More fiscal issues

Following up on Steve’s post, I visited the discussion forum for the web cast on Public Health Survival: Leadership in a Falling Market (which is now posted). One of the respondents wrote in to tell about his predicament – to save money, the City Council had dismantled his public health department, transferring some functions to other departments, cancelling others, and leaving this respondent as a “department of one.”

I was shocked by the drastic nature of this city council’s actions, and it struck me that a lot of drastic stuff might be going on out there that we in academia are not fully aware of. It would help us to know what is going on for you… that way we can think about things we could do or offer that would better serve you through these trying times. In any event, as a community of practice, it would be good for us all to know what’s going on and how different individuals, organizations, and communities are dealing with it. For example, the man who is the only member of his department is working on changing his role from one of “directing and controlling to one of advising and consulting,” he said on the discussion forum. Ideally, he is drawing upon connections he’s made in the past to work with others who are now doing the work he and his colleagues used to do. He asked, at the end of his post, whether there were any role models for such a drastic transformation. All I could think of was the importance of making sure you have a community of people and organizations who understand what public health is and why it is important to them that the public stay healthy and safe: that way you'll never truly be a "department of one." But I'd rather hear from you...

If you get a chance, please write in with your stories about “providing leadership in a falling market” – whether yours personally, or those you have heard from others, and what you are doing right now to cope with the challenges of these times. And we realize there are still the day-to-day challenges – what is getting cut in your health department? Are you seeing a change in your clientele as a result of the economic downturn? Also, if you’ve undertaken public health business planning in the past, are you having any positive results of work you’ve done building partnerships, using business practices, and the like?

- Anne

Fiscal issues

If you didn't see it live, take a look at the webinar on public health survival in a falling market-- should be archived at the site in the next week or so.

Here are two things that came out of the session that stuck with me and that seem to apply to our continuing discussion here:

• Reach Out To Partners: Now may feel like the time for your organization to circle the wagons, pull back, go into your shell.It isn't. Jim Marks at Robert Wood Johnson Foundation says now is the time to reach out, and Bobby Pestrunk, the new director of NACCHO, agrees. Here's my take on why: resource deficits make it tough on many different organizations that are trying to make communities more healthy. Bobby points out "your partners are hurting too." The fiscal crisis makes it more important-- and perhaps paradoxically easier-- for you to work together now. Leah Devlin (state health director in NC) talks about going after big grants and lining up health care partners, for instance.
  
• Look For New Resources: Of course. Yes, the budget is shrinking. Some things that your organization had been doing will no longer be possible. So what things do you stop doing? The opportunity here is to stop doing things that are inefficient and unimportant... and use the newly-discovered time and energy to do something new, different, more effective, more useful to your constituents, more valuable to your funders, more timely and relevant. As recently as last year, I had public health leaders tell me that their plates were too full, they had more programs and partners than they could track, and that they wished they could get out of some of their long-term commitments!
  

I'll stop there and listen to what you think--

--Steve Orton

Leadership Programs at NCIPH

Steve mentioned the Southeast Public Health Leadership Institute in his last post, and I thought I would take this opportunity to plug this and another leadership training program (the Emerging Leaders in Public Health program), both run through the Institute. Many of our Management Academy for Public Health Alumni are leaders in their organizations, and we see them in our leadership programs as well. This is great for us (because our alumni are wonderful) and we’ve had some really positive feed back from them, so we think it’s pretty good for them as well.

The Southeast Public Health Leadership Institute is a year-long leadership development program for mid- to senior level public health administrators working in the states of Arkansas, North Carolina, South Carolina, Tennessee, Virginia and West Virginia.

The Institute strengthens leadership competencies, such as creating a shared vision, personal awareness, systems thinking, risk communication, team building, ethical decision making and political and social change strategies. Each scholar also completes an individual learning plan, a community leadership project, a mentoring relationship and four small group assignments.

SEPHLI begins in December and ends the following December. Face-to-face interactions between the scholars and guest faculty occur three times during the program year: at the beginning, at mid-year (May) and at the end. Between these scheduled meetings, Institute activities take place via distance learning using a mixture of both real time and asynchronous delivery modalities. Scholar distance learning requirements include attending a minimum of four telephone conference calls and two online computer forums.

The Emerging Leaders in Public Health (ELPH) program is designed to prepare the next generation of public health leaders to serve in significant leadership capacities in the next decade. The program focuses on minority public health professionals because African Americans, Native Americans/Alaska Natives, Native Hawaiian/Pacific Islanders, Asian Americans, and Hispanics are under-represented in terms of public health leadership.

ELPH scholars learn through a combination of on-site intensive workshops, personalized coaching, action learning teams, and individualized leadership coaching.

Every year an extremely impressive cadre of scholars apply for and attend the programs. In both cases, scholars attend as individuals and complete individual projects. Unlike the Management Academy, their projects do not have to be for revenue generating programs, or use business planning at all – and they can be internal to their organizations. Check out the SEPHLI and ELPH websites to read some amazing stories about graduate success stories.

Applications for ELPH are being accepted now until May 31, 2009. SEPHLI applications are generally in late summer – we’ll keep you posted.

BHAG

Spent several hours with the new and graduating scholars of the Southeast Public Health Leadership Institute on Monday-- a group that included many graduates of the Management Academy on both sides of the room!

While I was there I talked to one health director who is preparing his management team to write a business plan on access to care in their county. He's very concerned about the rise in emergency room use.

The issue is complicated by the fact that his county has two mid-size towns in it, separated by 9 miles, and each with their own hospital. The two hospitals are both part of bigger networks of hospitals, and those two networks (Baptist and Novant) are battling with each other for market share in many different counties around the Winston-Salem market.

I got goosebumps hearing what this leader was going to ask his staff to do. They are going to try to build a strategic alliance for their community that would result in a win-win-win-win situation: a plan to create better, more sensible primary and urgent care in two adjacent communities, and reduce emergency visits simultaneously for two competitors!

Would love to hear your comments and suggestions for this team.

My reason for sharing the story was to inspire you. David Altman of the Center for Creative Leadership said at the conference that everybody should have a BHAG: that's certainly the point of a leadership development program. What is your Big Hairy Audacious Goal?

--Steve Orton

Attracting a Younger Workforce

I recently received the following email from a colleague, whom I had asked to write something for me:

i did a ppt for a buncha reporters a week or so ago. gives you some idea of the ground i would cover in the piece. I think the dec deadline is prolly doable but when is the deadline for the NEXT edition, btw?

My first thought on receiving this email was, Will I have to ask him to write “probably” instead of “prolly” in his article? My second thought was, Boy, I’m getting old!

Wouldn’t it be nice if we had the problem of too many young people entering the public health workforce? As you may know – by looking around and by reading the literature – our workforce is aging. Many of us are merely a bit too old to take easily to writing that looks like a phone-text message. Others are actually aging out – retiring – and leaving the workforce depleted. It behooves us all to think about ways to bring more young people into the profession. Positive benefits of this might be a workforce that is

- open to (and full of) new ideas
- more technologically savvy
- energetic and idealistic
- more in touch with the population we serve

So, how do we get people interested? One way might be to reach out to high schools, colleges, and universities to inform students about what public health is and how they might make a difference with a career in this field. A great way to do this might be through a public health business plan!

Some Dare County, NC grads started a great plan that involved middle school students teaching elementary school students about healthy living. Students took their involvement much further than the original plan required, and ended up getting involved in other local programs around addressing teen smoking and drinking. A team from Wilmington partnered with veterinary students and introduced them to population-level pet concerns while training them and tapping into their enthusiasm and budding expertise; a South Carolina team worked with a university partner to plan a women’s health clinic on campus. A team this year is planning a summer program for children that will provide intern possibilities to local college students.

Other teams over the years have planned programs at schools, or for young people, but not necessarily getting young people involved. A small tweak to their plan might add a component that ensures at least some kids say, “Hey, that might be something I want to do” (or, more likely, “i wanna do”) long-term!

AJM

Book Club Webinar

This week we had a couple of “Book Club” webinars for the current Management Academy cohorts. Thank you so much to everyone who participated. One of the things we did was look at the quotations on the chapter pages of the web site and talk about them. The quotation for Chapter 1 is “A goal without a plan is just a wish” – here are some of the things that came up:

“Wishful thinking is like writing a Christmas list. It is definitely a first step, but to actually fill up under the Christmas tree, you’ve got to save some money, figure out where you’re going to get the stuff, plan when you’re going to go shopping, what you’ll do if they don’t have exactly what you want.”

“Our group has gone through three feasibility plans. The first two ideas were just wishes, and when we started to plan we realized they were not feasible. You need a plan, to ask the hard questions, look for barriers, etc.”

“You may know where you want to be in the end, but unless you have made your plan you might not recognize when you’ve begun making steps in that direction.”

“The people who have the big picture in mind are not necessarily the same people who can see the details to do the plan. It’s as if the “big picture” people are wishing, and the “little picture” people are planning, and sometimes there’s conflict. A way to get around this is to make sure you have good community partners on the team because they’re often able to help you get to where you want to go.”

For the Chapter 2 quotation, “A wise man will make more opportunities than he finds,” some comments included:

“This may be true, but you need to have a structure in place to make opportunities happen. Entrepreneurs go out and create opportunities, but they have a system in place to get them going.”

“I am personally risk averse. It’s hard for me to see myself as an entrepreneur because I’d rather just stay back in the office and make things happen.”

“Staying and making things happen is also entrepreneurial – you’re making sure people are served.”

We talked about the quote for Chapter 3, from Abraham Lincoln and decided that "commitment to success" can have many definitions -- and sometimes "success" looks different at different stages of the process. Finally, the last quotation, "Ideas are like rabbits. You get a couple and learn how to handle them and pretty soon, you have a dozen" drew many different takes:

"Too many ideas are like rabbits taking over the house! You get too many things going and you can't do any of them well. Brainstorming makes us aware of multiple options -- but you need to narrow down the big goals. Take one rabbit and put it in a cage (called "The Definition of Plan") and develop that rabbit."

"I see the rabbits as a good thing. You just need to send a message to the rabbit people -- save that idea for the next project. Keep thinking of ideas, but begin nurturing just one at a time. Learn to control the rabbits!"

Thanks to everyone who participated. For those of you who didn't, please share your thoughts about the Chapter Page quotations from the web site when you get a chance. Have a great Turkey Day everyone! Don't worry about rabbits for a few days at least.

-- Anne

More on Flu's Clues

I'd be interested in hearing more about the project Steve wrote about Monday. It’s called “Flu’s Clues,” and it provides flu vaccine clinics in local public schools. As of mid-October, Tazewell County, VA, nurses had given 596 flu vaccines in 9 school clinics, with two clinics left to go. That’s quite an achievement! This happened in the Cumberland Plateau Health District of Virginia. We write about the CPHD at length in Chapter 7 of the book (Competitors and Partners) as an example of great partnering activity over several years that has resulted in some amazing projects (pp. 67-69).

Some thoughts and questions about this program:

First, this program is a good example of strategic budgeting. You could never just take the annual costs of this project and divide them by 12 to get monthly costs. How does a program like this deal with the large fluctuations in costs over the course of a year? Have any of you come up against this problem in their program planning?

Also, does this team have a plan to expand the program at some point to offer other products or services to school children? Well-child tests or other immunizations, for example? Or is this an example of something well-focused that should stay that way?

Public schools can be problematic when it comes to private sponsorship. Did you come up against that here? What about the rest of you who have experience working with schools – several teams have attempted such programs over the years. One obvious lesson might be to make sure you include a representative from the local schools on your planning team. What are other lessons learned to share from the process of working with public schools?

Anne Menkens

Outcomes Story

Talked on the phone a couple of weeks ago with Kathy Hypes, a public health manager in southwest Virginia. She and a team of colleagues created a business plan back in 2004 to fund flu shots for kids in the school system of Tazewell County, a rural county in the mountains of Virginia.

Talk about unforeseen barriers: for two years the whole country had problems getting the right flu vaccine. Finally last year the group launched their pilot flu shot program in Russell and Tazewell county elementary schools. From that pilot year the team gathered positive stories and used their pilot success to expand the program to the middle schools this year.

If you have worked with the schools before you realize the challenges associated with permissions, space, and timing for a project like this-- not to mention the challenge of making sure that you can generate enough revenue to support the work. Through a combination of Medicaid billing, insurance, state money for uninsured children and a contract with Anthem Healthcare, they have made the finances work-- and made a well-targeted intervention to prevent flu and the spread of flu with one of the larger institutions in the area.

From the Management Academy Director

We are so pleased to hear about the valuable lessons you have learned from the Management Academy for Public Health retreats. Several of the current participants mentioned improved Communication Skills, learning to Negotiate, mastering Finance Skills and the information received from their 360 Assessment.
One aspect that was consistently noted was that this entire 9-month program is a long learning process to reach your goal of creating a business plan that successfully addresses a community need. The Management Academy staff continues to be impressed by how much work is put towards creating the plan and then later working to get it implemented. Most teams are now meeting in person each week or every other week, in addition to conference calls and email exchanges. Earlier today, we received an email from a team that completed the Management Academy several years ago; their plan is being implemented now in its entirety. More information to come!

It is also great to see that you are using the teambuilding skills presented by Triangle Training as you continue to work with individuals who may have a style different from your own. Don't forget some of the valuable lessons about communicating openly and honestly, working together, setting goals and not giving up. As mentioned by our colleague, Carolyn, - "We have many challenges ahead", but I would like to add that the "Best is yet to come". Thinking of the best is yet to come, the current Management Academy participants will participate in several upcoming webinars about the book: Public Health Business Planning..............As you continue to read chapter by chapter, please feel free to share your thoughts here.

Partnering for Economic Sustainability

I heard on the news recently that there’s a silver lining to the economic troubles facing us right now: people actually live healthier during economic downturns! We eat at home more, we exercise more, we’re less apt to smoke and drink, and we don’t drive as much. I hope that’s comforting to all of you as you see your budgets shrink.

The good thing about the partnerships described in the comments to my last post is that they are broadly collaborative. That makes them more resistant to economic downturns. I count 54 members of the The Eat Smart, Move More Leadership Team – groups from academia, the medical industry, and non-profits; groups that are local, statewide, faith based, youth-oriented, and farm or school oriented; groups that focus on nutrition, or activity, or the environment that encourages healthy living. Bringing all these groups and individuals together to gather information and then actually DO something with that information is exciting. Someone will always have a new idea, the right expertise, and "know someone who knows someone" who can get it done.

“Vaccinate and Vote” is a collaboration between the Virginia Department of Health and the Augusta Medical Center and Eastern Virginia Medical School. It’s exciting because it brings together academia, the public health system, and a private health care center – around an issue important to all of them. The breadth of this type of collaboration is always a good thing in turbulent economic times, because it shares the cost AND because it nurtures longer-term collaboration. The next time these partners think of a good idea, they won’t have to re-start the negotiations. They’ll be able to “start where they left off” so to speak.

We’ve seen that phenomenon in our alumni, who often say, “We did that one MAPH project, and other ideas just kept coming up!” One team from a county Animal Control Services Division several years ago worked with local veterinarians (initially seen as competitors) to build and staff a spay/neuter clinic in their community. Since then, they’ve established continuing educational programs for local veterinarians and their staff, created educational programs for local schools, partnered with pharmaceutical company that makes rabies vaccine, and worked with the local college pre-veterinary program whose students act as interns in the spay-neuter clinic, among other projects. In a way, once you start, it never ends!

I look forward to hearing more about interesting and exciting collaborations going on. And what about challenges you’ve found? What did you do about them?

Business Planning for the Long Haul

You all have stepped up to the plate these last couple of weeks! Thanks to Monecia for getting the conversation started, and for all of you who are writing in. Keep it coming!

A lot of you mentioned Negotiation as a session of the MAPH that taught you a lot. Dee Dee Downey wrote about an interesting concept about negotiation: “Leave something on the table.” That is, when you’re negotiating, don’t try for the winner-take-all mentality. We're in this for the long haul: relationships are more important than winning.

Public health business planning is all about the long haul. To be successful and build sustainable programs, we have to be creating on-going relationships with partners, colleagues, local politicians, other organizations, and peers across the country. Not to mention communities of people who use and care about your activities. So besides not humiliating people you are in negotiations with, how can we put “the long haul” into action?

- Make note of those things left on the table. Every time you negotiate for something, write down what you wanted but didn’t get – this time. You might get them next time. Similarly, keep a list of the things your negotiating partner wanted but didn’t get. You just might come across an opportunity where what they want works for you.

- Note what your negotiating partner likes. Say you go to a potential funding partner with an idea for a dental clinic at the health department. They say, “We don’t do dental clinics; we do X.” Don’t waste your time tweaking the dental clinic idea for this partner. But do think about coming back later with an idea for doing X with their help. They’ll be more open to a new idea that fits in with their mission or goals.

- Keep a list of ideas that came up you hadn’t thought of before. They can be part of your next brainstorming session. Remember, long term thinking means there’s always another chance to launch an initiative.

- Always, always, always consider the Exit. We devote a whole chapter in the book to planning for the intentional or unintentional exit (Chapter 11). If you’re planning for the long haul, you know that sometimes over time programs need to change or end. If you plan to spin it off to a partner’s control, you’d better keep that partnership healthy throughout your planning and implementation phases!

We hear about great partnerships among our students and alumni. What examples can you share of partnerships you’re particularly proud of or hopeful about?

Anne Menkens

From the Management Academy Director

As Anne mentioned, the Management Academy for Public Health (MAPH) teams have been working hard on their feasibility plans and the meaning of the word "teamwork" has been made clear through a variety of tasks. Working together efficiently is of utmost importance now because each team has a lot of work to do in order to complete their business plan draft by January. The business plan must include detailed project operations, a marketing strategy, potential risks and a thorough description of a first year and a five year budget. The business plan development is a continuous process that has been building since the first MAPH retreat in July/August.

In the final hours of the first retreat, each group presented their first business plan idea to the other members of the cohort. Then as a follow-up, we had an almost 3-hour session during the second retreat for each group to present their current plan to their fellow colleagues. It was amazing to hear the changes and positive transformation that the plans have gone through. The members of the cohort, the business plan coaches and the local public health experts in the room were impressed by the research done to establish the true community need in a specific area. The topics of teenage pregnancy, the uninsured, childhood obesity, childhood immunizations/vaccinations, tuberculosis testing, community recycling, public health program evaluation and medical billing are all important to the residents of North Carolina, South Carolina and Wisconsin and each team had the statistics to prove it. What makes the Management Academy so unique is that each team has to consider how to address the community need, while at the same time, consider how to develop a self-sustaining program that doesn't merely rely on grant funds.

I would definitely be remiss if I did not mention the other activities that took place during the most recent on-site retreat. One of the goals of the Management Academy is to prepare the participants for new management challenges in public health. The faculty members focus, not only on business plan development, but also on improving the participants' individual managerial skills. The retreat included 360 Assessments, tips on negotiation and communication skills and work towards of a plan aimed at improving managerial competencies. Let's hear from the Management Academy participants about what they found most helpful during the retreat..................

"Fun & Fit"

Last week the current Management Academy teams presented their feasibility plans in a session that includes brief presentations and Q & A. This session brings out the meaning of “teamwork” for the Management Academy – it is clear at times like this that we’re all on the team: everyone in that room was there to understand the plans and help make each a better final product. We were lucky, too, to have two special guests: Dorothy Cilenti, a former North Carolina local public health director who is currently Deputy Director for Operations and Management at the NC Institute for Public Health, and Rosemary Summers, current Orange County Health Director.

One of the teams is proposing a program called “Fun & Fit,” which will be a summer day camp created to address childhood obesity. A structured camp for children between the ages of five and 14, “Fun & Fit” will incorporate play, cooking, field trips, swimming, sports, and gardening to encourage children to be active and make healthy food choices. It will also contain evening classes for parents and children on nutrition and health. The partners include the county school system, a local aquatics center, Smart Start, the local 4-H chapter, and the local campus of the state university, which will provide student interns to work with the children. It will be an eight-week program during the summer, with follow-up during the school year. The program will be subsidized through the Department of Social Services.

What are some of the challenges for a project like this? Some questions raised had to do with medical participation. Dr. Summers asked who would provide on-site medical supervision? And, perhaps it could be a prescription program, with doctors “prescribing” it for overweight or at-risk children. Would that help it be covered by insurance? Would that help the program planners target the children who would most need it? Related to targeting children, another question was raised about the program’s marketing: how would such a program be marketed so as to avoid stigmatizing children who attend? The team answered that it plans to target all children and avoid a stigma, which led one attendee to suggest that then they might only get the concerned parents whose children are not necessarily overweight or at risk, those who are already thinking about healthy behaviors and choices. The group ended by brainstorming ideas for encouraging participation – they could use active video games to “meet the kids where they are” – even offering such games as prizes for meeting healthy eating or activity goals. That team might have to go find another partner – maybe a video game company or store – who would donate things that could be incentives for the children.

Other challenges might be regulatory issues. Studies show that regulatory issues are the second most common reason given by MAPH students for plans not getting off the ground. Also, public health planners often neglect to “think like a business” when it comes to marketing. Marketing for a program like this might target doctors, parents, children themselves, and schools, and the marketing plan would have to comprise more than just public service announcements. There are a lot of competitors for children’s time in the summer.

What do you think? Can you -- our Community of Practice -- think of other ideas that would help this team make "Fun & Fit" the best plan it could be?

-- Anne

Feasibility Plans

The current MAPH scholars are here this week for their second on-site session. This is the session at which (among a lot of other things) they present their feasibility plans to the group and get feedback. Their ideas have come a long way from the first tentative ideas that were batted about in July. Any former scholars in our audience can well remember the feeling of free fall that comes that first week when you realize this is a long, sometimes difficult process of brainstorming, fact-finding, going back to the drawing board, and work, work, work. It’s exciting (like an epiphany) and yet terrifying (like a tsunami) (and I promise not to write any more about that word, this week at least!).

In conversations the last couple of days I’ve been asking these scholars – “what do you want to see more of in the book?” – and to a person, they all said, “We need a good example of a feasibility plan!” I have a few answers to that request:

1. Business plan coaches Pamela Santos and Catherine McClain do not want us giving out sample feasibility plans in the fear that you’ll see one of these imperfect plans and model your own after it. Plus, plans are so different that there is no perfect plan that would work across the board. We say that in the book, and it’s true: no one plan will work for everything, so it’s better to work with the parts and make your own plan. And, like your teachers told you in high school: there is value to figuring it out for yourselves.

2. The feasibility seems HUGE to you right this minute because it’s what you’ve been working on to present here this week. But it is a means to an end. After this session you will not go back and revise your feasibility plan: it’ll be time to write your business plan!

3. If you still insist that you need a model, on the member’s site of the MAPH web site (www.maph.unc.edu/members), under “Business Plan Project” there is a link to “Feasibility Plan Details,” where you can get very detailed descriptions of the parts of a feasibility plan with examples from past plans. Not one big plan from start to finish, but a close description of what the parts would consist of. I hope you were pointed in that direction when you began the program, but if not, there it is, better late than never. For those of you who are not in the Management Academy program, I’ll see about getting that link available to you if I hear back from you that you want it.

4. One of the readers of our book in manuscript said the feasibility chapter should have come first, because it is what you do first. We put it where it is because even though you do it first, you do need to know what the parts of the business plan are before you do it. And, again, it’s a means to an end. When you’ve done your business plan you forget about the feasibility plan. However, we can revise that chapter, move it, bulk it up for the new edition (if we’re lucky enough to get to do one) if we hear enough feedback that indicates that would be what you, our audience, wants. So let us know!

OK. I'll write more soon about the plans that were presented this week. And perhaps Monecia will give us an update "From the Director" --

-- Anne Menkens

Another Look at Tsunami + Epiphany

OK, Steve, I’ll take up your word, “epiphanami.” You’re right about all the positive connotations of a sweeping new way of seeing the world, a “tidal wave” of shared inspiration and motivation.

However, it also behooves us to look at the other side of things, if only because a lot of people in public health are afraid that the “epiphanami” of “thinking like a business person” about public health issues will destroy the field. They may not want to change the way they – or their stakeholders – think about public health because they may worry that the new way of thinking will make them answerable to a new set of private stakeholders. Tsunamis do, after all, bring annihilation to what was stable, staid, predictable, land. So how do we answer these doubters?

One thing to say is that the epiphanami is the effect, not the cause, of the upheaval affecting public health right now. As Professor Johnson points out, the earthquake going on in the middle of the sea is economic pressures, changing demographics, new demands for sustainability from granting organizations, changing political priorities – a host of things beyond the control of local public health. As public health professionals, we can either run for the hills to get out of the way, or we can accept the reality of the situation and work with it.

Better yet, we can embrace the situation! Build a boat and sail in the water brought in by the storm. That’s the epiphany part! The inundation feels like a disaster until we realize that we have some control over the situation. Not every business is going to be a proper partner. But bringing business people with an interest in public health into your circle of influence will make public health stronger and richer. And, “running things like a business” does not mean running things like a bad business! It means learning how to plan what you need and then do a budget, as opposed to fitting what you do into someone else’s budget. It means recognizing that things cost money, that the money has to come from somewhere, and that you can sustain yourself if you plan carefully.

Epiphanami -- further thoughts

I'm really stuck on the idea of an epiphanami--

Perhaps the main difference between an epiphany and an epiphanami is that an epiphany happens to one person, and an epiphanami happens to a whole group. A really good public health business plan idea often looks to me like an epiphanami:

• It makes a whole team of people go "wow" and motivates them toward a big goal
  
• It changes the way they think: a shared epiphany
  
• It changes the way they work going forward
  
• The plan builds its own momentum; it seems to gather strength
• It doesn't hit the beach and meekly return to the depths, it changes the landscape
  

Where does the power come from? I have some thoughts about that. One is that it comes from unleashing human potential in a new way. That's John Gardner, from On Leadership. People want to be inspired. Work gets fun when you are committed to an important, challenging goal.

Business planning provides that important, challenging goal to many of the public health teams we work with. Instead of responding to an RFP designed to meet the goals of others, a business planning perspective encourages you to focus on an issue you think is really important, and then commit to really learning and understanding what's happening. Learning fuels teams as they work their idea into a solid plan. Getting from vision to practical, sustainable plan is the challenge side of the equation. Sustainability is a serious challenge. Starting programs is easy compared to sustaining them. The energy to do that comes from commitment to the goal and belief in a new way of reaching that goal, a way that works now and works into the future.

--Steve Orton

"Accountability" Take 2

I have been getting another manuscript out the door this week and last, so have been absent from this page for awhile. Look for the new book next summer: Managing the Public Health Enterprise: A Practical Guide, ed. Baker, Menkens, and Porter, from Jones & Bartlett. It’s a collection of short essays from the “Management Moment” column of the Journal of Public Health Management and Practice, and some new contributions from our colleagues here at the NC Institute for Public Health and at the Dana-Farber Cancer Institute, all with the goal of giving short, practical advice for common management challenges. Steve Orton is in there multiple times – if nothing else, you’ll want to hear his inimitable voice again!

But I’m thinking now about his word “accountable.” Steve points out the root “count,” but there’s another meaning in there: “account” as in “story,” as in “narrative” – the “teller” at a bank counts your money, but a “teller” of a story describes something. When you are accountable, you give an account of, or answer for, your responsibilities – by telling about them.

So think of planning as telling a story. You gather data, put it together in a clear, open, way: and tell your story to the people that matter. Planners use facts about the past and an understanding of current trends, circumstances, and priorities to tell the story of what the future should be in both broad and deep detail. Evaluators are also story tellers: they use the information about how things worked to tell the story of process and outcome: what worked, what didn’t, and what were we able to accomplish. Yes, it's about counting, but how you report the numbers and to whom you report them matter as well. Your stakeholders, funders, and potential partners in the community cannot know unless you tell them.

Planners are often given less priority in some government settings: good planning takes a lot of time, and story tellers (both those who look to the future to plan new programs and those who look to the past to evaluate current ones) are often the first to get cut in budget crunches. We’re seeing it in our executive education programs: slightly fewer are enrolling this year because of budgetary insecurity around the country. But our students are the ones who go back to their organizations and tell the stories that get new partners excited in new programs. They’re the ones who try to resist the time pressure to demonstrate success: they know you can’t tell the story until you know what happened!

All this is to say: we understand the pressures that public health managers (and others) are under to demonstrate accountability while at the same time they’re not often given the time or tools to truly plan and evaluate their programs. We are thankful to the many public health departments from across the country that are investing in their employees by sending them to the Management Academy, and to the many community partners who are part of those teams. In challenging economic times, it is more important than ever to get the story out about the critical work being done in public health.

-- Anne Menkens

Accountability: Economics 101 for public health

An interesting article came across the desk this week-- on "Business Basics for Nonprofits." The article is a Harvard Business Review piece from February 2004 describing a talk by Jeff Bradach, a strategy consultant to non-profit groups. Here's the lead:

To transform aspirations into quantifiable impact, nonprofits [and public health agencies] need to become more familiar with traditional business tools such as business plans...

Why? Because

Today's... climate demands accountability.

Now, let me make a personal admission (blogging seems to encourage personal sharing). I've always been intimidated-- ok, scared-- of that term accountability. It sounds so judgmental and harsh! Somehow the term is connected in my brain with the notion of being punished for falling short in some area. Accounts will be settled! You will pay for your shortcomings!

Recently though I've started thinking about the word differently. When I hear it now I think:

COUNT-ability.

The ability to count something.

It's nothing personal: just a data inquiry. What are the facts? What is actually happening?

The article lists four areas where non-profits (and I think public health agencies as well) sometimes have difficulty with their counting: the first three are impact, process, and cost. And like the folks in the article, I think that business planning is an approach that can help you count better.

Impact: The difficulty here is in being specific about goals: exactly WHO we are trying to help and exactly HOW they are going to benefit. Among the key questions is "how do we define success?"

Process: The difficulty here is being specific about the steps necessary to get to the goal. Face it: you are working in a very complicated system. Sometimes people create interventions that don't have the results they expected. How do we know? Bradach wants you to figure out

what comes between the grand, inspirational mission and the activities and programs of the organization. By letting this in-between area remain grey, organizations have no way to measure whether programs are working, or even know if they are on the right track.

Cost: In public health, it isn't uncommon for cost and budget information to flow exclusively to one "business manager" type person, bypassing program staff entirely, and reaching leadership only in summary form. Does this sound familiar? Does your organization count costs effectively?

Bradach's clients typically don't. When he helps them do it they "often see that their spending doesn't align with what they had identified as key points in their mission."

Note that public health business planning requires that you look at all three of these areas.

That brings us to the fourth area, which the article calls "difficulty making hard choices." Across a whole organization, this sort of "counting" of goals, processes and costs might very well lead to some discomfort. Why? Because some people (people like me) will initially get itchy and warm and start jouncing their feet in a classic "fight or flight" response to perceived danger. Someone might get hurt!

Clearly it would be better, in a potentially difficult and emotionally charged situation, to have some data to base a decision on. Without data, these decisions will get hijacked by our individual or organizational lizard brains.

With data-- we might find out that some of our programs... aren't helping very much. Or aren't helping the right people. Or aren't exactly what our customers and stakeholders really need. In other words, we might find out that some of our programs are actually preventing us from moving towards our mission-- because they are tying down people and space and time who could be doing more important work.

Final word: business plans can help in your quest to "transform aspirations into quantifiable impact."

Am I right? Drop a comment and say what you think...

--Steve O

Epiphanami

I spent the end of last week at a leadership training program that I help run-- and as usual I learned more than I imparted.

The theme of the two days was innovation. The group spent half a day working on improv techniques with an expert from Chapel Hill who has his own improv company, and an adjunct appointment at the Kenan-Flagler Business School. The session is all about learning to take risks, listening to the clues that your teammates are giving you and running with them.

The take-away for me was that most people are ready to be much more creative, much more risk-taking, much more committed-- much more entrepreneurial-- than they show on a typical day at work. John Gardner in On Leadership says that this is the most basic function of leadership in organizations: unlock human potential. He argues that organizations get only a tiny fraction of the potential out of their workers.

The other take-away was to not use the term "take-away" any more. Far better is the term "epiphanami." I love this word! A participant came up with it as a way to describe the feeling of learning something, realizing something, really important for a whole group within an organization. I imagine getting a series of epiphanies at a leadership session-- or being in a group of people that all get related, reinforcing epiphanies-- such that the whole group is picked up on the wave and flung at the shore with astounding force.

An epiphanami (epiphunami?), I think, is an epiphany with the power and the breadth of a tsunami, an epiphany with the potential to bring real change. That's the link back to innovation: the point of being an entrepreneur within a government or non-profit organization is to chase your BHAG, your big hairy audacious goal, in a new way, instead of responding to another RFP (and chase somebody else's goal).

--Steve Orton

Business Planning at the State Level

I had a conversation yesterday with a member of a current Management Academy team that happens to be from the state health department. In North Carolina we have an essentially decentralized public health system. Most of our 100 counties have their own health department (some counties double up); and they are individual entities whose employees do not work for the state. This structure gives them more flexibility than is enjoyed by county-level health departments in states with more centralized systems, such as South Carolina, and, it gives them more flexibility than those who work at the State Department of Health and Human Services. So much of what we talk about in this book and at the Management Academy assumes a certain level of flexibility: to create new positions or change old ones, to influence hiring, to affect priorities, and, most important, to incorporate revenue generation into programs. For the most part, our examples in the book and our examples and case studies in the program all assume a level of flexibility unrealistic in some government settings.

So, the challenge is to come up with ways to apply entrepreneurial thinking within less than flexible settings. This team from the state is submitting a feasibility plan for a program to build capacity in the public health workforce. Their analysis of need turned up the need for better evaluation, and the fact that public health entities now often must hire outside consultants to undertake evaluation of implemented programs required by funders. Their industry analysis turned up many great courses and on-line trainings, as well as well-vetted standards and paradigms, so they decided not to create a curriculum. They decided instead to focus on creating a program that offers web resources, links to courses, study guides, etc., as well as developing an exam that would serve as a certification tool for public health professionals who wish to improve their evaluation skills. State funders, representatives of the national associations for public health (NACCHO and ASTHO), local health directors in NC, and individuals involved with accreditation are all excited about the possibilities for such a program.

The team’s business plan advisor has not weighed in, and I’m not sure of all the financial details, but to me it sounds interesting and exciting. In terms of lessons for others at the state level, it might be good to think “big picture” about needs in public health. Perhaps the types of programs you should be thinking about are those that serve others in public health, dealing with training programs for public health or health care professionals, working with state-wide partners, or thinking about priorities that transcend the state, such as the accreditation movement or preparedness activities.

I’ll share more of this team’s story in future columns – as their plan moves from “blue sky” to black and white details – as well as stories from other “less flexible” sites. If you have other examples or thoughts to share, please do.

-- Anne Menkens

NACCHO-ASTHO in Sacramento-- what's your take?

Today is a bittersweet day-- the NACCHO-ASTHO conference starts in Sacramento and I won't be attending. This is my favorite conference-- a great experience for anyone who is interested in public health management and leadership. The sessions are usually very good, and the sessions are designed to facilitate networking.

UNC will have a booth at the show, and information about the book will be available there. Stop by and introduce yourself to Monecia Thomas, the new director of the Management Academy (and also the director of the Emerging Leaders in Public Health program).

I would love to hear about how you are using the book, how you are using business planning principles in your public health work, what innovative new ideas you're working on developing and getting funded-- and what sort of interesting stuff you learned in Sacramento!

--Steve Orton

Preparedness and Business Planning

We in the southeastern US are anxiously watching three hurricanes coming our way. Hanna, Ike, Josephine… like unwanted old friends coming to visit, we’ve seen this before. Did you know that the skills of public health business planning are applicable to disaster planning?

This application can be direct: some teams every year tackle a preparedness problem in their plan. We write in the book about a Virginia team that created a plan to train childcare management and workers in disaster preparedness and create a certification program for that. Another team developed a disaster preparation training program for faith-based organizations interested in helping special needs groups, such as the blind, or those who do not speak English. That more recent team included a Spanish-speaking member as their community partner and envisioned working with the State Bioterrorism Department, local emergency centers, and local businesses to develop this program.

The application can also be indirect: in December, 2001, MAPH evaluation staff surveyed MAPH graduates to see whether and how their training had an impact on their ability to do terrorism and disaster-related work post-9/11. Of the 74% of respondents who said they did such work in their jobs, 90% said that MAPH contributed to their ability to respond. Now, MAPH teaches a lot more than writing a business plan, but the list of things respondents gave as having contributed to their ability includes much that goes into writing a business plan. They listed:
- partnerships, networking and negotiations
- communication, including presenting and writing plans
- planning, including strategic and business planning
- managing people, including delegation and team building
- managing projects
- personal confidence, including management, leadership and priority-setting

On a related note, in an article in Public Health Reports (122:1, Jan/Feb 2007), some of our colleagues at the NC Institute for Public Health compared preparation for two hurricanes: Hurricane Floyd in 1999 and Hurricane Isabel in 2003. They looked at the capacity building activities in the intervening years to see whether there was a correlation between having undertaken these activities and doing a better job preparing for the later hurricane. Surprise! There was – and, among other things like infrastructure development, the capacity building activities are the kinds of things we talk about every day. One important example is partnership building. In this case, partnerships among state and local agencies, health care facilities, businesses, and professional associations involved in preparedness and response. These are the kinds of people you are talking with about your own business plans. Whether or not you are talking about disaster planning, you are talking, getting to know each other, building trust and advancing relationships. When you do turn to disaster planning, you'll have a lot in place with which to work.

I can’t link to the article here, but you should read it if you can. It has the somewhat unwieldy (yet informative) title, “Evaluation of Public Health Response to Hurricanes Finds North Carolina Better Prepared for Public Health Emergencies” by Davis, MacDonald, Kline, and Baker.

Enjoy! And wish us luck with our “visitors” over the next few weeks.

-- Anne Menkens

Succession Planning 2

One of the corollaries of Anne's last post on succession planning in government is this: there is lots of talent in your town or your region that would improve your organization. Where are you looking for your next manager hire?

The default thought might be to find a public health graduate program, of course. But the next person hired as a manager in local public health is probably not coming straight out of a school of public health.

I talk to health directors frequently, at trainings and at national meetings. Even if you are lucky enough to be located near a big school of public health (and most aren't) you will find it hard to recruit graduates of those programs to do community-level health work. Most of the MPH grad students I run into in Chapel Hill, for instance, are aiming for jobs in healthcare, or policy jobs in DC, or international work, or research, or teaching.

Luckily, public health has room for talented managers from all kinds of different educational backgrounds. Great, hard-working, public-spirited managers in your town may be waiting for your call. Certainly there are folks out there who could help you do some of the things you need to do: assess the community, assure quality and access, develop policies to create more. Local knowledge is kind of an important selling point, actually.

Our book is based on the idea that government and non-profit organizations are trying to learn best practices around planning and efficiency and quality from other sectors. Recruiting is a powerful way to help your organization learn. So I would argue that recruiting from outside is actually important-- not just something to settle for.

Yes, these new hires will need to be oriented to population health and trained in that perspective. Again, lots of adult education resources and programs are available to help you do that--including some that are entirely on-line.

--Steve Orton

Succession Planning in Public Health: Just Ask

One issue we don't really deal with in the book, but that we know is important to public health planning and practice, is the idea of succession planning in public health. As the workforce ages and retires, who is going to replace you at the helm (or even in the galley) of these important organizations? Who in their right mind would want to take a job in a public health department, with its maze of bureaucratic requirements, its never ending list of needs and much shorter list of resources, the worries that follow you home after long days that you think will never end? For that matter, in an era when politicians themselves seem to disown the hand that feeds them, complaining about "big government" as they cash their paychecks and enjoy their benefits, who would want to work in government at all?

A recent Gallup Poll had some encouraging advice: just ask.

Despite generational differences in priorities, information sources, and modes of communication, a majority of Americans now say that a job in public service would be appealing. Yet, 60% of those under age 30 say they have never been asked to consider a job in government. However, if asked by their parents (33%)or the newly elected President in 2008 (29%), a significant share of Millennials say they would give such a request a great deal of consideration.

What does that mean for you in public health? One thing it might mean is that there are people in your organization who want to move up the ladder, but haven’t been invited. Think about asking them to join action teams for future projects or decision-making tasks. Consider giving someone on your staff a task you now do, and see how he or she handles it. When you delegate a responsibility, really delegate it: get it off your shoulder and onto theirs, and see how they do without micromanaging. The staff member might find they really like the added responsibility, might discover a skill they didn’t know they had. Finally, introduce them to public health business planning ideas -- to inspire and motivate them to work to build sustainable programs. You might discover someone you want to groom for bigger and better things within the organization.

Local Knowledge

One of the big barriers to getting started on a public health business plan is this: worrying that you don't know enough.

As it turns out, local knowledge is one of the most important factors for business plan success. So you might already know a lot of the important details, or have easy access to them through your local partners.

Yes, the science is important (the general framework provided by national or state-level statistics is nice; the references to model programs are important too). Knowing how to build a budget is important (and it is not hard to learn). Just as important is getting the details right about your local community, local needs, and local assets.

I mention it now because of an interesting article from the New York Times published today: Report Says Public Outreach, Done Right, Aids Policymaking .

For decades, laws have required many government agencies to seek public participation in the establishment of environmental policies. And for decades critics have derided the requirement as producing little more than confusion, delay, expense, distorted science and, as a government report once put it, “a proliferation of opportunities to misinterpret or misapply required procedures.”

But a growing body of evidence suggests that the process, done correctly, can improve policies and smooth their implementation, according to a report issued Friday by an expert panel convened by the National Research Council. Though critics often assert that members of the public are too ignorant to weigh the science involved in environmental policies, “public participation can help get the science right and get the right science,” said Thomas Dietz, the director of the Environmental Science and Policy Program at Michigan State University, who headed the panel.

“A lot of science has to be applied to a very local context,” he said in a telephone interview. “Local knowledge is essential.”

The article includes links to the full report if you're interested.

Health, Obesity and Business

A few weeks ago we got the following comment from David, who quoted Dr. Jim Johnson, a faculty member at the Kenan-Flagler Business School and teacher in the Management Academy for Public Health:

"... In the companies he had consulted with, Dr. Johnson stated that the number
one factor a business looks at is the health status of the community. Why?
Because of the potential cost to the company. Yet, our commissioners continue to
focus on tax rates and education levels, both very important, but with barely a
nod towards the community's health. Wonder what it will take to make us truly
realize what our "good health" is worth to us?"

A recent article in the Charlotte Observer, reprinted in our local Raleigh News & Observer which also quoted Dr. Johnson, looked at the issue of businesses assessing health status before committing to communities from a slightly different angle:

… Among other considerations, companies could be eyeing obesity rates before
deciding where to put new plants and offices. The idea is that by examining
obesity rates and avoiding opening where more obese people live, companies can
cut their future health care costs. For the Carolinas, that could spell trouble,
given that the majority of residents are tipping the scales.

This makes me think of a few things, in no particular order:

- recent data are calling into question the assumption that overweight equals unhealthy. For example, a recent New York Times article cited data from the Archives of Internal Medicine that showed that in a study of cardiovascular risk factors in 5,400 adults, half of those deemed overweight and one-third of those deemed obese were "metabolically healthy" -- that is, they had healthy levels of "good" cholesterol, blood pressure, blood glucose, etc. And, about a quarter of slim, "healthy-weight" individuals had at least two cardiovascular risk factors. So any company thinking of using obesity rates as proxy for health should consult with someone who knows the latest research (i.e., a health care or public health researcher or professional -- someone who understands the big picture about health and all it entails) before using that to determine whether to set up shop.

- As David suggests, a good strategy for communities trying to attract business would be to improve the health of its community. Community health insurance? Community design to encourage safe activity in neighborhoods and public spaces? Community resources toward public swimming pools, parks, playgrounds, tennis courts, basketball courts? Community health clinics? There are a lot of things to think about. They cost money, but so do unhealthy citizens and empty worksites.

- A good business strategy for businesses who are already established would be to improve the health status of their employees. How could they do this? One commenter to the N & O story said she tries to apply to companies that offer a gym or fitness discount, and suggested that companies have subsidized cafeteria and gym on the premises to make it easier for employees to fit healthy living into their schedule. Here at the NC Institute for Public Health we don’t have such facilities, but we do have in our written policy manual the support for staff members’ taking breaks to exercise, the commitment to having healthy food at company events, the support for on-site exercise clubs, etc.

- Several Management Academy teams have been built around partnerships with businesses that want to help their employees be healthier. We wrote a few weeks ago in this space about a team in Oklahoma building a partnership around health insurance and business interests. We write about others in the book – in Chapter 6 we mention a plan in Virginia that aimed to provide health screenings and education at worksites (pg. 55). In their exploration of need that team had found that businesses are desperate for public health help in implementing such programs. Visit the “Business Plan” section of the MAPH website (www.maph.unc.edu) for many more ideas. Note that in general, the plans do not solely address obesity; rather they look at the big picture of overall healthy living.

That's all for today.

-- Anne Menkens

Business Plan idea: farmer's market

Access to fresh fruits and vegetables seems to be a barrier to good health in many places across the U.S.-- especially low-income city areas and poor rural areas. Should public health be involved in creating farmer's markets?

Why not? Columbus, Ohio is doing it-- they have a public health farmer's market in a downtown neighborhood-- and it takes food stamps.

A team from rural eastern North Carolina-- the Northeast Partnership represents a group of counties in the state's northeast corner-- has written a business plan to create a farmer's market in their community. In addition to a market, the Northeast Partnership team plans to use churches as a distribution point for a "CSA" style product. CSA stands for community-supported agriculture; generally a CSA works like a subscription. Every week or so, subscribers get a set amount of produce, whatever is fresh at that point in the season.

The role of public health in this process? Bring together partners, money, and information.

First, assessment: the Northeast Partnership knows that access to healthy food is a major problem for portions of their community. Partners: they have existing partnerships with local churches and church networks that have a strong interest in health ministry. Money: they have grant finding and grant writing skills and a track record of finding start-up funds.

The partnership is now pursuing grants from two different directions: from public health sources that fund healthy food and exercise programs, and from agriculture sources like USDA that support local farmers. That money will be used to jump-start a natural market.

By natural market I mean organic produce-- but I also mean that the market is designed to become self-sustaining, generating enough revenue to go by itself without requiring huge amounts of time and effort from the public health department.

--Stephen Orton

More on the research-practice divide

To follow up on Steve's last post (below) -- Colleen Bridger's point is a good one. A lot of what we've found in evaluating the Management Academy teams is that the barriers to success are not the type of things public health researchers usually look at. For example, as we talk about throughout the book, and I quote from Chapter 15, "the primary reason that business planners fail to implement in public health settings is lack of organizational support." Organizational resistance is not something that researchers deal with when analyzing the efficacy of individual interventions -- organizational support is generally assumed going in. Now this effect can be mitigated by improved planning methods -- improving communication with those who hold the purse strings, aligning strong community partners, etc. -- but sometimes, the research about whether something works has nothing to do with how it can actually work in the real world.


On a related note, one public health director who read our book in manuscript urged us to remind readers, too, that not everything they do can be put into this model. As she said (and we tried to acknowledge in the book), some things partners have no interest in contributing to, some things are just mandated and paid for by the government, some things are just mandated and not paid for but meant to be free. (Although nothing's free; it still behooves you to think strategically about how much these "free" things cost and how you pay for them).


We'd be interested in ideas from practitioners about how they'd like researchers to proceed -- what would they like to see come out of schools of public health, what would really benefit them and their work. We'd also be interested to hear from researchers about things they're doing to acknowledge and maybe fix the disconnect between what they do and what public health practitioners do on a daily basis.


Anne Menkens

Evidence-Based Practice and Business Planning

The Journal of Public Health Management and Practice recently got a compelling letter from Colleen Bridger, the health director of Gaston County NC, about the lack of good public health research that is grounded in real public health practice. Here's the gist of her letter:

My concern is the following: how many times do we locals need to hear from the folks in the academic ivory towers how we are not doing it right, before those folks actually spend some time in our shoes trying to figure out why?

Colleen's concern with the public health research being published is that it is not replicable in the real world-- and researchers aren't helping to figure out why not:

I do not believe it is because local health officials are stubbornly clinging to our tried and true methods, nor do I believe it is because we do not know how to understand or interpret research results. I believe that just like in clinical medicine where there is a vast difference between a drug's efficacy in clinical trials and its actual effectiveness in real-world applications, a parallel exits in real-world public health. Have any academicians tried to implement a best practice obesity prevention intervention in a local community outside the scope of a research project? We cannot exclude participants because they do not meet our selection criteria and we cannot pay them to participate, only cajole. Yes, I understand the need to develop gold standard research studies to identify what works, but we are missing the implementation component.

Obviously, searching for evidence-based interventions is a critical part of any public health business plan. Your communities count on you to do things that are likely to work. Colleen points out that our system throws up barriers though. The gold standard research studies can't be replicated on a budget. The more relevant programs from the practice community can't be evaluated-- or the evaluations can't be published because they aren't up to the standards of academic journals.

And good luck finding the write-ups of the programs that fail.

It is much easier now than it was 10 years ago for managers in public health to do the library work to find the relevant research. With Web 2.0 technologies, it should get easier for managers to find their "community of practice," to communicate with the other people across the country who are doing similar work. Neither of those things addresses Colleen's issue, though. Kellogg's program to fund community-based research scholars is the right approach.

-- Steve Orton

Comments on "important challenges"

We asked a week or two ago about the important challenges facing public health.

In response to your question as to what are the most important public health challenges these days, I would offer the following -- the pressure that the increase in population is putting on our public health systems. These include medical care for different population groups, especially the elderly; increasing amounts of resources for meeting the needs of larger populations, and here I would mention public water supplies , as we are still in a drought; and the effect that development to provide for more people is having on environment, and here I would mention the loss of wildlife habitat, recreational open space, and natural vegetation.

Great point-- as you say, the population pressure comes from the numbers, but also the density and the location of population increases. Note that many of the populations that are increasing are populations that have unmet health needs (immigrants, children, elders, the uninsured).

A friend who attended the Wisconsin Public Health Association Conference added the following:

Youth violence -- it cannot merely be a problem for law enforcement: its causes are broad, and it affects all of us in some way. By the way there was also a talk about the importance of partnerships in public health, which seems right down this book's alley.

Violence is slowly being recognized as a public health issue. I see lots of room for alliances between traditional public health organizations and the many organizations that work on violence prevention specifically. Lots of other groups have a big stake in this issue: law enforcement, health care, economic development, education. A huge challenge but also as you point out a huge opportunity. People who work with the victims of violence are really hungry for solutions on the prevention side.

A central challenge for a violence prevention alliance will be to figure out how to start understanding the issue the same way, and how to start taking useful steps, and how to share the work (and the cost) in a way that is equitable and sustainable.

There are school-based programs and outreach programs that have been rigorously evaluated-- read more about them on thecommunityguide.org.

Americans learned to recycle; most of us quit smoking; a few of us went to the moon; we sent a robot to dig up water from the surface of Mars. The fact that the violence issue is complex could be scary-- or it could keep people interested and motivated!

--Steve Orton

Team Outcomes: bricks and mortar

Outcome story: Gaston County NC put a business plan team together last year that combined representatives from the county public health department with the head of a local community health center. Their goal: to build a shared space for community health and public health clinics and offices. The two groups see the new building as a key part of their strategic alliance-- and a central way to address a serious problem with access to care in a neighborhood called Highland.

Last month, their board of commissioners gave the go-ahead on the Highland project-- including making county land available without cost. Next step: architect drawings!

--Steve Orton

What if Health Care Costs were treated like Gas Costs?

Last night we had our “book launch” for Public Health Business Planning here in Chapel Hill. It was a wonderful event, attended by the current cohort of Management Academy, some former students, the Dean of the UNC School of Public Health, faculty, friends, family, and colleagues from across the country. Thank you all for coming!

One conversation out of many sticks with me this morning. I was talking with one of my colleagues here at the NC Institute for Public Health who runs our Leadership Novant program, and we got talking about rising health care costs. It seems that so much attention has been paid to gas costs recently, but rising health care costs are affecting families, businesses, and communities at least as much as rising gas prices. According to a recent info sheet from the National Coalition on Health Care, national health expenditures on health care costs were $2.3 trillion in 2007. If that number is too vast to mean anything, think of this: the annual premium that a health insurer charges an employer for a health plan covering a family of four averaged $12,100 in 2007. Workers contributed nearly $3,300 toward that premium, or 10 percent more than they did in 2006. You can see that would be devastaing to a full-time minimum wage worker making $10,712, but even people making an average income are feeling the hit, for insurance that often covers less and less. An article in the Washington Post pointed out that even when costs are not directly passed on to employees, the increased prices are effectively lowering pay because employers cannot afford to give regular raises under these conditions.

It's not that the media are ignoring this problem, but it is not front and center the way gas prices are this summer. We mused, one of the reasons we think about gas prices so much is that we look at them all the time: at every corner gas station, there’s a huge sign showing today’s price per gallon. Every nightly news segment starts with a story about the price of gas and its effect on a family’s budget, tourism, the trucking industry, food prices… you name it. What if every corner had a sign saying what today’s price for a colonoscopy was, with flip-numbers ready to go up that next dime per procedure? “Get your colonoscopy today because tomorrow it might be doubled in price!” What if every news day started with a run down of the many things families are giving up because they have to pay such high health insurance premiums? Or, worse yet, how many more families are going without health insurance because they need to eat, pay rent and, yes, buy gas? What if the cost of not preventing flu, tooth decay, heart attacks, cancer were broken down into a per-person or per-illness figure and flashed before our eyes every time we went to the drug store? If every time we had to fill a prescription it was like filling a gas tank, putting one pill in at a time and watching a meter go up, we'd pay more attention!

Food for thought.

Anne Menkens

Seeing through the fog

Big day in Chapel Hill today: the twenty-second cohort of the Management Academy started their program at the Rizzo Center.

Jim Johnson talked about civic entrepreneurship this evening. A couple of points hit me as especially relevant right now. First is the notion that most organizations, and most managers and leaders, are in a fog bank right now. It is difficult for most people to clearly see beyond what is right in front them.

Organizations that can find some clarity, that can see ahead instead of focusing right in front of them, will be at a great advantage. Some organizations will be stopping on the side of the road (try not to rear-end them as you go by).

Second is that even in the fog, some things are predictable. To deal with the unexpected, you have to be flexible and lucky. But some things are completely expected. There's no excuse for ignoring the obvious.

Demographics provides a great example. Your workforce is aging. The first baby boomer, Jim said, turned 62 on January 1st this year. That leading edge of the boom generation hits retirement age in three short years, 2011. Are you prepared? Are new leaders and managers being identified and prepared in your organization? Are systems and incentives being put in place to recruit the new workers you will need? Are systems and incentives being developed to retain the baby boomers that you want to stick around a while longer, even though they might be more expensive and less able to read small print and zip around the internet? Or is the organization focused on more immediate concerns?

One team tonight said they wanted to design a business plan to sustain an effort that is currently being maintained by grant funding. They know that grant funding, like an aging cohort of workers, eventually goes away.
The entrepreneur does two things that might seem at odds: one, see clearly what is really happening now , and two, see what could happen, even if it is completely different.

--Steve Orton

Adult Learning

Adult learners, I salute you...

The Dean of the School of Public Health, Barbara Rimer, recently blogged about adult learners. She was responding to a recent New York Times article about why some people continue to develop and others seem to stop.

Dean Rimer writes, "I’ve had to work really hard to develop my quantitative skills, but the more I’ve used these skills, the easier it becomes. Many of us, particularly those of a certain age (read: well over 50), grew up thinking that if we weren’t a natural at something, we just couldn’t or shouldn’t do that thing."

Many public health leaders and managers I've met feel that they don't have business skills, that they aren't good with money and budgets. They aren't "naturals" at it. Many of them started in public health because they cared about people, not money or math.

I'm in that category myself-- I never figured to be in public health, and I never figured to have "director" in my title. I've come to believe that, in order to accomplish the things I want to accomplish, I need to keep learning new skills.

Those who decide to work on it, learn it. Sustained effort trumps talent. I remember a study about success in music: the predictive factor wasn't talent, it was the amount of time spent practicing (duh).

The vast majority of the roughly 1,000 people who have enrolled in the Management Academy for Public Health have never written a business plan before-- but all of the graduates wind up writing one. And our graduation rate is 94%! Adults can learn. You may learn by reading, or studying a mentor, or taking a class. Many adults learn by setting themselves a challenge to try something new (especially if it is something that is really important and relevant to their job).

Writing a business plan can be that challenge for you. If so I hope the book, and this blog, help you stay on track!

--Steve Orton

The Size of the Pie

Thanks for the input on public health challenges-- tell us more!

By the way-- these challenges will likely have to be met by using existing resources more efficiently, or by creating new alliances and generating new revenue. Why? Because it looks like the size of the pie for governmental public health is not going to grow soon.

Jonathan Oberlander, who gave the Foard Lecture at UNC this spring (you can watch the webcast), warned the audience against "irrational exuberance" about the possibility that a new president might make dramatic changes in health care and population health. I heard similar forecasts from several healthcare executives this week. Folks in state and federal public health are expecting cutbacks, not big new expenditures. In many areas, the mortgage crisis is going to slowly deflate tax revenues.

So financial help is not on the way. If you want pie, it is time to start rolling out your own dough!

Advice from the Community

The two new cohorts of the Management Academy for Public Health are coming to town over the next two weeks. This is the on-site at which teams get their marching orders—they meet with their business plan advisors for the first time and vet their ideas together; they sit for the first lectures, on business planning, social marketing, civic entrepreneurship, managing people, and finance; and they do the first exercises that will make their working groups into true teams over the next nine months of hard work.

Before they come this year, we are soliciting advice and thoughts for them from our Community of Practice: what do you think are the most important challenges facing public health these days? How are different public health departments addressing these challenges? What have you seen in your own community, or through your public health colleagues? More generally, what does it take to make a successful public health manager these days?

We’d appreciate your thoughts on any or all of these questions – or another we haven’t even thought of – to welcome our new students to town.

View from the states

I spent part of two days last week with a group of state health department leaders at their national meeting. These senior deputies meet annually to connect and learn from each other. The central theme of the meeting during my time there was to learn to improve business practices in public health agencies.

By saying "business practices," I think they meant the following: how can we manage our resources more efficiently, so we get the most health out of the dollars and effort that we have available?

For example: they talked about how to use GIS tools to turn data into usable information (for instance: which way is the wildfire smoke going to drift in California, and what communities will be at risk for respiratory impact?); how to use web tools to collaborate more efficiently; how to efficiently track and integrate the huge portfolio of federal money that moves into a state every year, on the way to hundreds of government and non-government public health organizations; how to develop the public health workforce in general and build key management skills in state agencies in particular.

The effort is to become smarter: to know what's happening now, know what's needed, know where the money is being spent, know how to measure change to see whether the resources need to be shifted. These are efforts, on a broad state-level scale, that mirror what you try to do in creating a business plan.

Senior deputies are essentially the top management layer for the state public health agencies, with responsibility for executing strategy more than setting it. They manage lots of data about people and communities in their state; they integrate the work of people in their own agency and with huge numbers of partners who own a piece of the health puzzle; they disburse and/or track the money that funds the work that results ultimately in healthy environments and healthy people. They want to be able to say, about the programs of yours that they fund, "this is clearly a well-designed program; the money spent on this program is likely to result in a healthier community long-term."

As a public health business planner this should sound like good news to you. Of course most organizations have areas of discontinuity, where the goals they espouse clash with their actual behaviors-- and individuals are just the same. No organization is perfect. They throw up barriers to achieving their own goals. For now I want to highlight the desire to change the structures that are barriers and move to structures that reward efficiency and effectiveness and strategic partnerships and sustainability. Progress is being made!

News from Oklahoma

Dear Readers,
Some of what we will do in this space will be to share with you more examples of interesting and successful public health business plans from the Management Academy for Public Health. In the book we deal primarily with teams who attended and completed the Management Academy for Public Health several years ago – they’re the ones whose plans have been implemented, whose outcomes we know. Of course there are many more recent teams we didn’t get to write about—so, until we write another edition of Public Health Business Planning (if we’re so lucky as to get to do so) we will use this blog to share new stories.

An Oklahoma team that just graduated from the program in April has designed an exciting employee wellness program. They are working to create a strategic alliance of the Oklahoma State Department of Health, the Oklahoma Department of Career and Technology Education, and Blue Cross/Blue Shield of Oklahoma, to implement training of businesses on health improvement policies. When the businesses implement these policies, which will provide opportunities for employees to improve their nutrition, increase their physical activity, and eliminate tobacco use, then the businesses would receive a health insurance rate reduction from the Blue Cross/Blue Shield. The plan will be sustained in part by educational fees paid by the businesses.

For many reasons, this is a great plan – it involves a variety of partners who all have an interest in its success; its dependence on grant funding will go down over the years; it will not “make or break” the health department – they can implement it and, if necessary, exit without disturbing their core services and other activities.

One member of that team, Julie Cox-Caine, has just been promoted. She’s now a senior deputy reporting to the state health commissioner. We wish good luck to the team, and hope to hear more from them about their success!

-- Anne and Steve

Welcome to public health business planning

Hello and welcome to the public health business planning blog!

Anne Menkens, Pam Santos and I have really missed the fun work of writing the book-- most of it was written in the summer and fall of 2007. So this blog will give us a chance to write some more on one of our favorite topics.

We plan to use this blog space to talk about business plan outcomes we've heard about, books and articles we've read, follow-ups on teams we wrote about in the book (and follow-ups on teams that we didn't write about but could have), and points that we should have discussed last fall when we wrote the book but somehow overlooked.

We look forward to hearing your questions and comments about business planning in public health. Write us!

Steve Orton