Health Institutes. (2010). What is a public health institute? Retrieved November 23, 2013, from http://www.nnphi.org/about/ what-is-a-public-health-institute New Orleans Health Department (NOHD). (2013). New Orleans community health  improvement report: Community health profile & community health improvement plan. New Orleans, LA: Author. Retrieved August 8, 2013, from http://www.nola.gov/nola/media/Health-Department/Publications/ NOLA-Community-Health-Improvement-Final-Report.pdf



References

273

New Public Health. (2012, November 20). Angela Glover Blackwell: NewPublicHealth Q&A [Web log report]. Princeton, NJ: Robert Wood Johnson Foundation. Retrieved July 25, 2013, from http://www.rwjf.org/ en/blogs/new-public-health/2012/11/angela_glover_blackw.html New York City Department of Health (DOH) and Mental Hygiene. (2002, January 29). Thomas R. Frieden, MD, MPH, begins tenure as NYC health and mental health commissioner: New commissioner outlines priorities and vision for the next four years [Online press release]. New York City, NY: Author. Retrieved August 15, 2013, from http://www.nyc.gov/ html/doh/html/ press_archive02/pr05-129.shtml New York City Department of Health (DOH) and Mental Hygiene. (2013). Biography of Thomas Farley, M.D., M.P.H. New York City, NY: Author. Retrieved November 5, 2013, from http://www.nyc.gov/html/doh/ html/about/commish-bio.shtml New York State Health Foundation. (2011, June 9). NYSHealth hosts “A conversation with Dr. Jeffrey Brenner” [Online report]. New York, NY: Author. Retrieved July 8, 2013, from http://nyshealthfoundation.org/news-events/events/ nyshealth-hosts-a-conversation-with-dr.-jeffrey-brenner1 O’Byrne, B. (2011). Interview with Dr. Jeffrey Brenner. Physician Advocate, Winter 2011. Lawrenceville, NJ: Medical Society of New Jersey. Retrieved July 8, 2013, from http://www.njhitec.org/files/1813/4600/8626/Jeffrey_ Brenner_Interview_MSNJ_Winter_2011.pdf O’Leary, J. (2012). Learn to speak the language of ROI. In HBR guide to finance basics for managers (pp. 105–111). Boston, MA: Harvard Business Review Press. O’Reilly, C. A., & Pfeffer, J. (2000). Hidden value: How great companies achieve extraordinary results with ordinary people. Boston, MA: Harvard Business School Press. Organization of Economic Co-operation and Development (OECD). (2013). Public spending on health and long-term care: A new set of projections. Main paper, Economic Policy Paper no. 6. Retrieved July 26, 2013, from http://www.oecd.org/economy/public-spending-on-health-and-longterm-care.htm Paley, J. (2010). The appropriation of complexity theory in health care. Journal of Health Services Research and Policy, 15(1), 59–61. Pascale, R., Sternin, J., & Sternin, M. (2010). The power of positive deviance: How unlikely innovators solve the world’s toughest problems. Boston, MA: Harvard Business Press. Patton, M.Q. (2010). Developmental evaluation: Applying complexity concepts to enhance innovation and use. New York, NY: Guilford Press. Pawson, R. (2013). The science of evaluation: A realist manifesto. Thousand Oaks, CA: Sage. Pfeffer, J. (2010). Power play. Harvard Business Review, 88(7–8), 84–92.

274

References

Pfeffer, J., & Sutton. R. I. (2007). Hard facts, dangerous half-truths, and total nonsense. Boston, MA: Harvard Business School Press. Pink, D. H. (2009). Drive: The surprising truth about what motivates us. New York, NY: Riverhead Books. PolicyLink. (n.d.). About us: Our mission [Organization website]. Oakland, CA: Author. Retrieved July 29, 2013, from http://www.policylink.org/site/ c.lkIXLbMNJrE/b.7977453/k.FBB8/PolicyLink_About_Us.htm Porter, J., & Baker, E. L. (2005a). The management moment: Partnering essentials. Journal of Public Health Management Practice, 11(2), 174–177. Porter, J., & Baker, E. L. (2005b). The management moment: Selecting partners and setting the stage. Public Health Management Practice, 11(4), 369–372. Porter, L. W., & Lawler, E. E. (1968). Managerial attitudes and performance. Homewood, IL: Irwin. Poverty Forum. (2009). Forum participants: Angela Glover Blackwell, Founder and CEO, PolicyLink [Online biography]. Retrieved July 29, 2013, from http:// thepovertyforum.org/ bio-blackwell.php Princeton University. (2009, September 4). Innovations for successful societies: Dora Akunyili [Oral interview and transcript]. Princeton, NJ: Author. Retrieved July 5, 2013, from http://www.princeton.edu/successfulsocieties/content/ superfocusareas/traps/ME/oralhistories/view.xml?id=338 Public Advocates, Inc. (n.d.). Mission & history: Our organization. San Francisco, CA: Author. Retrieved July 30, 2013, from http://www.publicadvocates .org/mission-and-history Public Health Accreditation Board (PHAB). (2013, March 4). Eleven public health departments first to achieve national accreditation status: Public Health Accreditation Board recognizes high-performing health departments (Online press release). Alexandria, VA: Author. Retrieved August 12, 2013, from http://www.phaboard.org/wp-content/uploads/Eleven-Public-HealthDepartments-First-to-Achieve-Accreditation.pdf Public Health Foundation. (2010). About the Core Competencies for Public Health Professionals. Retrieved August 9, 2013, from http://www.phf.org/ programs/corecompetencies/Pages/About_the_Core_Competencies_for_ Public_Health_Professionals.aspx Public Health Functions Steering Committee. (1995). Public Health in America. Public Health Functions Project, 2008. Retrieved August 9, 2013, from http://www.health.gov/phfunctions/public.htm Public Health Leadership Society (PHLS). (2002). Principles of the practice of ethical public health. New Orleans, LA: Author. Retrieved July 21, 2013, from http:// www.apha.org/NR/rdonlyres/1CED3CEA-287E-4185-9CBD-BD405FC60856/0/ ethicsbrochure.pdf Quinn, R. E., Faerman, S. R., Thompson, M. P., McGrath, M. R., & St. Clair, L. (2011). Becoming a master manager: A competing values approach (5th ed.). New York, NY: Wiley.



References

275

Rashid, F., Edmondson, A. C., & Leonard, H. B. (2013). Leadership lessons from the Chilean mine rescue. Harvard Business Review, 91(7), 113–119. Rath, T. (2007). StrengthsFinder 2.0. New York, NY: Gallup Press. Ray, K. (2002). The nimble collaboration: Fine-tuning your collaboration for lasting success. St. Paul, MN: Wilder Foundation. Reed, K., & O’Connor, B. (2010). Accreditation beta test quality improvement project: Final report: Comanche County Health Department: Improving community engagement. Lawton, OK: Comanche County Health Department. Retrieved August 7, 2013, from http://www.naccho.org/topics/infrastructure/ accreditation/upload/Comanche-Final-Report.pdf Regents of the University of Minnesota. (2013). Minnesota Taconite Workers Health Study. Retrieved from http://taconiteworkers.umn.edu/index .html Resnicow, K., & Page, S. E. (2008). Embracing chaos and complexity: A quantum change for public health. American Journal of Public Health, 98, 1382–1389. Rhode, D. L., & Packel, A. K. (2009). Ethics and nonprofits. Stanford Social Innovation Review, 7(3). Retrieved August 11, 2013, from http://www .­ssireview.org/articles/entry/ ethics_and_nonprofits Richmond, B. (2000). The “thinking” in systems thinking: Seven essential skills. Toolbox Reprint series. Waltham, MA: Pegasus Communications. Riley, W. J., Moran, J. W., Corso, L. C., Beitsch, L. M., Bialek, R., & Cofsky, A. (2010). Defining quality improvement in public health. Journal of Public Health Management and Practice, 16(1), 5–7. Robert Wood Johnson Foundation (RWJF). (2013a, February 21). New Orleans, Louisiana: 2013 Roadmap to Health prize [Online press release]. Princeton, NJ: Author. Retrieved August 8, 2013, from http://www.rwjf.org/en/aboutrwjf/newsroom/newsroom-content/2013/02/new-orleans--louisiana-2013-roadmaps-to-health-prize.html Robert Wood Johnson Foundation (RWJF). (2013b, February 21). Santa Cruz County, California: RWJF Roadmaps to Health prize (Online press release). Princeton, NJ: Author. Retrieved August 8, 2013, from http://www.rwjf .org/en/about-rwjf/newsroom/newsroom-content/2013/02/santa-cruzcounty--california--2013-roadmaps-to-health-prize.html Robert Wood Johnson Foundation (RWJF). (2013c). Cleveland: Using data to improve blood pressure control in African American patients in Northeast Ohio (Online report). Princeton, NJ: Author. Retrieved August 10, 2013, from http://forces4quality.org/using-data-improve-blood-pressure-controlafrican-american-patients-northeast-ohio?term_id=4 Robert Wood Johnson Foundation (RWJF). (2013d, August 7). How has care improved in Cleveland? Princeton, NJ: Author. Retrieved August 9, 2013, from http://forces4quality.org/how-has-care-improved-cleveland?term_id=143 Robert Wood Johnson Foundation (RWJF). (2013e, June 6). NYC public health as a model: Kimberly Isett and Miriam Laugesen Q&A. Princeton, NJ: Author.

276

References

Retrieved from http://www.rwjf.org/en/blogs/new-public-health/2013/ 06/nyc_public_healthas.html Roberts, L. M., Spreitzer, G., Dutton, J., Quinn, R., Heaphy, E., & Barker, B. (2005). How to play to your strengths. Harvard Business Review, 83(1), 75–80. Robison, J. (2009, January 8). A military general’s leadership lessons. Gallup Business Journal. Retrieved from http://businessjournal.gallup.com/­ content/113629/military-generals-leadership-lessons.aspx Rogers, E. (2003). Diffusion of innovations (5th ed.). New York, NY: Free Press. Roos, R. (2013a, December 5). New health preparedness index gives US overall good marks [Press release]. Minneapolis, MN: Center for Infectious Disease Research and Policy, University of Minnesota. Retrieved December 6, 2013, from http://www.cidrap.umn.edu/news-perspective/2013/12/ new-health-preparedness-index-gives-us-overall-good-marks Roos, R. (2013b, January 24). Study puts global 2009 pandemic H1N1 infection rate at 24%. Minneapolis, MN: Center for Infectious Disease Research and Policy, University of Minnesota. Retrieved July 7, 2013, from http:// www.cidrap.umn.edu/news-perspective/2013/01/study-puts-global2009-pandemic-h1n1-infection-rate-24 Rosenberg, M. L., Hayes, E. S., McIntyre, J. H., & Neill, M.(2010.) Real collaboration: What it takes for global health to succeed. Berkeley, CA: University of California Press. Rovner, J. (2013, February 6). Debate rages on even as research ban on gun violence ends [Web log report]. Washington, DC: National Public Radio. Retrieved June 28, 2013, from http://www.npr.org/blogs/health/ 2013/02/06/170844926/debate-rages-on-even-as-research-ban-ongun-violence-ends Russell Reynolds Associates. (2013). The DNA of the Global Health Leader. Retrieved August 22, 2013, from http://www.russellreynolds.com/ content/dna-global-health-leader Salmon, J. L. (2006, June 26). Chapter overhaul adds to Red Cross turmoil. Washington Post. Retrieved August 10, 2013, from http://www .washingtonpost.com/wp-dyn/content/article/2006/06/26/ AR2006062601163.html Sandfort, J. (2006). Casa de Esperanza. Case A and Case B. Evans School of Public Affairs, University of Washington, DC: The Electronic Hallway. Sava, A., Armitage, K., & Kaufman, A. (2013). It’s time to integrate public health into medical education and clinical care. Journal of Public Health Management and Practice, 19, 197–198. Schlipköter, U., & Flahault, A. (2010). Communicable diseases: Achievements and challenges for public health. Public Health Reviews, 32(1), 90–119. Singhal, A., Buscell, P., & Lindberg, C. (2010). Inviting everyone: Healing healthcare through positive deviance. Bordentown, NJ: Plexus Press.



References

277

Skills for Health, Public Health Resource Unit. (2009). Public health skills and career framework: Multidisciplinary/multi-agency/multi-professional. Bristol, England: Author. Retrieved September 29, 2013, from http://www .­s killsforhealth.org.uk/component/docman/doc_view/1869-publichealth-skills-career-framework-03-2009.html Slack, P. (2013). Southwest light rail, for the sake of the North Side. Minneapolis Star Tribune, October 21. Smith, K., Jarris, P. E., Inglesby, T., Hatchett, R., & Kellermann, A. L. (2013). Public health preparedness research. Journal of Public Health Management and Practice, 19(5), S6–S8. Snowden, D. F., & Boone, M. E. (2007). A leader’s framework for decision making. Harvard Business Review, 85(11), 69–76. Sommer, A. (2013). 10 lessons in public health: Inspiration for tomorrow’s leaders. Baltimore, MD: Johns Hopkins University Press. Spear, S. J. (2005). Fixing health care from the inside, today. Harvard Business Review, 83(9), 78–91. Starr, K. (2012, September 18). The eight-word mission statement. Stanford Social Innovation Review. Retrieved July 17, 2013, from http://www.ssireview .org/blog Sterman, J. D. (2006). Learning from evidence in a complex world. American Journal of Public Health, 96, 505–514. Stires, D. (2006, May 11). Technology has transformed the VA. Fortune: CNN Money. Retrieved August 7, 2013, from http://money.cnn.com/magazines/ fortune/fortune_archive/2006/05/15/8376846/ Stokols, D., Hall, K. L., & Vogel, A. L. (2013). Transdisciplinary public health: Definitions, core characteristics, and strategies for success. In D. HaireJoshy and T. D. McBride (Eds.), Transdisciplinary public health: Research, ­education, and practice (pp. 3–30). San Francisco, CA: Jossey-Bass. Strom, S. (2006, March 24). Red Cross sifting internal charges over Katrina aid. New York Times. Retrieved August 8, 2013, from http://select.nytimes .com/gst/abstract.html?res=F60E11FD3C540C778EDDAA0894DE404482 &fta=y&incamp=archive:article_related Suchman, A. L., Sluyter, D. J., & Williamson, P. R. (Eds.) (2011). Leading change in healthcare. London: Radcliffe Publishing. Swanson, R. C., Bongiovanni, A., Bradley, E., Murugan, V., Sundewall, J., Betigeri, A., Nyonator, F., . . . Labonte, R. (2010). Toward a consensus on guiding principles for health systems strengthening. PLoS Medicine, 7(12), e1000385.doi:10.1371/journal.pmed.1000385 Swanson, R. C., Cattaneo, A., Bradley, E., Chunharas, S., Atun, R., Abbas, K. M., Katsaliaki, K., . . . Best, A. (2012). Rethinking health systems strengthening: Key systems thinking tools and strategies for transformational change. Health Policy and Planning, 27, iv54–iv61.

278

References

Tarlov, A. R. (1999). Public policy frameworks for improving population health. Annals of the New York Academy of Sciences, 896, 281–293. Tarlov, A. R. (2008). Health production: A common framework to unify ­public health and medicine. In J. Colgrove, G. Markowitz, and D. Rosner (Eds.), The contested boundaries of American public health (pp. 176–200). New Brunswick, NJ: Rutgers University Press. Taylor, V. (ed.). (2012). Leading for health and wellbeing. London: Sage. Taylor-Powell, E., Jones, L., & Henert, E. (2003).Enhancing program performance with logic models. University of Wisconsin-Extension. Retrieved September 8, 2013, from http://www.uwex.edu/ces/pdande/evaluation/ pdf/lmcourseall.pdf Thomas, J. (2004). Skills in public health ethics. New Orleans, LA: Public Health Leadership Society. Retrieved July 23, 2013, from http://phls.org/ CMSuploads/Skills-for-the-Ethical-Practice-of-Public-Health-68547.pdf Thompson, J. M. (2010). Understanding and managing organizational change: Implications for public health management. Journal of Public Health Management and Practice, 16(2), 167–173. Tomes, N. (2008). Speaking for the public: The ambivalent quest of ­twentiethcentury public health. In J. Cosgrove, G. Markowitsz, & D. Rosner (Eds.), The contested boundaries of American public health (pp. 57–81). New Brunswick, NJ: Rutgers University Press. Trochim, W. M., Cabrera, D. A., Milstein, B., Gallagher, R. S., & Leischow, S. J. (2006). Practical challenges of systems thinking and modeling in public health. American Journal of Public Health 96(3), 538–546. Tulchinsky, T. H., & Varavikova, E. A. (2010). What is the “new public health”? Public Health Reviews, 32, 25–53. Turning Point. (2006). Welcome to Turning Point. Retrieved August 9, 2013, from http://www.turningpointprogram.org/ Turnock, B. J. (2012). Public health: What it is and how it works (5th ed.). Burlington, MA: Jones & Bartlett Learning. U.S. Burden of Disease Collaborators. (2013). The state of US health, 1990–2010: Burden of diseases, injuries, and risk factors. Journal of the American Medical Association, 310, 591–608. U. S. Department of Health and Human Services (U.S. DHHS). (2000). The ­public health work force: Enumeration 2000. Washington, DC: Bureau of Health Professions. U.S. Department of Health and Human Services (U.S. DHHS). (2008, August). Consensus statement on quality in the public health system. Public Health Quality Forum. Retrieved September 8, 2013, from http://www.hhs.gov/ ash/initiatives/quality/quality/phqf-consensus-statement.html U.S. Department of Health and Human Services (U.S. DHHS). (2011). Healthy People 2020 Framework. Retrieved from http://www.healthypeople .gov/2020/Consortium/HP2020Framework.pdf



References

279

U.S. Department of Health and Human Services (U.S. DHHS). (n.d.). Assistant Secretary for Preparedness and Response (ASPR) [Online profile]. Washington, DC: Author. Retrieved August 22, 2013, from http://www.hhs.gov/open/ contacts/aspr.html U.S. Department of Health and Human Services (U.S. DHHS), Office of Disease Prevention and Health Promotion. (2010, November). Healthy people 2020. Washington, DC: Author. Retrieved from http://www.healthypeople .gov/2020/TopicsObjectives2020/pdfs/HP2020_brochure_with_LHI_ 508.pdf United Health Foundation. (2013). America’s health rankings. Minnetonka, MN: Author. Retrieved from http://www.americashealthrankings.org/ United Nations. (2013). Millennium Development Goals and Beyond 2015. Retrieved October 3, 2013, from http://www.un.org/millenniumgoals/ University of California Davis Health System. (2011, February 23). Kenneth W. Kizer named director of new Institute for Population Health Improvement at UC Davis Health System (Online press release). Davis, CA: Author. Retrieved August 6, 2013, from http://www.ucdmc.ucdavis.edu/welcome/­ features/2010-2011/02/20110223_Ken_Kizer.html University of Wisconsin Population Health Institute. (2013). County health rankings & roadmaps: Our approach [Webpage]. Madison, WI: University of Wisconsin. Retrieved October 12, 2013, from http://www .­countyhealthrankings.org/our-approach/ Urban Strategies Council. (2008). About the Urban Strategies Council. Oakland, CA: Author. Retrieved July 31, 2013, from http://www.urbanstrategies .org/about/ Van de Ven, A. H. (1999). The buzzing, blooming, confusing world of organization and management theory. Journal of Management Inquiry, 8, 118–125. Vickers, G. (1958). What sets the goals of public health? Lancet, 271, 599–604. Vroom, V. H. (1964). Work and motivation. New York, NY: Wiley. Walker, W. (2001, October 29). Storm brews over Sept. 11 funds. Toronto Star. Retrieved August 10, 2013, from http://www.commondreams.org/ headlines.shtml?/headlines01/1029-05.htm Weikart, L. A., Chen, G. G., & Sermier, E. (2013). Budgeting and financial management for nonprofit organizations: Using money to drive mission success. Thousand Oaks, CA: Sage. Wenger, S. L., Bahrke, L. S., Baumann, E. J., Sabbert, J. K., Stafford-Alewine, S., & Wagner, T. J. (2011). The Heartland Health story. Retrieved July 18, 2013, from http://nwmoinfo.org/uploads/Heartland%20Journey%20Story-Article% 202011%20V2.pdf Westley, F., Zimmerman, B., & Patton, M. Q. (2007). Getting to maybe: How the world is changed. Toronto, Canada: Vintage Canada. Wholey, D. R., White, K. M., & Kader, H. (2010). Accreditation and a­ ccountability: Is the cart before the horse? American Journal of Public Health, 100, 4–5.

280

References

Wiist, W. H. (Ed.), (2010). The bottom line or public health: Tactics corporations use to influence health and health policy, and what we can do to counter them. New York, NY: Oxford University Press. Wilder Research. (2010, February). Logic models: Better thinking for b ­ etter results. Retrieved September 8, 2013, from http://www.wilder.org/WilderResearch/Publications/Studies/Program Evaluation and Research Tips/ Logic Models - Better Thinking for Better Results - Tips From the Wilder Research Program Evaluation Series, Fact Sheet.pdf Wilkinson, R., & Pickett, K. (2009). The spirit level: Why equality makes societies stronger. New York, NY: Bloomsbury Press. World Health Organization (WHO). (2005). Outbreak communication: Best practices for communicating with the public during an outbreak [Expert consultation meeting report]. Retrieved September 16, 2013, from http://www.who .int/csr/resources/publications/WHO_CDS_2005_32web.pdf World Health Organization. (WHO). (2008). Closing the gap in a generation: Health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. Geneva, Switzerland: World Health Organization. World Health Organization (WHO). (2013a). Constitution of the World Health Organization. Retrieved August 17, 2013, from http://www.who.int/ governance/eb/constitution/en/ World Health Organization (WHO). (2013b). Health Impact Assessment. Available at: http://www.who.int/hia/evidence/doh/en/ World Health Organization (WHO). (2013c). World Conference on Social Determinants of Health. Available at: http://www.who.int/sdhconference/en/ Wright, K., Rowitz, L., Merkle, A., Reid, W. M., Robinson, G., Herzog, B., Weber, D., . . . Baker, E. (2000). Competency development in public health leadership. American Journal of Public Health, 90, 1202–1207. Wyatt, S. W., Brady, K. T., & Maynard, W. R. (2013). Partnerships in public health: Working together for a mutual benefit. In J. W. Holsinger, Jr. (Ed.), Contemporary public health: Principles, practice, and policy (pp. 193–204). Lexington, KY: University Press of Kentucky. Yip, J., & Wilson, M. S. (2010). Learning from experience. In E. Van Velsor, C. D. McCauley, & M. M. Ruderman (Eds.), The Center for Creative Leadership handbook of leadership development (3rd ed., pp. 63–95). San Francisco, CA: Jossey-Bass. Yukl, G. (2013). Leadership in organizations (8th ed.). Upper Saddle River, NJ: Pearson Education. Zaccaro, S. J. (2007). Trait-based perspectives of leadership. American Psychologist, 62(1), 6–16. Zaccaro, S. J., Kemp, C., & Bader, P. (2004). Leader traits and attributes. In J. Antonakis, A. T. Cianciolo, and R. J. Sternberg (Eds.), The Nature of leadership (pp. 101–124). Thousand Oaks, CA: Sage.



References

281

Zenger, J. (2013, July 16). Throw your old plan away: 6 new ways to build leadership development into your job. Forbes. [Online article]. Retrieved November 26, 2013, from http://www.forbes.com/sites/jackzenger/ 2013/07/16/throw-your-old-plan-away-6-new-ways-to-build-leadershipdevelopment-into-your-job/ Zhang, Z., Ilies, R., & Arvey, R. D. (2009). Beyond genetic explanations for leadership: The moderating role of the social environment. Organizational Behavior and Human Decision Processes, 110, 118–128. Zimmerman, B. (2011). How complexity science is transforming healthcare. In P. Allen, S. Maguire, and B. McKelvey (Eds.), The Sage handbook of complexity and management (pp. 617–635). Los Angeles, CA: Sage. Zismer, D. K. (2013). An argument for the integration of healthcare management with public health practice. Journal of Healthcare Management, 58, 253–257.

Index

ACA. See Affordable Care Act accountability, 206, 210–213, 219, 229 for funds, 219 accreditation, 224–227 PHAB guidelines, 12, 13 adaptive leadership, 32, 33–34 Affordable Care Act (ACA), 86, 109 Akunyili, Dora Nkem, 163–165 Albrecht, Karl, 98 Allina Health, 14–16, 126–127 Applied Survey Research (ASR), 217 ASPPH. See Association of Schools and Programs of Public Health Association of Schools and Programs of Public Health (ASPPH), 46–47 competency framework, 47, 81 competency model, 80, 88 model for MPH graduates, 85 Association of State and Territorial Health Officials (ASTHO), 200 ASTHO. See Association of State and Territorial Health Officials autonomy, 118 Azzahir, Atum, 136–139 balanced scorecard, 208, 216 Baldrige Award, 216 Baldrige system of performance ­management, 216 Bennis, Warren, 157, 238 Berwick, Donald, 121–123



Better Health project, 218 Blackwell, Angela Glover, 59–61 Bloomberg, Michael, 179, 180–182 brand, 115, 130 Brenner, Jeffrey, 148–150 Briscoe, Alex, 146–148 campaigning, 161, 164, 170–174, 180 CAP. See Community Assessment Project Casa de Esperanza, 115, 116 case studies commitment to equity, 59–61 counterfeit drugs, invasion and battling, 163–165 Courage Center’s story, 124–128 Cultural Wellness Center (CWC), 136–138 financial management, 65–67 flu vaccine efficacy, 89–91 gun violence, 85–87 innovative collaboration, 148–150 lifelong leadership, 236–239 National Culture of Preparedness, 202–203 New York City’s public health reforms, 180–182 public health emergencies, 186–188 public health “godmother,” 249–251 quality improvement (health care), 121–124, 224–226, 228–230 right coalition partners, 147–148 social determinants, 11–16

283

284

Index

CCIVI. See Comprehensive Influenza Vaccine Initiative “C” continuum of collaboration, 134 CDC. See Centers for Disease Control and Prevention Center for Infectious Disease Research and Policy (CIDRAP), 89–92 Centers for Disease Control and Prevention (CDC), 18, 87, 89, 108, 196, 250–251 CHA. See community health assessment change leadership, 103 change management, 103–104 childhood obesity prevention program, 212 Children’s Safety Network (CSN), 86 CHIP. See Community Health Improvement Plan CIDRAP. See Center for Infectious Disease Research and Policy Cleveland Aligning Forces for Quality, 218 coalition, 150. See also diverse coalition core supporters, 174–176 issue-specific allies, 176–177 collaboration accountability in, 212 “C” continuum, 134 clinical disciplines, 92 nature of, 134–136 process of, 35 collaborative leadership, 35, 45, 50, 78, 242 Collins, Jim, 114, 238–239 Comanche County Health Department, Oklahoma, 224–226 comfort with ambiguity, 69, 71–72, 185, 186 Community Assessment Project (CAP), 216–217 community-based participatory research, 92, 102 community engagement improvement, 225 community health assessment process, 12 ordinance-based, 111 programs, 13–15 community health assessment (CHA), 225 Community Health Improvement Plan (CHIP), 225 community self-determination, 58, 63–64, 139 community wellness, national model of, 13 competencies categories, 44 clusters of, 44–45 components of, 37 continuous improvement, 209–230 core, 115–116 defined, 37 diverse coalition, 142–154

execution and continuous improvement, 209–230 framework for public health leadership, 37–42 individual, 37 of leaders, 36 leadership, 20–24 power, 170–179 population health, invigorating bold(er) pursuit of, 114–130 of social awareness, 98 of social skill, 98 surprise, 193–201 complex adaptive systems, 101–103 complex systems, 113 continuous improvement, 208–209 diverse coalition, 141 focusing on, 101–103 population health, invigorating bold(er) pursuit of, 113 scholarship on, 113 surprise, 191–192 systems thinking, 99–101 understanding, 208–209 complexity leadership, 32, 36–37 Comprehensive Influenza Vaccine Initiative (CCIVI), 89, 90 Council on Linkages Between Academia and Public Health Practice (COL), 45–46 Council on Linkages competency model, 82, 85 County Health Rankings and Roadmaps website, 84 courage, 69, 72–73, 111–112 Courage Center, 115, 124–128 creativity, defined, 227 CSN. See Children’s Safety Network cultural communities with health, 136–138 cultural competence, 152 Cultural Knowledge for Health, 137 Cultural Wellness Center (CWC), 136–138 CWC. See Cultural Wellness Center deficit reduction proposals, 109 Dickey amendment, 86, 87 diffusion theory, 228 DiSC®, 242 discrimination, 12, 60 distributing control models, 153 diverse coalition, 141–154 five competencies building relationship, 152–153 governance role, 153–154 local conditions assessment, 142–144

planning, 150–151 right partnership, 144–150 knowledge, 140–141 nature of collaboration, 133–136 values and traits, 138–140 diverse communities, 136–137 doctor of public health (DrPH), 46, 47 DrPH. See doctor of public health effective leaders characteristics/qualities of, 43, 54, 69 competencies of, 206 Ehlinger, Ed, 131 EHR. See electronic health record electronic health record (EHR), 230 electronic medical records, 218 Eliminating Health Disparities Initiative (EHDI), 135 Ellwood, Paul, 74 emergency response plan characteristics of, 193–194 practice and test, 194 Emergency Risk Communication Branch (ERCB), 196 emotional intelligence, 98–99 empathy, 69, 71, 138–139 end-of-life issues, support and care, 15 environmental health, 217–218 equity, foundation and focus on, 60 equity theory, 97–98 evidence-based decision making, 207 evidence-based knowledge on leadership, 20–21 evidence-based public health, 84 execution and continuous improvement five competencies building accountability, 209–213 financial management, 219–221 innovation and risk management, 226–230 measurement, 213–218 quality improvement methods, 221–224 knowledge, 207–209 values and traits, 206–207 expectancy theory, 96–97 exploitation, 226 exploration, 226, 229–230 external audits, 220 extrinsic motivation, 94–96 Farley, Thomas, 180–182 financial management, 221 competencies, 219 performance, 216

 Index

285

financial stewardship of public health funds, 219–221 Fineberg, Harvey, 17, 171 flow, 118 flu vaccine efficacy, 89–91 flywheel, 124 Frieden, Thomas, 180–181 Frieden health impact pyramid, 8, 10, 16 funding, organization/program, 128–129 generic leadership models, 42–44 George, Bill, 236, 238 giving back (leadership development), 234, 236, 238, 248–249 global disparities in health outcomes, 4–5 goal-setting theory, 97 Goldilocks tasks, 118 Goleman, Daniel, 98 government’s role public health issues, 158–159 WHO on, 64 Greenleaf, Robert, 32–33 Guiding Principles for Health Systems Strengthening, 215 gun violence in United States, 85–87 health inequities, 61, 120, 135, 143, 167 social determinants of, 11–13 health equity, improvement ­recommendations, 9–10 Health Impact Assessment (HIA), tools and techniques of, 151 Health in All Policies movement, 9 HealthPartners, 14–16 Health Resources and Services Administration (HRSA), 18 health system-community collaboration, 13–16 Healthy People 2020, 7, 8, 108 hedgehog concept, 115 Herzberg’s research on job enrichment theory, 96 HIA. See Health Impact Assessment Himmelman, Arthur, 134–135 H1N1 (swine) flu virus, 90 Honoré, Russel, 201, 203 hospitals, quality measures for, 214 hot-spotting, 149 HRSA. See Health Resources and Services Administration Human Genome Project, 56 Hurricane Katrina, 11–13, 201–203 hurricane relief, responses to, 66–67 Hurricane Rita, 201–203 Hurricane Sandy, 67

286

Index

improvement-driven organization, 227 ineffective leadership, 109–110 influence effective use of power and, 156, 161 formal authority and, 165, 179 informal, 162 in large organizations, 170 leader’s authority and, 174 reporting relationship and, 166, 168 influenza (flu), 89–91. See also flu vaccine efficacy information systems, redesign of, 130 initiative, 69, 70, 185–186, 207 innovation, 226–228 encouraging, 229–230 Insights Discovery®, 242 Institute of Medicine (IOM), 5, 9, 83, 121 recommendations of, 17 integrative leadership, 32, 34–35 key practices of, 35 philosophy and practices of, 35 integrity, 69, 138–139, 206–207 effective use of power, 158 transparency, 158 interagency and cross-sector, 30 interdependence, 58, 62–63 collaboration styles, 139–140 work activities, 62–63 internal controls, 220 Internet, 197 interpersonal skills, 94 intrinsic motivation, 94–97 leverage, 117–118 reliance on, 112 IOM. See Institute of Medicine job enrichment theory, 96 Joint Center for Political and Economic Studies, 12 justice, 59–61 Kessler, David, 171 Kizer, Kenneth, 228–230 knowledge, 38 applied, 98 change management, 103–104 continuous improvement, 207–209 diverse coalition, 140–141 influence, 159–160 for leadership, 38–39 power, 159–160 for public health leadership, 77–104 population health, invigorating bold(er) pursuit of. See population health, invigorating bold(er) pursuit of

public health science, 80–93 surprise preparation, 190–192 understanding complex systems, 99–103 understanding people, 93–99 Kruse, Lowell, 236–238 leadership, 24–26. See also public health academic study and associated scientific research on, 21 adaptive, 33–34 attributes of, 47 competencies, 22–24 cluster, 47 models, 21 complexity, 36–37 defined, 17–18, 36 evidence-based knowledge on, 20–21 ineffective, 109–110 integrative, 34–35 leverages individual contribution, 21–22 versus management, 22–23 resources, 23–24 servant, 32–33 Leadership Challenge model, 43–44 leadership development, lifelong priority assessment by others, 243 challenges, in sustaining, 248–249 from coaching, 247–248 from experience, 246–247 goal, 235 from knowledge, 245 lifelong priority, reasons for, 233–251 from mentoring, 247–248 from networking, 247 planning, 243–244 self-assessment, 239–243 three stages of, 236 lean production, 223 Leitheiser, Aggie, 200 life expectancy, differences in, 4 lifetime of leadership. See leadership ­development, lifelong priority LinkedIn, 247 logic models, concept of, 212 low-income communities, 60 Lurie, Nicole, 184, 186–188 Malcolm Baldrige National Quality Award, 216 management, leadership versus, 22–23 Maslow’s hierarchy of needs, 95 master of public health (MPH), 46, 80 MBTI®. See Myers-Briggs Trait Inventory® MDH. See Minnesota Department of Health Meadows, Donella, 102

measurement competency, 217 measurement theory, 213–214 Medicaid programs, 5 medical care expenditures, proponents of, 23 Medicare programs, 5 mentors, respect for, 138 message mapping, 197 metrics, 213–218 Minnesota Department of Health (MDH), 135, 200 mission, 116–117 mortality rate, 214 motivation, 94–98 intrinsic and extrinsic, 94–97 MPH. See master of public health MSCCA program, 125 mutual accountability, 153 Myers-Briggs Trait Inventory® (MBTI®), 243 NAFDAC. See National Agency for Food and Drug Administration and Control National Agency for Food and Drug Administration and Control (NAFDAC), 163 National Cancer Institute, 102 national health expenditures in 2011, United States, 17 National Health Security Preparedness Index™ (NHSPI™), 200–201 National Institutes of Health (NIH), 18 National Model of Care, 150 national model of community wellness, 13 National Public Health Leadership Development Network (NLN), 44–45 National Rifle Association (NRA), 86 National Violent Death Reporting System, 87 National Voluntary Accreditation Program Beta Test, 224 networking relationships, 245, 247 New Orleans Health Department (NOHD), 11–13 NHSPI™. See National Health Security Preparedness Index™ NIH. See National Institutes of Health NLN. See National Public Health Leadership Development Network NOHD. See New Orleans Health Department not-for-profit settings, 29 NRA. See National Rifle Association 100,000 Lives Campaign, 121–123 organizational performance excellence, 216 organizational resilience, 193 Osterholm, Michael, 89–91

 Index

287

partnership, 14, 153 increasing needs for, 130 selection of, 144–146 passion, 69, 72 performance management, Baldrige system of, 216 performance measurement, 213–214, 216 knowledge on, 208 persistence, 69, 73–74, 111–112, 158–159, 163, 178 personal accountability, 210–211 personal attributes, classification of, 54 persuasive communications, developing skills in, 119–120 Pfeffer, Jeffrey, 155–156 PHAB. See Public Health Accreditation Board PHLS. See Public Health Leadership Society Pink, Daniel, 118 Pink’s transformational approach, 118 Plan-Do-Study-Act (PDSA) cycle, 222–223 planning, key characteristics of effective, 123–124 PolicyLink, 60–61 political support organization/program, 130 population health defined, 10 delivering health care services for, 148–150 improvement of, 12–13 knowledge, 112–113 resources, 23–24 population health, invigorating bold(er) pursuit of, 41, 120–121 credibility building, 118–119 five competencies agenda articulation, 116–117 critical assessment, 114–116 enlisting others in vision, 117–123 planning process, 123–128 resource requirements, 128–130 knowledge, 112–113 program/organization, state of, 114–116 values and traits, 110–112 verbal and written communications, 119–120 positional authority, 161–163 positive deviance approach, 104 poverty, 12, 60 power effective use of, 155–157 five competencies coalition building, 174–177 dealing with opponents, 177–178

288

Index

power (cont.) positional authority and informal ­influence, 162–170 specific issues, addressing, 170–174 strategic agility, 178–179 government’s role, 158 integrity and, 158 knowledge, 159–160 manage “up,” 165–167 managing “across,” 168–170 managing “down,” 168 persistence and, 158–159 transparency of, 158 understanding sources of, 159–160 values and traits, 157–159 power law, 191 PPHF. See Prevention and Public Health Fund Prevention and Public Health Fund (PPHF), 109 prevention and public health model, 12 prevention-focused characteristics of public health science, 88–89 program-level accountability, 211–212 public funds, 219 public health, 3–4 ability of, 17 advantage of, 95 agencies, performance standards for, 108 challenges, 4–7 circumstances of, 29–32 community-based participatory research in, 92 continuous improvement in, 42 contribution to public gain, 17 core discipline areas of, 81 ethics, 56 evidence-based research in, 89 evidence, issue in applying, 84 forces limiting the influence of, 25 funds, financial stewardship of, 219–221 groundbreaking evidence in, 91 influence and impact of, 41–42 initiatives, 129, 217 interventions, long-term nature of, 31 issues, 86–87, 100–101 knowledge, 21 clusters of, 80 law, 55–56 legal and ethical foundation of, 55–58 long-held beliefs about, 89 metrics, 214–215 opportunities for, 109 prepare for surprise in, 42 principles for ethical practice of, 57 problem, reality of, 217

professionalism, 57 programs, 219 quality characteristics of, 215 science, 207–208 separation of powers, 56 social determinants framework for, 8–9 solutions, 5–16 definition of, 8–9 value of, 16 vision of, 10–11 Public Health Accreditation Board (PHAB), 12, 224 accreditation guidelines, 12 creation of, 226 self-assessment using quality improvement techniques, 225 public health leaders, 18–20, 107, 212 function in all sectors, 19 guidelines for, 219 knowledge, 108 values and traits, 53–75 public health leadership competencies for, 39–42 competency of, 20, 21 complexity of challenges, 30 definition of, 28 existing competency models for, 48–49 ASPPH, 46–47 Council on Linkages Between Academia and Public Health Practice (COL), 45–46 generic leadership, 42–44 National Public Health Leadership Development Network (NLN), 44–45 Turning Point initiative, 45 United Kingdom Department of Health, 47–48 framework, 37–39 knowledge, 77–104 political circumstance, 29, 31–32 public setting of, 29–30 resource scarcity, 30 role, 55 types of emergencies, 31 Public Health Leadership Society (PHLS), 57 principles, 57 website, 58 public health organizations agenda for, 112 transparent financial management in, 65–67 public health professional, definition of, 19 public health science, 79, 112 complex systems focusing on, 101–103 systems thinking, 99–101

continuous improvement, 207–208 core disciplines, 80–81 cross-cutting content areas in, 81–82 diverse coalition, 140 diverse specialties of, 81 dynamic characteristics of, 87–88 evidence-based characteristics of, 83–85 influence, 159 population health, invigorating bold(er) pursuit of, 112 prevention-focused characteristics of, 88–89 surprise, 190–191 transdisciplinary characteristics of, 91–92 understanding people motivation, 94–98 social and emotional intelligence, 98–99 value-laden characteristics of, 92 public health workforce, 18–21 public-private partnerships, 153 public settings, 29 qualitative measurements, 214 quality improvement and accreditation movements, 227 methods and tools of, 221–224 status quo to achieve, 228–230 technology backbone for, 230 rapid process improvement workshops (RPIWs), 223 reliance on evidence, 85, 110–111, 207 decision making, 62 program/organization performance, 207 resource constraints, 110–111 reliance on intrinsic motivation, 112 requisite role of government, values of ­public health leaders, 58, 64–65 resilience, 193, 200 resources organization/program, 128–129 scarcity, 30 respect collaborative activities, 138–139 personal level, 63 public concerns, 196 values of public health leaders, 58, 63 return on investment (ROI), 220 Rio Political Declaration on Social Determinants of Health, 5 risk-taking, 226–228 Roadmaps to Health tools, 150 Robert Wood Johnson Foundation (RWJF), 11, 55, 170, 177, 178, 182, 245 romance of leadership, 24 RWJF. See Robert Wood Johnson Foundation

 Index

289

scholarship on complex systems, 113 scientific evidence, 84 Selecky, Mary, 245, 249–251 self-assessment, 239–243. See also StrengthsFinder® competencies, 241–242 knowledge, 240 using quality improvement techniques, 225 values and traits, 240 self-awareness, 98 self-management, 98 servant leadership, 32–33 authenticity, 38 encouragement of, 44 SHLI. See State Health Leadership Initiative single-page strategic framework, 126 Sister Kenny Rehabilitation Institute, 124, 126 Six Sigma process, 222, 223. See also quality improvement skills, 39 communication, 42 individual, 37 of public health leaders, 30, 42 Slack, Reverend Paul, 151 social determinants framework for public health, 8–9 social determinants model, 7, 8, 26 social innovation process, 103–104 social intelligence, 98 social justice, 56, 110, 206 community outcomes, 110 fundamental human rights, 58–59 public health programs, 206 public policy issues, 175 resource distribution, 138 values of public health leaders, 58–59 socioeconomic and health disparities in New Orleans, 13 Sommer, Alfred, 74, 90 specialized knowledge clusters, 82 stakeholders credibility, 142–144 needs, 114 performance measures, 216–217 State Health Leadership Initiative (SHLI), 245. See also Robert Wood Johnson Foundation statistical analyses, limitations of, 213 strategic framework for needed decisions, 126 strategic planning competencies, 220 StrengthsFinder®, 242

290

Index

surprises five competencies, 192 effective communication, 194–198 emergency response plan, 193–194, 198–199 learning and improvement, 199–201 resilience promotion (individual and community), 193 knowledge, 190–192 values and traits, 185–186 systems archetypes, 100 systems thinking, 82, 99–101, 208–209 applications of, 101 concepts, 99, 102 traditional, 99 use of, 102 teamwork, 152–153 technology, organization/program, 129–130 360-degree feedback, 243 traditional emergency response plans, 193 traditional quality improvement, 226 traits. See also values and traits comfort with ambiguity, 69, 71–72, 185, 186 courage, 69, 72–73, 111–112 defined, 38 empathy, 71, 138–139 initiative, 70, 185–186, 207 integrity, 69, 138–139, 206–207 passion, 69, 72 persistence, 69, 73–74, 111–112, 158–159, 163, 178 respect, 138–139 transactional leaders, 34 transdisciplinary knowledge, 83, 91–92 transformational leadership, 34 transparency, 219 decisions and actions, 188–190 in financial management, 206–207 regulatory powers, 65 in use of power, 158 transparent financial management in public health organizations, 65–67 Triple Aim, 109 Turning Point framework, 45

Turning Point initiative, 45, 170, 177. See also Robert Wood Johnson Foundation Twitter, 197, 247 United Kingdom Department of Health, 47–48 United Nations Millennium Project, 108 University of Wisconsin Population Health Institute framework, 10 unsustainable economic model, 125–126 Urban Strategies Council (USC), 60 USC. See Urban Strategies Council U.S. health policy, 110 values and traits, 67–69 comfort with ambiguity, 69, 71–72 continuous improvement, 206–207 courage, 69, 72–73 diverse coalition, 138–140 empathy, 69, 71, 138–139 initiative, 69, 70, 185–186, 207 integrity, 69, 138–139, 206–207 passion, 69, 72 persistence, 69, 73–74, 111–112, 158–159, 163, 178 population health, invigorating bold(er) pursuit of, 110–112 power, 157–159 public health leaders, 37–38, 53–75 respect, 138–139 self-assessments, 240 surprise, 185–190 Ventura, Jesse, 20, 143, 155, 167, 169, 179 Veterans Health Administration, 228 Vickers, Geoffrey, 131 vision, 116–117, 123–124 sharing, 122 WHO. See World Health Organization Winnable Battles, 108 work-in-process approach, 13 World Health Organization (WHO), 5 best practices, 8, 195–196 Commission on Social Determinants of Health, 9