A Limited Management Review of the Department of Health
Executive Summary
Introduction
The PEER Committee conducted this review in response to a citizen’s complaint alleging that management decisions of the current State Health Officer, who assumed the office in October 2002, have negatively impacted the department’s operations.
Background
Definition of Public Health
The Future of Public Health1 defines public health as “what society does collectively to assure the conditions in which people can be healthy.” The health of a community is a shared responsibility of many entities, organizations, and interests in the community, including health service delivery organizations, public health agencies (including state departments of public health), other public and private entities, and the people of a community.
The U. S. Public Health Service’s 1994 Essential Public Health Services Working Group of the Core Public Health Functions Steering Committee identified the following core functions of public health:
The Mississippi Board of Health: Powers, Duties, and Responsibilities
MISS. CODE ANN. §41-3-1 (1972) specifies the composition of the Mississippi Board of Health and Section 41-3-15 authorizes the board to establish programs to promote public health and to mitigate threats to public health in Mississippi. Subsection (4) (m) of that CODE section authorizes the Board of Health to employ, subject to the regulations of the State Personnel Board, qualified professional personnel in the subject matter or fields of each bureau and other technical and clerical staff as may be required for the operation of the department.
MISS. CODE ANN. §41-3-5 (1972) authorizes the Board of Health to elect an executive officer (the State Health Officer) to a six-year term of office. The State Health Officer must be a physician with a graduate degree in public health or health care administration, or a physician the board believes to be fitted and equipped to execute the statutory duties of the position. The board selected the current State Health Officer, Dr. Brian Amy, at its meeting on May 17, 2002. He began his term of office in October 2002.
Subsection (2)(a) of MISS. CODE ANN. §41-3-43 (1972) authorizes the Board of Health to create public health districts of two or more counties for the purpose of administering health programs and supervising public health workers in the district. The statute directs the board or its executive officer to appoint for each such district a district director who must be a licensed physician well trained in public health work and who works full-time for the district.
Conclusions
Multiple Organizational Changes Since October 2002
Within a period of twenty-three months, the Department of Health implemented four organizational changes in the structure of the department, at least two of which were major revisions in the structure of the organization. Making this number of organizational changes within such a short period precludes departmental personnel from developing the working relationships necessary to accomplish the organization’s mission.
Prior to October 2002, the organizational structure at the Department of Health had been in place for at least six years. Since the current State Health Officer began his term of office in October 2002, the department has experienced at least four organizational changes. (See Appendix D, page 45 of the report, for details on the specifics of the organizational changes and Appendix E, page 51 of the report, for copies of the organization charts for each of the organizational changes.) The primary changes to the organizational structure were in the number and composition of offices created to carry out programs and in the creation of offices to emphasize specific support functions such as internal evaluation/quality assurance, planning, and budgeting.
During this period of frequent organizational change, the department’s staff hardly had time to adjust to one organizational change before another took its place. The result was confusion among the staff members, including several key staff members expected to implement the changes, concerning their roles and responsibilities and the reasons for the changes.
Failure to Obtain Formal Board Approval or to Consult Several Key Staff Prior to Organizational Changes
When making the organizational changes, the Department of Health’s management team did not obtain formal approval of the Board of Health for the organizational change plans, which is required by state law, nor did they consult with many of the key staff members who would be responsible for implementing the changes.
Although MISS. CODE ANN. Section 41-3-15 (1) (1972) states that the Department of Health’s staff organization is subject to the approval of the Board of Health, the official minutes of the board for the last four years do not reflect that the board reviewed or formally approved any of the organizational change plans prior to their submission to the State Personnel Board for approval. By failing to obtain the Board of Health’s formal approval prior to implementing the changes, the department has failed to comply with the law and has denied the board the opportunity to exercise its responsibility for overseeing and administering organizational changes at the department.
Also, prior to implementing the organizational changes, the Department of Health’s management team did not consult with some of the staff members who would be responsible for implementing the changes. The effect of this situation is that staff members may not have the same understanding of the changes, do not understand how the changes promote the objectives of the department, and see some of the changes as a hindrance rather than a help to improving program quality and efficiency.
Restriction of Internal and External Communications
The Department of Health’s management team has changed the channels of communication for staff members without clearly stating the intent of or goal for the changes and without documenting the desired communication procedures in formal, written policies or staff memoranda. The management team has also restricted traditional professional channels of communication and relationships with external information sources and with public health providers, a situation that could affect the staff’s ability to promote and protect public health.
Since October 2002, the department’s management team has changed its philosophy regarding professional communication between and among managers and staff at every organizational level of the department and between the department’s staff, citizens, and health care providers. The management team has restricted traditional professional channels of communication and relationships with external information sources. These changes in the department’s internal and external communication patterns have been identified, described, and confirmed in similar, consistent ways by program staff at every level of the department.
PEER found that:
Focus groups of field and central office staff members reported to a consultant that communication at the department was a major issue for concern. The consultant was studying ways to enhance service at all levels of the Department of Health.
County Planning and Budgeting Model Not Used for Resource Allocation or Performance Measurement
The department’s Chief Science Officer developed the county planning and budgeting model to be used for planning and policy formulation, as well as resource allocation. However, the Chief Science Officer resigned before the model was made functional in terms of planning health services for counties or allocating resources for the delivery of health services.
The Chief Science Officer developed the county planning and budgeting model in 2003. The department identified twenty indicators of a county’s “health capacity,” then weighted each indicator based on its “importance for transforming public health status.” Although the department has placed an interactive version of the model on its website that allows the public to change indicator values to test their impact on a county’s public health standing, the model is not linked to any program or source to be used for planning or allocating resources. According to MSDH staff, although the model exists, the department does not use it for planning health services for counties or allocating resources for the delivery of health services. Thus the department lost an opportunity and has wasted the resources devoted to the model’s development.
Fewer Accountability Controls
Since October 2002, the Department of Health has reduced its accountability controls over programs and services by eliminating its Bureau of Service Quality and by not implementing its Internal Management System.
The Department of Health’s Bureau of Service Quality, charged with some of the quality assurance functions formerly performed by the Office of Field Services, was eliminated during the department’s recent organizational changes. The Internal Management System, set forth in the department’s FY 2004 five-year strategic plan, incorporates a process to monitor program service delivery at the county and district level. However, the agency is not carrying out this process.
The loss of these two accountability measures has left the agency without a specialized central office staff that can make unbiased assessments and recommendations on the agency’s efforts in achieving program goals. This leaves the evaluation of programs to those who are directly involved in administering them.
Unsuccessful Implementation of Quality Improvement Efforts
Due to implementation problems, the Department of Health’s recent efforts at improving the quality of its programs and decisions have not been successful, resulting in wasted staff resources and employee frustration.
Since assuming office in October 2002, the focus of the State Health Officer has been on improving the quality of the department’s programs and decisions. While these are laudable objectives, the current management team has been unable to achieve the desired improvement, in large part because of implementation problems similar to those encountered with the organizational changes.
Specifically, the MSDH management team imposed utilization of performance improvement tools (e.g., the Performance Measures Action Plan and a pilot program utilizing ISO 9000) on the department’s staff with unrealistic time frames for achievement and under the threat of termination for failure to achieve performance improvement targets. As a result of the abandonment of efforts without results, the resources devoted to their development have been wasted and employees are frustrated with the frequent initiation and then abandonment of the efforts.
Loss of Public Health Experience and Knowledge
The epidemiology function, recognized as one of the core functions of public health, has lost much of its public health knowledge base and experience due to a reduction in the number of staff positions, departure of experienced employees, and changes in the communication flow between the central office and field staff. Also, the loss of other experienced and key departmental staff has compromised the department’s ability to deliver services and improve performance.
The Epidemiology function and the public health districts are important components of the Department of Health’s service delivery structure. Controlling disease through epidemiology is a core function of public health and the public health districts are “front-line” contacts with the state’s citizens.
PEER found that the Department of Health has lost much of its experience and knowledge base in the Office of Epidemiology. In July 2002, the Epidemiology Office had thirty authorized and twelve filled positions. As of July 1, 2004, the office had ten authorized and six filled positions.
Due to the departure of experienced employees, including the State Epidemiologist, the Epidemiology staff has lost much of its institutional memory and the capacity to respond to health care practitioners both inside and outside the department. The department has also lost a Deputy State Health Officer with twenty-six years of departmental experience, the Chief Science Officer, the Director of the Office of Evaluation, and the State Epidemiologist, as well as several central office nurses with responsibilities for oversight of field staff.
Contrary to requirements of state law, the State Health Officer has made district administrators, who are not licensed physicians, responsible for directing public health programs at the district level and has relegated district health officers to the role of medical consultants.
MISS. CODE ANN. Section 41-3-43 (1972) requires the Board of Health or State Health Officer to appoint for each public health district “a district director, who shall be a licensed physician, well trained in public health work, who shall give his entire time to the work.” However, beginning in 2002 and continuing into 2003, the Department of Health’s management team changed the role of the district health officers from district directors to that of medical consultants, placing the district administrators, who are not licensed physicians, into the position of district director in violation of state law.
The effect of these restrictions on the role of the district health officers is that they may be constrained in their ability to protect public health.
Recommendations
In the event that the board approves future reorganizations of the department, it should make clear to the State Health Officer and his management team that reorganizations should not be modified or overturned until such time as the board can assess the reorganization for its achievement of the agency’s goals.
If the Department of Health’s management team wants to request a change in the requirements of MISS. CODE ANN. Section 41-3-43 (1972) regarding the district health officers’ duties and responsibilities, the management team should present written evidence of need for the change to the appropriate legislative committees for debate and consideration. Unless and until the Legislature changes these requirements, the department should comply with the law regarding this issue.