TRANSFORMINGPUBLIC HEALTH

PRACTICE

TRANSFORMINGPUBLIC HEALTH

PRACTICELeadership and

Management Essentials

BERNARD J. HEALEYCHERYLL D. LESNESKI

Copyright © 2011 by John Wiley & Sons, Inc. All rights reserved.

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Library of Congress Cataloging-in-Publication Data

Healey, Bernard J., 1947–Transforming public health practice : leadership and management essentials / Bernard J. Healey,

Cheryll D. Lesneski.—1st ed.p. cm.

Includes bibliographical references and index.ISBN 978-0-470-50895-4 (pbk.); 978-1-118-08993-4 (ebk.); 978-1-118-08994-1 (ebk.);

978-1-118-08995-8 (ebk.)1. Public health administration. I. Lesneski, Cheryll D., 1949– II. Title.RA425H383 2011362.1–dc23

2011021315

Printed in the United States of AmericaFIRST EDITION

PB Printing 10 9 8 7 6 5 4 3 2 1

C O N T E N T S

Introduction xiii

Acknowledgments xvii

The Authors xix

The Contributors xxi

Part One Issues and Methods of Public Health Practice

1 The Need for Change in the Practice of Public Health 3

Mission and Services of Public Health 3

Public Health’s History and Its Impact on Current Services 10

Gap Between Mission and Current Public Health Practice 13

2 The Success of Public Health Programs: Critical Factors 27

Definition of Public Health 30

Public Health Systems 31

Community Health Workers 34

Population-Based Medicine 36

Problems in Our Health Care System 36

The Need for Improved Accountability of Public Health Professionals 39

Local Health Departments 39

Epidemic of Chronic Diseases 42

Information Management 44

Expansion of Health Education Programs 45

Public Health and the Legacy Concept 46

The Need for Leadership Development in Public Health 48

vi CONTENTS

3 Critical Issues for the Future of Health Carein the United States 53

Why We Are Failing in Our Health Care Reform Efforts 57

Root Causes of the Failures of the Health Care System 60

Other Problem Areas 68

Solution to the Problems in Our Health Care System 70

New Model of Health Care Delivery 72

Public Health as a Potential Solution to the Health Care Crisis in America 75

4 Application of Epidemiological Conceptsto Health Care Delivery 81

Descriptive Epidemiology 83

Epidemiology of Communicable Diseases 89

Epidemiology of Emerging Infections 91

Analytical Epidemiology 92

Epidemiology and the Centers for Disease Control and Prevention 95

Data Management 95

Surveillance Systems 97

Managerial Epidemiology 99

Application of Epidemiological Concepts to Health Care 101

5 Shifting the Focus from Communicableto Chronic Diseases 105

Communicable Disease Threat 108

The Challenge of Chronic Diseases 111

The Need for Investment in Preventing Chronic Diseases 114

Health Education 116

The Need for Partnerships to Combat Chronic Diseases 118

Opportunity to Improve the Way Health Care Is Delivered 121

Part Two Issues and Methods of Public Health Leadershipand Management

6 Leadership and Politics in Public Health 129

Development of Power in Health Care Delivery 130

Leadership and Politics in Health Care Delivery 134

CONTENTS vii

Public Health Leadership Styles 137

Transformational Leadership and Public Health 140

Public Health as a Change Agent 142

Public Health Leaders and Power 143

Public Health Leaders and Conflict Management 145

Can Political Appointees Lead Public Health Departments? 146

Communication Skills of the Leader 147

Leadership Development in Public Health 148

Culture of Public Health Workers 150

Public Health Leaders and Innovation 153

7 Empowering Public Health Workers 159

Leadership and Quality Improvement 161

The Public Health Employee 164

Transformational Leadership, Worker Empowerment, and Self-ManagedWork Teams in Public Health 165

The Role of Culture 166

Culture and Change 169

Empowerment of Workers in Public Health 173

Disappearance of the Public Health Worker 176

8 Partnerships to Improve the Public’s Health 179

Public Health Partners 179

Value of Partnerships for Public Health Organizations 181

Building Community-Wide Partnerships Using an Ecological Model ofHealth 183

Successful Partnerships 189

Assessing the Role of Partnerships in Improving Community Health 190

9 Leading and Managing Change in Public HealthOrganizations 193

Public Health and the Urgent Need for Change 193

Challenges Facing Local Public Health Leaders 194

Millennium Development Goals 195

Urgent Need for System Change 196

Visioning the New Public Health 200

Leadership for the New Public Health 201

viii CONTENTS

Changing the Public Health System for the Future 206

Managing Change 207

10 Developing an Outcomes Orientation in PublicHealth Organizations 213

Quality Nexus of Public Health and Health Care 214

Focusing on Core Functions and Essential Public Health Services 216

Current Quality Improvement Efforts in Public Health Organizations 223

Gaps in the Quality of Public Health Services 226

Federal Leadership of Quality Improvement in Public Health 227

Road Map to Improve Public Health Outcomes 233

11 Opportunities for Improvement in PublicHealth Practice 239

Disruption and Change in Public Health 242

Public Health Education and Health Promotion Programs 244

The Need for a Chronic Care Model 247

Minimal Political Appreciation of Public Health Activities 248

Use of Technology in Risk Communication 250

Public Health Leadership Required 252

Value of Prevention Programs 254

The Process of Innovation 259

12 Local Solutions to Reduce Inequities in Healthand Safety 263Larry Cohen, Anthony Iton, Rachel Davis, Sharon Murriguez

13 Challenges in the New World of PublicHealth Practice 299

Determinants of Health 300

Obesity Epidemic 302

Climate Change 305

War and Armed Conflicts 309

CONTENTS ix

Case Studies

Case Study 1 Innovation in Health Education Programs 315

Case Study 2 Disabilities 321Jill D. Morrow-Gorton

Case Study 3 Formation of Community Partnerships toPrepare for H1N1 327Marc C. Marchese

Case Study 4 Municipal Health Department LeadershipInside Out 331Ted Kross

Case Study 5 The Power of Data: Osceola County Secures aFederally Qualified Health Center 337Julia Joh Elligers

Case Study 6 Using MAPP to Get Up & Go! in St. ClairCounty 341Lisa Jacobs

Case Study 7 Partnering for Improved Infant Healthin Stanislaus County 345Lisa Jacobs

Case Study 8 Innovation in Colorectal Cancer EducationPrograms 349

References 355

Index 375

To Kathy, my wife of forty years, my two wonderful children,Alison and Bryan, and my two-year-old grandson, John.

Bernard J. Healey

To the memory of my parents, Melton Harold and Clara Eva Smith,for their wonderful love and support for me throughout

our lives together.

Cheryll D. Lesneski

I N T R O D U C T I O N

IN THE EARLY YEARS of the last century the life expectancy of most Americanswas approximately forty-five years of age. The length of life has increased formen and women in this country by over thirty years since then. A large portion

of this longevity is the direct result of public health activities associated withimmunizations, health education programs, and various prevention programsdeveloped by state and local public health departments. This represents a successstory for public health in the United States.

The activities of public health departments, which focus on the preventionof health problems before they occur, make up one of the most importantcomponents for achieving better population health in every community in theUnited States. If we are ever to improve the health of the population, thereis a very real need for public health interventions within every communitypopulation. This will not happen until the public health system’s infrastructureis rebuilt, an endeavor that must include leadership training for those placed incharge of this area of health care services delivery in our country.

Improvement of the Health of the Population

When we think about the U.S. health care system, the process of curingand treating diseases is usually the only idea that pervades our thought process.Turnock (2009) points out that activities dedicated to maintaining and promotinghealth are not usually considered health services by our current medical caresystem, which has always left the prevention and promotion of health to publichealth agencies primarily funded by the government. Over time, however, theinterest in and funding for these public health activities have been reduced, andit seems that public health activities only become visible in times of crisis.

According to Mays et al. (2004), the public health system in the UnitedStates has been receiving growing attention because of emerging health dangers,trends in health policy, and developments in the health care marketplace. In

xiv INTRODUCTION

recent years, primarily due to threats of bioterrorism, the epidemic of obesity,and type 2 diabetes, a great deal of attention has been given to the role ofprevention in our health care system. The new health care reform bill, signed byPresident Obama in April 2010, mentions the need to prevent chronic diseasesand their complications. Prevention is the major responsibility of public healthdepartments, so a great deal of attention has recently been given to the potentialrole of public health as our health care system is being reformed.

According to the April 2010 issue of the Nation’s Health (‘‘Q&A withSurgeon General Benjamin’’), the eighteenth surgeon general of the UnitedStates, Regina Benjamin, wants to ‘‘transform our sick care system into awellness system.’’ Benjamin believes that although the public health system isthe cornerstone of the U.S. population’s health, it has not received the resourcesthat it deserves. She advocates reversing this trend, pointing out that Congresshas appropriated $1 billion for prevention and wellness programs as part of theAmerican Recovery and Reinvestment Act. This money will be used to increasethe number of public health workers and continue the expansion of preventionand wellness efforts in U.S. communities.

The increase in life expectancy in the United States can in large partbe directly attributed to the many public health accomplishments that weremade possible by dedicated workers. Work directed toward reduction of tobaccouse, efforts to encourage better nutrition and more physical activity, properimmunizations, and health education programs are just a few of the services thatpublic health departments developed and implemented during the last twentyyears. These accomplishments in the area of preventive health care occurreddespite the depleted public health infrastructure.

Chronic diseases—such as heart disease, cancer, and diabetes—are theleading causes of death and disability in the United States. As the burdenof chronic diseases in the United States continues to increase, public healthdepartments should make greater efforts to identify and implement interventionsthat successfully reduce disease risk, especially in the workplace. According to theFlorida Department of Health (2011), these diseases account for seven of everyten deaths and affect the quality of life of ninety million Americans. Althoughchronic diseases are among the most common and costly health problems,however, they are also among the most preventable.

The public health challenge has moved way beyond defeating organisms thatcause communicable diseases and into the new world of preventing communitypopulations from developing chronic diseases that cannot be cured. Thesechronic diseases are caused by high-risk health behaviors that result from lifestylechoices that can be changed. Altering lifestyle behaviors may very well serve toincrease longevity as well as quality of life in older years. In order to meet this

INTRODUCTION xv

challenge, public health departments need strong leadership and empoweredfollowership to unite the community.

Opportunities for Public Health Departments

The primary role of public health is to prevent illness or disease from ever occur-ring. Because practitioners in this field prevent things from happening, publichealth has never been given the respect that it deserves—we are often unableto understand the value of something that did not happen. Because most ofmedical care encompasses very visible efforts to cure disease, most of the creditfor medicine success usually is reserved for the medical care system. This is unfor-tunate because the increase in the length of life since the early 1900s resulted fromsuch public health services as immunizations and health education programs.

Hemenway (2010) argues that public health is constantly underfunded dueto the fact that the benefits of public health activities usually show visible resultsin the future rather than the present. Unfortunately, most people do not seekmedical care until they have become very ill, whereas public health is performingits magic before illness occurs. This is the main reason why the leaders of publichealth departments need to spend more time communicating what they do andwhy they do it. Public health has always been one of the best-kept secrets of ourhealth care system. It is time for public health leaders to spend less of their timefighting undeserved budget cuts and more time publicizing their success stories.It is time to raise public health to the stature that it has earned with its varioustriumphs over the years.

Health care services delivery in this country is undergoing rapid changein structure, process, and required outcomes. The recently enacted health carereform bill has included $500 million a year to be allocated to ‘‘comparativeeffectiveness research,’’ which is designed to reduce the cost of health care byrequiring the health care system to become more efficient in its use of resources.It is becoming the norm to compare various treatment options in order toascertain the least expensive method of producing the required outcome withoutsacrificing quality. It is indeed a time of change for the delivery of health care inthe United States.

This change will also produce great opportunities for the improvementof Americans’ health, as the nation slowly begins to realize the necessity ofpreventing very expensive health problems from occurring in the first place. Thisreform in our health care system is producing a great opportunity for public healthdepartments to increase their relevancy in the delivery of health care services tomillions of Americans. According to Beerel (2009), relevancy is engaged power

xvi INTRODUCTION

that can be used to achieve goals. This is clearly the opportunity that has presenteditself to public health departments in our country. Americans are starting to realizethe relevancy of population-based medicine, health promotion, and diseaseprevention—especially in relation to the current epidemic of chronic diseases.

Even though they have high costs at the start, chronic disease and injuryprevention programs do very well when cost-benefit analysis is applied to theoutcomes associated with their implementation. Public health departments needto expand their success with identifying the causes of chronic diseases into aneffort to prevent the occurrence of these diseases or, at the very least, to postponethe onset of their complications until later in life.

We wrote this book in order to discuss the need for new skill developmentfor our public health workforce, leadership training for those responsible forpublic health programs, along with empowerment of public health employees toexpand prevention efforts for the population. Among the skills that public healthworkers require are change management and conflict management techniques,culture-building abilities, quality improvement skills, communication skills, andteam-building and collaboration skills.

There is no question that developing a strong public health infrastructureis one of the most important things we can do to improve the health of ourpopulation. It is also critical to note that this infrastructure needs strong leadersdedicated to the achievement of public health goals, which must focus on pursuingoutcomes rather than activities that are not producing measurable results. Thisis going to require profound change in the way public health departments areorganized and led.

A C K N O W L E D G M E N T S

WE WOULD LIKE to begin by acknowledging the dedicated people whowork in public health and who, despite limited resources, have accom-plished so much in making the United States a better place to lead a

healthy life. This is really a book about how to help public health departmentsachieve even greater success stories in the future through better leadership. Thosewho work in public health departments throughout this country have so muchmore to contribute if only allowed to do their work. This can only be accomplishedthrough leadership, worker empowerment, and increased resources.

During the process of writing this book we met many dedicated people whodemanded professionalism in everything they tried to accomplish. A numberof individuals, to whom we are truly indebted, helped us with the writing ofparticular chapters. They are the wonderful individuals who work at PreventionInstitute, a nonprofit national center dedicated to improving community healthand equity through effective primary prevention: Larry Cohen, Rachel Davis,Anthony Iton, and Sharon Murriguez.

A number of additional individuals contributed case studies in public health,including Julia Joh Elligers and Lisa Jacobs from the National Associationof County and City Health Officials; Ted Kross from the Wilkes-Barre CityHealth Department; Jill D. Morrow-Gorton, who is a developmental pedia-trician serving as the medical director of the Office of Developmental Programsin the Commonwealth of Pennsylvania’s Department of Public Welfare; andMarc C. Marchese, a professor at King’s College in Wilkes-Barre, Pennsylvania.

Three more individuals to whom we are truly indebted helped us with thereview of this new public health text. They are Celeste Torio, Michele Shadeand Helda Pinzon Perez. They helped us sharpen our ideas to make this book amuch better addition to the literature concerning public health practice.

During the entire research and writing process for this book we were sur-rounded by intelligent, caring individuals who cared only about making our ideasbetter. We are very fortunate individuals to have had the opportunity to write abook for a national publisher, but we are equally fortunate to have been able towork with such talent.

T H E A U T H O R S

Bernard J. Healey is a professor of health care administration at King’sCollege in Wilkes-Barre, Pennsylvania, and is currently the director of the King’sCollege graduate program in health care administration. He began his career in1971 as an epidemiologist for the Pennsylvania Department of Health, retiringfrom that position in 1995. During his tenure with the government he completedadvanced degrees in business administration and public administration, and in1990 he finished his doctoral work at the University of Pennsylvania. Dr. Healeyhas been teaching undergraduate and graduate courses in business, public health,and health care administration at several colleges since 1974.

Dr. Healey has published over one hundred articles about public health,health policy, leadership, marketing, and health care partnerships. He has alsowritten and published two books, one about health promotion and one aboutoccupational safety and health in public health practice.

Dr. Healey is a member of the American Association of Public Health andthe Association of University Programs in Health Care Administration. He is alsoa part-time consultant in epidemiology for the Wilkes-Barre City Health Depart-ment and a consultant for numerous public health projects in Pennsylvania.

Cheryll D. Lesneski teaches courses in public health practice and communityhealth improvement as an assistant professor in the Public Health LeadershipProgram at the University of North Carolina at Chapel Hill’s Gillings Schoolof Global Public Health. She also works for the U.S. Department of Healthand Human Services, promoting sound financial management of public healthorganizations within a continuous quality improvement framework. In 2005 Dr.Lesneski received a doctorate in public health in the Department of HealthPolicy and Administration at the Gillings School. Her dissertation, DevelopingPerformance Measurement Systems for Local Public Health Agencies Using theBalanced Scorecard, was published by VDM in 2009. Dr. Lesneski has beena public health practitioner for over twenty years, serving as a local public

xx THE AUTHORS

health agency director for ten years in the Florida Department of Health. Shecontinues to work with the Florida Department of Health to promote continuousquality improvement techniques in learning collaborative settings. Dr. Lesneskialso served as an improvement adviser and evaluator with the North CarolinaCenter for Children’s Healthcare Improvement and the National Initiative forChildren’s Healthcare Quality.

T H E C O N T R I B U T O R S

Larry Cohen MSW, is founder and executive director of Prevention Institute,a nonprofit national center dedicated to improving community health and equitythrough effective primary prevention—taking action to build resilience and toprevent illness and injury before they occur. With an emphasis on health equity,Mr. Cohen has led many successful public health efforts at the local, state,and federal levels concerning injury and violence prevention, mental health,transportation and health, and chronic disease prevention as it relates to dietand physical activity. Mr. Cohen has advanced a deeper understanding of howsocial determinants shape health outcomes, and Prevention Institute providesresources, conceptual frameworks, and tools to help communities address theunderlying causes of health inequities. Prevention Institute has also successfullyled state and national efforts to incorporate a focus on and investment in primaryprevention as a significant part of health care reform and stimulus funding forcommunities.

Rachel Davis MSW, is managing director at Prevention Institute. Mrs. Davisoversees Prevention Institute’s work in the areas of health equity, communityhealth, violence prevention, mental health, and children and youth. She developstools for advancing primary prevention, provides consulting and training forvarious community and government organizations, and advances the conceptualwork of the organization. With funding from the federal Office of MinorityHealth (OMH), Mrs. Davis developed and piloted THRIVE (Tool for Healthand Resilience in Vulnerable Environments), a community resilience assessmenttool that helps communities bolster factors that will improve health outcomesand reduce disparities experienced by racial and ethnic minorities. An articlewritten by Mrs. Davis on the tool and its initial pilot testing was published in theAmerican Journal of Public Health. She is currently overseeing an OMH-fundedproject to disseminate THRIVE.

xxii THE CONTRIBUTORS

Anthony Iton MD, JD, MPH, was in October 2009 appointed as seniorvice president of healthy communities at The California Endowment. Prior tohis appointment, Dr. Iton served from 2003 as both the director and countyhealth officer for the Alameda County Public Health Department. In that role heoversaw the creation of an innovative public health practice designed to eliminatehealth disparities by tackling the root causes of poor health that limit quality of lifeand life span in many of California’s low-income communities. Dr. Iton, who hasbeen published in numerous public health and medical publications, is a regularpublic health lecturer and keynote speaker at conferences across the nation.He earned his BS in neurophysiology, with honors, from McGill University, inMontreal, Quebec; his JD and MPH at the University of California, Berkeley;and his MD from Johns Hopkins University School of Medicine. Dr. Iton hasserved on the Board of Directors of Prevention Institute.

Lisa M. Jacobs is currently a full-time MSW candidate at the University ofPennsylvania in Philadelphia. Prior to beginning her graduate studies, Ms. Jacobsserved as the Mobilizing for Action through Planning and Partnerships (MAPP)Program Associate at the National Association of County and City HealthOfficials (NACCHO) in Washington DC. As program associate, Ms. Jacobs sup-ported the MAPP program and National Public Health Performance StandardsProgram (NPHPSP) by developing and posting Web content, communicatingwith local health department staff in regard to MAPP and NPHPSP activities,developing fact sheets and guidance documents, and planning and cofacilitat-ing MAPP trainings in communities throughout the United States. While atNACCHO, Ms. Jacobs also served as a member of several organization-wideinitiatives including the Health Equity and Social Justice Team. Prior to joiningNACCHO, Ms. Jacobs participated in the National Women’s Health Network’sHelen Rodriguez-Trias Women’s Health Leadership Internship. Ms. Jacobsreceived her BA from Scripps College of the Claremont Colleges Consortium inClaremont, California.

Julia Joh Elligers, MPH, is a senior analyst at NACCHO. She providestechnical assistance and training to local communities, implementing a strategicplanning process for community health improvement called Mobilizing for Actionthrough Planning and Partnerships (MAPP). She also provides assistance tocommunities using the National Public Health Performance Standards (NPHPS);NPHPS helps local public health systems assess their capacity to deliver the tenessential public health services.

THE CONTRIBUTORS xxiii

Ted Kross is director of the Wilkes-Barre City Health Department. Hegraduated from Pittston Hospital School of Nursing (as a registered nurse witha diploma in nursing) in spring 1982. He was hired as a staff nurse at the NPWMedical Center in 1982 with an interest in critical care nursing. He began workingin emergency medicine in 1983 and continued in various leadership positions atseveral different institutions through 2008. In 1995 he graduated from King’sCollege in Wilkes-Barre, Pennsylvania, with a BS in health care administration(HCA), and he continued in school at King’s College and graduated with honorsin 2005 with an MS in HCA. He managed the emergency department from 1997through 2007 at Geisinger Wyoming Valley Medical Center in Wilkes-Barre,and has worked as a prehospital registered nurse (health professional) on life flightinterfacility transfers and emergency medical services (EMS) on several groundadvance life support (ALS) units up to the present. He wanted to expand hisprofessional career and pursued a director position at Calvert Memorial Hospitaljust south of Washington DC in 2007. He has been married to a registered nursefor twenty-three years with four children ages thirteen to twenty.

Marc C. Marchese, PhD, received his doctoral degree in industrial-organizational psychology from Iowa State University in 1992. For the pastseventeen years he has been a faculty member at King’s College in Wilkes-Barre,Pennsylvania. He is currently a professor of human resources management andhealth care administration. He has also published numerous articles in academicjournals. Some recent examples include ‘‘Tobacco: The Trigger to OtherHigh Risk Health Behaviors’’ in the Academy of Health Care ManagementJournal; ‘‘Mentor and Protege Predictors and Outcomes in a Formal MentoringProgram’’ in the Journal of Vocational Behavior; and ‘‘The Use of MarketingTools to Increase Participation in Worksite Wellness Programs’’ in the Academyof Health Care Management Journal.

Jill D. Morrow-Gorton, MD, MBA, is a developmental pediatrician servingas the medical director of the Office of Developmental Programs in the Common-wealth of Pennsylvania’s Department of Public Welfare. She graduated from theUniversity of Pennsylvania School of Medicine and did her pediatric internshipand residency at Tufts New England Medical Center at the Boston FloatingHospital. She completed a developmental pediatric fellowship at St. Louis Uni-versity at the Knights of Columbus Developmental Center at Cardinal GlennonChildren’s Hospital. She is board certified in both pediatrics and developmentaland behavioral pediatrics. In 2004 she completed an MBA at Lebanon ValleyHospital in Annville, Pennsylvania.

xxiv THE CONTRIBUTORS

Sharon Murriguez (formerly Sharon Rodriquez), BA, worked as a pro-gram assistant at Prevention Institute from 2007 to 2009. While at PreventionInstitute, Mrs. Murriguez focused her efforts on developing training tools andstrategies aimed at eliminating health disparities and promoting health equityand community health. She was instrumental in designing and delivering ahealth disparities training series for grantees of The California Endowment.She also worked on Advancing Public Health Advocacy to Eliminate HealthDisparities, a national effort funded by the Robert Wood Johnson Foundationto strengthen public health capacity through policy. A key component of thiseffort was to develop, pilot, and disseminate a Web-based tool to provide policyand prevention training to assist public health professionals and local electedand appointed officials in eliminating health disparities and improving healthoutcomes within their communities.

TRANSFORMINGPUBLIC HEALTH

PRACTICE

P A R T

ONE

I S S U E S A N D M E T H O D SO F P U B L I C H E A L T H

P R A C T I C E