Back in Nebraska

Reflections on my latest trip to Nebraska, where five new teams started writing business plans last week.

•  Nebraska public health folks are really well networked in their communities. These five teams include representatives from the YMCA, school systems, a non-profit doing youth development, multiple hospitals, extension service, a board of health, and a rep from the Chamber of Commerce. 
•  Nebraska communities do a good job on their CHA process as a result of their strong networks, and people involved in Community Health Assessment work (especially partners) are ready to get down to action. For the more action-oriented, it is a huge relief to get down to the specifics of *what we're going to do* in response to the data and the priorities. 
• If you have a good CHA, you are ready to write a business plan. These Nebraska teams clearly have the data they need (or they know where to find it). And they have committed partners - even more committed now than they were before!
• If you spend time driving in Nebraska, you may come to believe that your GPS is broken, because it displays a single straight line in the middle of the screen for long stretches of time. It isn't a malfunction, it's just I-80. 
• Nebraska demographical fact: five cows for every person. North Carolina fact: three turkeys for every person.

Next session: next week in Asheville! I'll be watching for turkeys.

-- Stephen Orton

On The Road in Raleigh

We launched four new teams in Raleigh this week! Here's a quick look at the projects going forward from that group:

• A phone app/game to help drive school culture change
• A revenue-supported plan for delivering quality improvement training
• On-line weight loss and lifestyle change program... already piloted, and it works
• Diabetes Education at the local level, sustained by revenues

A key theme for me at this session is this: Public Health agencies are ready, willing and motivated to find partners and revenue streams to support their work. Gone are the days when we had to convince some teams that it was OK to think about generating revenue... now revenue-generation is seen as an important part of the public health portfolio. That doesn't mean *every* project or function needs to be revenue-supported, because some can't or shouldn't. It does mean that agencies need to have the tools to create business plans when revenue-generation is appropriate and will make a product or service better, more effective, more integrated, more sustainable.

-- Stephen Orton

Management Academy On The Road

Here's a quick update on our Management Academy On The Road program. We completed a pilot in Florida with five counties; we launched a new group in Maryland this spring; two more groups launch this summer. The program is two on-site days, supported by webinars and technical assistance before and after (details on the MAPH website).

Here's a short list of business plan ideas in development across these groups.

• An ER Diversion project with hospitals, public health and the Federally Qualified Health Center
• An "Academic Health Department" plan to allow the county to participate in clinical trials, bringing in revenue and expanding treatment options
• A dental clinic add-on to an existing Ryan White organization
• A free clinic to create a bridge for the uninsured until 2014
• A health coaching project
• A project to combine substance abuse/behavioral health in an integrated organization

What ideas are sitting in your community's health improvement plan? What ideas are bubbling up from your community health assessment or your MAPP process? Can we help you push them to implementation?

--Steve Orton

Business Planning On The Road

Yes, we are piloting a program that provides business planning development to communities where they live. We're starting by targeting MAPP communities at the "Action Cycle" end of their process. (MAPP = Mobilizing Action through Planning and Partnership-- check it out at naccho.org/mapp)

Here's how the program works.

• We consult with you in advance to identify the best ideas to develop business plans around, and then form teams around those ideas.
• We come to your community for a one or two-day session; you convene as many members of your MAPP team as is necessary to get one or two or four business plans started.
• At the end of that session, your team or teams will have a good outline of a feasibility plan completed.
• We meet via webinar or conference call with each team as they develop a full feasibility plan.
• If the plan is in fact feasible, we coach them through the full business plan.

I should clarify what I mean by "team" in this context: I mean a cross-community team. For instance, you might have team members from the health department, the hospital, the other hospital, the United Way, the YMCA, the school system, the community health center, the county-- or all of the above.

We're in the middle stages with several teams in Florida right now, and some of the feasibility plans look really good. Two stand-out plans: adding dental services to an existing HIV clinic, and doing ER diversion with at least two and probably three different hospitals across a county.

The lesson for me is this: communities can develop business plans very quickly and efficiently if they already have a good, fresh assessment in hand, and a wide range of partners queued up and ready to go. That defines the MAPP communities we're working with: motivated partners, good data, identified priorities.

-- Stephen Orton

Success Story: Highland Health Center

Congratulations to our friends in Gaston County NC on their Highland Health Center Grand Opening and Building Dedication last Tuesday, July 27!

A Gaston County team developed the business plan through the Management Academy to plan out how to co-locate health department and health center services. You can read more about the Grand Opening here.

This is a classic example of a public health business plan:

• Starts from health needs
• Identifies a key target market (in this case a specific section of the city)
• Maps out a mutually beneficial alliance (in this case, the health department and the FQHC in the city)
• Shows how the money will flow

Hats off to the whole team, and thanks to Health Director Colleen Bridger for sending them!

--Steve Orton

Recovery Act funds for Public Health

It seems that some public health agencies have access to Recovery Act funds to do specific new things.

The challenge is to figure out how to spend that money in a way that makes a difference during the two years you have it, without losing those gains at the end of the time. One way to approach such an opportunity is to think in terms of start-up funding. Spend the money (time, effort) building something that can then go by itself.

Perhaps in two years you can build something that creates more community health and generates sufficient revenue on its own to support itself through user fees. Perhaps you can build something that generates sufficiently impressive results after two years that you can interest some other funder-- one that values the outcomes you are creating. Perhaps at the end of two years, you operationalize your exit plan: your agency steps back and the program is taken over by an external partner who cares about it and can run it sustainably, with the thanks and blessing of your busy staff!

Outcomes Story, South Carolina

I got a nice email from an alum a couple of weeks ago, Marie Horton from the South Carolina Dept of Health and Environmental Control, DHEC.

We were in the 2001-2002 group. Our project concerned training food establishment staff with the help of a video we produced on food safety. The video was based on our SCDHEC health inspector inspection sheet... The project was a success. I ended up pushing the video through to completion and we had it translated into Spanish and Mandarin a few years ago. The Environmental Health Division has it up on our SCDHEC website, if you want to take a look.

Here's a link to the "food protection" links page at DHEC. Note that DHEC staff partnered with the restaurant association to create and fund this video. This is all by way of background for what comes next:

The Environmental Health Division is working on a new product. They received grant money to produce a food defense video to prevent intentional food contamination. The planning meeting is next week and they have asked me to come and represent our Management Academy team. They want input on our experience in preparing our video.

Just wanted to share that with you. The work lives on!!!!!!!!!

I love the fact that this team implemented their plan. And I love the fact that their experience-- the specifics of what they did and the general lessons about business planning-- continue to bear fruit. Onward and upward!

-- Steve Orton

Business Planning and Flu Epidemics

Like everyone else in the public health community, we have been thinking a lot about swine flu lately. Public health leaders, managers and practitioners are scrambling to plan for what may come.

I recently contact John Dreyzehner, District Director of the Cumberland Plateau Health District in the Virginia Department of Health. Dr. Dreyzehner has sent many teams to the Management Academy over the years. We wrote about some of those in Chapter 7 of the book, “Competitors and Partners,” pages 68 – 69. One of the programs produced by a team from Dr. Dreyzehner’s district was called “Flu’s Clues,” an influenza vaccination program for children ages 3 – 9, based at the local Head Start programs and elementary schools

Steve and I posted back in November (17th and 20th) about “Flu’s Clues.” The program is now in its third year – now called “See you later fluigator” or “Fluigator” for short, with a sick alligator as a mascot, to avoid intellectual property issues. I asked Dr. Drehzehner whether having the program in place was making swine flu preparation any easier. Here are his thoughts:

“[The vaccination program] certainly increases ours and our partners confidence in being able to push out vaccines and treatments. At this point we can do points of distribution/Dispensing (PODs) in our sleep. The challenge at the moment, as is to be expected, is universal agreement on how/if to widely employ the present Tamiflu resource and to do it in a fashion that is consistent with legal equirements and good medical practice.

“There is understanding that we have to target it to the ill for treatment and, some think, their caretakers to begin at the first sign of illness. In one concept of operations I drafted we have accessible PODs open 8-12 hours daily at various location as drive through or walk -up (will spacing to prevent transmission). No ill (but sometimes exposed people) come in and complete and sign a medical attestation form regarding the illness in the person they are responsible for and get a course for that person(s) AND a reserve course for themselves and any other exposed in the household/place exposed to begin with the onset of fever and respiratory symptoms. In this way, the entire population can be assured the treatment is available for use in 12 hours or less to any one at any time. This works as long as this tricky virus remains sensitive. That is the readers digest version of one of my plans. But it is very doable.”

It sounds as if the Cumberland Plateau Health District is ready to do what it needs to do to address this possible epidemic. The challenge is deciding exactly what ought to be done – but it’s good to have the infrastructure in place to do it. They have that infrastructure in place because somebody thought of an idea, they partnered with important community institutions, they wrote a business plan that accounted for funding it, and they implemented it.

Let's hear from some of our readers -- what are you doing about swine flu? What obstacles are you coming up against?

Shovel-ready?

I've been inspired by the term "shovel-ready" in the media reports about the stimulus package. I think that's one of the things we want to foster in public health: organizations that have a set of shovel-ready plans that they would be ready to start quickly.

Maybe some of you have more money than you have ideas-- that's a difficult state of affairs but it can be solved. Innovation is a process you can learn. We've written some about it already.

I'm guessing most of you-- especially now-- don't have lots of extra money to spend. Do you have more ideas than money? Should you?

I think it would be a bad plan to quit brainstorming and quit planning at this point. Because what if someone does offer you some money? What if some stimulus money appears, and needs to be spent in a hurry? What if you wound up with some extra time on your hands, as funding for certain projects dries up?

The answer is this: you will want to have a little folder of "shovel-ready" plans. This is exactly what the business planning structure is about-- getting from the back of the envelope to a fleshed-out, researched, vetted plan with real need, a real chance, a real budget, real partners. A business plan is shovel-ready: ready to get funded and get going.

Let's talk more about developing "shovel-ready" public health ideas-- are you developing plans now? Why or why not? What would constitute shovel-readiness in your organization? Drop me an email or respond here!

--Steve Orton

Industry Analysis and Competitor/Partner Analysis

During a recent webinar, someone raised the question, “What is the difference between industry analysis and analyzing competitors for potential partnerships?” The answer might be worthwhile to share with our larger audience:

When you analyze the industry, you are asking questions about the work you want to do, where you want to do it, how to do it best, and so on. Who else does it (competitors) is part of the analysis, and interviewing them about their experience with the work is an important step, but the questions are broader than that. What types of organizations succeed at doing this, and what exactly did they do that helped them succeed? This last is called a “key success factor” – and it’s very important. One team this year is planning to operate a primary care clinic at the health department. They know it’s needed in their community, mostly by the uninsured, but they’ve learned through their industry analysis that a key success factor for such programs is to include patients who have insurance (but who may not have a primary care doctor) in the mix of clientele. To ensure that they can include this factor in their program, the team is working on the customer service angle of their organization – making the waiting area more welcoming and time-efficient, and making sure that customer service is considered as their organization builds a new facility in the coming months.

Now, making competitors into strategic partners is the next step. Use your industry analysis to figure out what you bring to the table, what you need from your partners, and how you two can most effectively work together, mutually beneficially, to get the job done in a sustainable way. So, you’ve identified you need clientele from a broad range of “ability to pay,” then think about what partners would help you get there. If you only partner with the local hospital, you’ll get all of their uninsured patients and none that can pay. Is there a health network in your area that works to coordinate care for the under-insured poor? Is there a Community Health Center that has trouble keeping providers, or needs a place to send the overflow of patients? Talk to specialists who will take referrals, and private practitioners who will refer to you or work with you to provide care.

This example may not seem exactly like “public health” work, but unfortunately public health providing primary care is a reflection of the current economic times. And ideally, public health brings prevention to the equation, making the whole community healthier over the long haul, than they would be without your participation in primary care.

More to come.

Book Club Webinar 2

We had a book club webinar yesterday to talk with current MAPH students about their progress in terms of industry analysis, community need, competitors and partners, marketing, and project operations. Some of the following issues, thoughts, and suggestions were raised. Do you have any further advice for our community of practice?

Issue: When your community health assessment identifies a problem, but industry analysis reveals a barrier to meeting that problem in a sustainable way.

Example: We have developed an obesity prevention program that will be a summer camp for children. Industry analysis revealed that one success factor is being able to charge enough to pay for the health care and physical education personnel who will work for the program. Alternatively, a success factor is to have a pool of professionals available for volunteer work. We won’t be able to charge enough, so that becomes a barrier for us. We are in a rural county with low income population. We don’t have a large number of professional volunteers to call upon either.

Some ideas: 1) broaden your area of reach. Look to make it a region-wide program rather than just for your county; 2) start smaller; 3) see if insurance will pay, if children are referred by physicians; 4) partner with another group running a summer camp (YMCA?), and be part of their program; 5) charge a sliding-scale fee; 6) consider things that could be offered in-kind to support the program.

Issue: We’ve got a community health assessment telling us exactly what the public should do to be more healthy. How do we communicate with people about the need to change behavior, environment, etc. without insulting or patronizing them?

Thoughts: Public health workforce needs development in social marketing. We need to learn how to talk with people and understand their struggle. We don’t want to send the message – “your neighborhood is run-down and has bad grocery stores and no sidewalks” or, “you are overweight and need to exercise more and eat better” -- because these messages are not going to encourage change. The message of need has to first come from them, and it has to be communicated respectfully. Sometimes public health people are too focused on the big picture and all the problems that need to be solved. We need to step back and give people space, “partner with people,” listen to them and have respect for their understanding of their own community and its strengths and challenges.

Issue: We’ve brainstormed and identified partners who “have what we need,” but they aren’t interested in working with us. It may be the economic times, or it may just be the small relative scale of the project we’re planning, but we can’t make headway getting partners on board.

Suggestions: think of the partnership as more than a one-shot deal, more than just what they can give you: think of it strategically and long-term. If you can, get on their board, or on the board of some other community project they’re involved with. If you are not the appropriate person in your organization to do this, identify the colleague who is appropriate, and try to get him or her involved. This way the potential partner will see the value you bring to the table and may be more apt to consider you a potential partner. Also, try to find out why the potential partner is not interested. Is it a current circumstance, like the economic downturn, or are they truly not interested in the project? If the latter, find out what they are interested in, and come back later with a different plan, closer to their interest. Either way, if you become involved with their organization in some way, they will be able to see the value of working with you.

Issue: We have not really communicated with our superiors about our project since we first were accepted to the Management Academy. Our project has changed a lot since then.

Suggestions: The Management Academy curriculum has begun including very early discussions with business plan advisors, to troubleshoot before teams even begin so that project change may become less of an issue going forward. The risk here is that your project may have changed to the extent that you need some of your colleagues to help you in its operation. If they don’t know what you’re working on, will they be willing to be part of it when the time comes to implement? Another risk is that your boss may not give you the resources or other support you need if he or she feels you have not communicated well. Try to get a standing agenda line at your staff meetings for talking about your Management Academy progress.

Issue: We’re facing budget cuts of 23%, and have been asked to plan for an additional 15% on top of that. All we’re talking about at staff meetings is this reality.

OK, so maybe new programs are not what your staff meetings are about right now. Fair enough. Keep plugging away. Remember we’ve been through rough times before. Remember that broader support for your programs, in the form of partnerships and ample communication with political and other stakeholders, is going to carry you through.

To our readers: Please help our scholars with the issues they have raised! Have you faced similar challenges? What advice do you have? Thanks to all who participated.
-- Anne

The Time is Right...

I was talking with Monecia Thomas, the director of the Management Academy for Public Health, about recruitment for the program. She and the program coordinator, Nancy Cripps, have been working hard contacting teams that have expressed interest and urging them to submit applications. All are due at the end of May, but because it is a competitive process, the earlier the better!

We know that funds are tight right now, but I’m going to lay out a few reasons this is actually the perfect time to come to the Management Academy.

1. The economy may get worse, and the skills you gain at the Management Academy will see you through the rough patches. It will help you manage your people and resources more efficiently and effectively; it will maximize your connection with the larger community of individuals and organizations interested in the public’s health; it will give you the means to bring money in to your organization that is not tied to political or grant makers’ priorities. The external evaluation of our pilot phase indicated that public health agencies had garnered $6 million in revenue from training that had cost $2 million to provide. And that was back in 1999-2002: we’ve had hundreds more students since then, all of whom have written, and many of whom have implemented successful business plans for revenue-generating public health projects. Imagine what the next large evaluation study may show!

2. The political environment is changing. All signs point to a greater willingness of the new administration to put federal monies towards health care and public health priorities in the coming years. Already Congress and President-Elect Obama are preparing to renew the bill that provides health insurance for low-income children. Also, insurance for legal immigrants under 21 may be added back into the bill, after having been cut more than a decade ago. As public health managers, you can be at the forefront of this new era. Expertise in building strategic partnerships, managing data to make the best case for your priorities, and managing money to support shifting emphases will all help you.

3. The workforce is changing. It has to: we must bring in new public health professionals and management to fill the void that will be created as today’s public health workforce retires. How better to groom that promising middle manager for a leadership role than to teach him or her strategies for managing money, people, and information? Do they know how to delegate tasks? Do they know how to read a budget? Do they know how best to communicate in written work or oral presentations?

Public Health Business Planning: A Practical Guide is about one small part of the Management Academy for Public Health. Call Nancy Cripps at (919) 966-2248 or Monecia Thomas at (919)843-8541 to learn more about the rest of the program.

-- Anne Menkens

Big Hairy ATTAINABLE Goals

Making New Years resolutions is not all bad. If you take Steve’s words of advice and make your resolutions positive statements with a clear mission, and break them down into concrete things you can do to reach that mission, a resolution to succeed could be the ticket to success.

In Chapter 1 of the book (pg. 11 to be exact), we list a few examples of initiatives that started out as Management Academy business plans. Here are some of the New Years resolutions that might have been the germs for those plans:

• Deal with mental health issues in our community
• Bring private practice behavioral health providers into the orbit of the public health department
• Increase positive results for low-income, at-risk pregnant women
• Decrease Medicaid costs for treatment of at-risk pregnant women
• Provide training options for public health workforce development in Wisconsin
• Increase physical activity in our community’s children
• Help the family members of HIV-positive patients to get health care services
• Improve waste water treatment in rural Virginia

Notice a few things:

• Each of these resolutions is a positive statement of a concrete (not abstract) goal
• Each resolution is a reasonable goal for a public health organization
• Each resolution is easily broken down into specific objectives, tasks, plans
  

When we talk about BHAGs, the A stands for Audacious, but it could also stand for Attainable. Audacious is better, because it gets your attention, and it forces you to say WHAT should be done and WHY, without worrying too early about the WHO or HOW. But Attainable should be your next thought: WHO’s going to do it? HOW will they do it? And answer positively, as if the sky’s the limit, but stay concrete. WHO will do it? The 10 new people we’re going to hire. HOW will we hire them? By partnering with these potential stakeholders…. WHEN? Maybe not today, but by this particular date, if we do these particular things.

So don’t stop making resolutions. Just keep it real, as they say. And don't wait for January 1.

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

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

"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

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.

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

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

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