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

Business Planning and MAPP

Business planning is indicated for public health organizations that are trying to

1. start new initiatives, that will...
   
2. collaborate with external partners, working together to...
   
3. generate revenue, and ultimately...
   
4. be sustainable (i.e., self-supporting) into the future (e.g., after the grant ends).

Maybe this goes without saying-- but the foundation of a strong business plan is a deep awareness of what the community (or market if you prefer) that you plan to serve actually needs and wants. That's the awareness that processes like MAPP are designed to create.

That's why we are so glad to be working with the Mobilizing for Action through Planning and Partnerships (MAPP) program-- a strategic planning process to help communities understand their community health needs, assets and opportunities, and then take meaningful action on them.

The public health business plan fits in at the "action" phase of MAPP, laying out the details of how a new initiative will work with the various partners, and connecting those details all the way back to specific needs, specific customers, and specific attributes of a community.

I mention all this now because the Management Academy for Public Health is offering scholarships to three MAPP communities this spring-- to come to Chapel Hill for training starting in August. Deadline for applying with your MAPP team is coming up fast, May 15, 2009. In addition to some great management training the team will have the opportunity to develop a business plan with the support of business plan coaches, UNC staff... and a room full of great colleagues from North Carolina and across the country!

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

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

"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

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

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

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