This year, the Management Academy for Public Health begins its 11th year. The 54 participants represent North Carolina, Nebraska and Virginia. Upon graduation, this group will join over 1050 public health professionals who have completed the Academy, gained valuable management skills and in some cases, went on to fully implement their business plans.
This year's cohort is focused on a variety of important health issues for their communities. Through their Community Health Assessments and the MAPP process (Mobilizing Action through Planning and Partnerships), they are aware of the problems in their communities. Even though most teams are in the preliminary stages of determining their specific business plans, they have already started preparing their general ideas to develop a sustainable business plan.
The current list of topics include: Increasing vaccination rates, establishing a community health center and developing plans to address mental health services, health data analysis, occupational health, diabetes, teen pregnancy, access to primary care, substance abuse and the need for more school health nurses.
In order to develop a viable business, participants learn valuable business skills. During the on-site retreat August 3-6, the faculty spent a lot of time imparting tips related to businesses outside of public health. Frequently, Management Academy participants say "We are not a business; we are public health".
What do you think are some of the best and worst characteristics of a business organization and why do you think some participants are unwilling to accept attributes of businesses outside of public health?
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In public health, we often don't think of our decisions as business or economic decisions, we only think of them in terms of the service we're giving to each individual. The problem with this thinking is that the same laws of scarcity apply to public health services as any business's services. If we work less efficiently, we serve less people. If we make less money, we have less programming and serve less people. I don't know of any way to think about efficiencies or to compare costs and benefits without doing so in business terms.
Health departments in our region recently worked with a dental efficiency expert. Many of our staff members did not initially like the idea of not seeing clients when they arrived late. The question the expert posed to us was whether there were other people equally in need who we were not yet serving. We answered that there are lots of people who need dental care that no is able to provide at this time. Her challenge was that as long as we were allowing people to come in late and receive dental care, we would be operatign inefficiently, and thereby denying other people care. She also relayed a history of experience that when people are expected to be on time and respect the dental practice's time, they will find a way to be on time.
Our health dept.implemented a Same Day Scheduling system with a late arrival/reschedule clause this year. Our staff initially resisted the change to a scheduling system that is generally used in the private sector, not public health. It was a "hard sell" for this project team, and the implemention phase was very trying for both staff and clients.
Statistics document increased patient show rates and decreased "no show" rates when appointments are scheduled within 24-48 hours-not 3 weeks in advance.
We are now more efficient in providing clinical services to more clients. Integrating best clinical business practice into public health has been challenging but has improved our service.
My belief is that a country with as much wealth as ours could and should offer equal health care to all. Since public health is not "for profit," I have naively made the assumption that this work must be more altruistic than health care provided in the private "for profit" sector. Because of this I have chosen to work in the public verses private care system.
MAPH is broadening my narrow view. Private health care's using a business model which requires profit making to survive does not automatically mean that private health care values money more highly than the people it serves. Public health's historical lack of a business operating model also does not automatically equate to its valuing human needs over money making.
Someone might choose to work in private care because profit can be used to offer more services or to fund the cost of individuals who are unable to pay. Someone else might choose to work in "non-profit" public care because a salary is provided whatever your output.
Business is not a dirty word. Public health is not a higher professional calling than private health. Both cost money to provide. Because taxes have funded public health, we have been removed from the process of financial survival.
The best care for the most people is a goal of most of us in health care. It all costs money. If taxes can no longer support this goal in public health we need to adapt. Incorporating aspects of the business model into public health work is a means to being and providing our best.
Businesses are often more efficient and more responsive to the needs of their clients. This is usually attributed to "chasing the profit motive," which I think is true, but isn't the whole story. I believe government and nonprofit organizations can also be set up in ways that make them more efficient and responsive. In most cases it's a matter of setting up some sort of a feedback loop that rewards good behavior.
On the negative side, there's little doubt that businesses are capable of acting in their own best interest at the expense of their customers or society as a whole. Sometimes businesses even put short-term profitability ahead of their own long-term solvency (General Motors, for example).
These sorts of behaviors stand out in peoples' heads as examples of "businesses behaving badly," and I believe it taints people's perceptions of businesses in general (especially in the public and nonprofit sector).
The 'best' characteristic of a business is a sincere customer focus...providing what customers want, the way they want it and constantly monitoring to make sure the business is on track.
The 'worst' characteristic of a business is the fatal flaw of believing they (the business)are the only game in town, often neglecting needed change or improvement.
The health departments where I have worked have exhibited a bit of both characteristics. Client satisfaction surveys resulted in the expansion of evening hours, but not on Saturdays or Friday nights. Wait times were addressed by an 'open access' appointment system but not all clients can just walk in and need a set appointment time in order to make arrangements for work and childcare.
Most business people seem to understand the balance between their product, service, costs and profit. Most frontline public health workers have no idea about revenues and expenditures and are offended by the notion that they must meet a service/production quota and operate with limited resources. "For the Good of the People" isn't good enough anymore.
Some of the best characteristics of a successful business organization are accomplishing the mission/goal of the organization with good marketing strategies, reaching the target audience, and producing/showing outcomes. A good organization also provides a place for employee development, mentoring and growth. Without a good employee retention rate and growth both in terms of salary and professional advancement, the mission and outcomes the organization wishes to attain may be difficult to reach. Money and generating revenue is also the bottom line in several business. This is becoming more common in the world of public health as we're seeing more public health organizations using business techiniques to reach their missions.
Some of the issues people may have with this relates to 'selling out'. Public health is supposed to serve everyone, the undeserved, those who cannot afford private healthcare. We're also supposed to reach more people with prevention and awareness messages/programs. People may have issues with obtaining sponsorship with private organizations and with generating revenue.
At the same time, if your public health organization isn't able to provide the service, reach the target audience, or obtain outcomes because of lack of funds, then you're not really able to serve the public.
I think intermingling the business world and public health missions is needed to continue operating and growing public health services. You can still meet your mission and perhaps even better if your organization is creative in the way it provides the service. Our organization is finding the business plan very useful in marrying the two worlds.
Many of us in clinical practice have chosen a career in the field of public health out of a concern for those individuals who have difficulty advocating for themselves to obtain quality health care. The satisfaction we have gotten from providing needed health care for the less fortunate and the appreciation they have expressed has made the transition to more business-like practices uncomfortable at times. However, I think most of us in public health know that the time has come for us to think more like a business. For instance, the awareness that business has for its competition tends to result in higher efficiency, quality customer service and a higher quality product. However, business also has a reputation for being "all about the bottom line". I would hate to see public health abandon our traditional priority, the health of the public, for a greater concern for our bottom line.
Among the best characteristics of good businesses: a clear understanding of their market and the need/desire they fill (their "niche"); a strategic plan that includes measureable goals, timelines and a QI feedback loop; and a keen eye on the bottom line. Among the worst: such a focus on the bottom line that the "niche" is sacrificed if the profit margin for that "business line" isn't large enough. Reminds me of something one of my accounting teachers used to say: "Regardless of what the company's published mission/vision/values statements are, their REAL ethical document is their budget."
My experience has been that good business principles can easily be applied to public health work. In general, those principles are the same ones that make any endeavor a success: know where you're headed and why, figure out how you're going to get there, measure whether or not you got there, repeat as needed.
Where I feel the struggle is not with those ideas, but with the reality that the "niche" that public health serves is mandated and largely controlled by a public body/government. It's our job to remain in that "niche" (protecting the general public and/or serving those with the gretest need and the least resources) even when bottom line considerations would suggest that we abandon it.
A few years ago, there was a lot of talk (at least, here in Virgina) about Public-Private Partnerships. These endeavors combined public dollars with corporate and individual contributions to make improvements in the community. I'm seeing MAPH as another variation on that approach. Instead of public health relying only on the hidden form of public/private partnerships - that is, tax dollars from business, which fund our jurisdictions, which fund us - we are learning to create new visions of community AND business partnerships. We're learning the language of business so we can translate "public health speak" into "business speak." The challenge is to find the "sweet spot" where the two can meet successfully.
Mission and purpose, accountability, meeting specific goals and objectives, and being cost-effective are all attributes that both the public and private sector should strive for. It seems to me that some of the differences have to do with different language, rather than with content. I think that public health is still at a very early point in the process of making a business case for preventive activities, and may never make a business case. Does that mean that these activities are not worth doing? No, it means that the questions may be different.
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