Improving the Performance of the Los Angeles County Department of Health Services

Metropolitan Service Planning Area Health Office (SPA 4)

SPA 4 VIEWPOINT

IMPROVING THE PERFORMANCE OF THE LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES (DHS)

SPA 4 BEST PRACTICE COLLECTION

RELIABLE INFORMATION FOR EFFECTIVE COMMUNITY HEALTH PLANS, PROGRAMS AND POLICIES

M. RICARDO CALDERÓN, SERIES EDITOR

July 2001

Los Angeles County Department of Health Services • Public Health

At a Glance METROPOLITAN SERVICE PLANNING AREA HEALTH OFFICE (SPA 4)

241 North Figueroa Street, Room 312 Los Angeles, California 90012 (213) 240-8049

The Best Practice Collection is a publication of the Metropolitan Service Planning Area (SPA 4). The opinions expressed herein are those of the editor and writer(s) and do not necessarily reflect the official position or views of the Los Angeles County Department of Health Services (LAC/DHS). Excerpts from this document may be freely reproduced, quoted or translated, in part or in full, acknowledging SPA 4 as the source.

Internet: http://www.lapublichealth.org/SPA 4

LOS ANGELES COUNTY BOARD OF SUPERVISORS

Gloria Molina, First District Yvonne Brathwaite Burke, Second District Zev Yaroslavsky, Third District Don Knabe, Fourth District Michael D. Antonovich, Fifth District DEPARTMENT OF HEALTH SERVICES Fred Lead, Acting Director Jonathan E. Fielding, MD, MPH, MBA. Director of Public Health and County Health Officer

James Haughton, MD, MPH. Medical Director, Public Health

BEST PRACTICE COLLECTION TEAM M. Ricardo Calderón, Series Editor Manuscript Author & SPA 4 Area Health Officer

Carina Lopez, MPH.

The SPA 4 Best Practice Collection fulfills the DHS local level goal to restructure and improve health services by “establishing and effectively disseminating to all concerned stakeholders comprehensive data and information on the health status, health risks, and health care utilization of Angelinos and definable subpopulations”.1 It is a program activity of the SPA 4 Information Dissemination Initiative created with the following goals in mind: To highlight lessons learned regarding the design, implementation, management and evaluation of public health programs To serve as a brief theoretical and practical reference for program planners and managers, community leaders, government officials, community based organizations, health care providers, policy makers and funding agencies regarding health promotion and disease prevention and control To share information and lessons learned in SPA 4 for community health planning purposes including adaptation or replication in other SPA’s, counties or states To advocate a holistic and multidimensional approach to effectively address gaps and disparities in order to improve the health and well-being of populations The SPA 4 Information Dissemination Initiative is an adaptation of the Joint United Nations Program on HIV/AIDS (UNAIDS) Best Practice Collection concept. Topics will normally include the following: 1. SPA 4 Viewpoint: An advocacy document aimed primarily at policy and decision-makers that outlines challenges and problems and proposes options and solutions.

2. SPA 4 Profile: A technical overview of a topic that provides information and data needed by public, private and personal health care providers for program development, implementation and evaluation.

3. SPA 4 Case Study: A detailed real-life example of policies, strategies or projects that provide important lessons learned in restructuring health care delivery systems and/or improving the health and well being of populations.

4. SPA 4 Key Materials: A range of materials designed for educational or training purposes with up-to-date authoritative thinking and know-how on a topic or an example of a best practice.

Project Manager, Information Dissemination Initiative

Visuwat Taweesup Graphic Design

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July 2001

Introduction

The World Health Organization (WHO) carried out an analysis of the world’s health systems and published its findings in The World Health Report 2000. According to this report, the U.S. spends a higher portion of its gross domestic product than any other country but ranks 37 out of 191 countries according to its performance.2 The main message from this report is that “the health and well being of people around the world depend critically on the performance of the health systems that serve them.”2

The U.S. spends a higher portion of its gross domestic product than any other country but ranks 37 out of 191 countries according to its performance.2 The health and well being of people who live in Los Angeles County (LAC) depend upon the performance of the Department of Health Services (DHS), the second largest municipal health system in the U.S. Improving DHS performance will, therefore, enhance the health of LAC residents and the nation as a whole.

This document provides

recommendations to find a successful new direction for the Department of Health Services. It was prepared in response to the request of the former Director of Health Services, Mr. Mark Finucane, for input and feedback from staff at his employee forums.

It was also developed in response to his expectations that “each executive manager make a very personal commitment to accomplishing the tasks necessary to succeed over the next 5 years” and the “need to unleash the creativity that exists within the Department.” 3

The health and wellbeing of people around the world depend critically on the performance of the health systems that serve them.2

“New opportunities rarely fit the way an industry has always approached the market, define it, or organize to serve it.”

-Peter Drucker

The “Improving DHS Performance Viewpoint” is intended to stimulate discussion and reflection regarding health system performance. It aims to propel continued dialogue and encourage the pioneering of new combinations of innovative concepts and approaches through a format of 10 Problem Statements, 28 Recommendations, and a Sum-

3 Improving DHS Performance: SPA 4 ViewPoint

mary Table. It is hoped that the DHS Executive Team will be open to needed, challenging, controversial, and/or futuristic performance improvement routes. This will enable DHS to (a) achieve further extraordinary improvements, (b) not to fall short of its potential, and (c) develop the best and fairest health system possible for Los Angeles County residents with available resources.

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Discussion and Recommendations

Problem Statement I:

The protection, promotion, and maintenance of the health of a population are not a function of a health department alone. The health of LAC residents cannot be improved with only medical and public health interventions.

with other health departments, (c) partnerships with community-based organizations and the private forprofit sector, (d) intra- and interdepartmental collaboration with other LAC departments and (e) effective relationships with state and federal agencies.

Recommendation #1: A Health System Approach must be adopted.

In this system: (a) all public, private for-profit, and non-profit organizations, institutions, and resources devoted to producing health actions are equally involved, and (b) all efforts to improve health rely upon multidisciplinary and multisectoral interventions.

The protection, promotion, and maintenance of the health of a population are not a function of a health department alone. The health of Los Angeles County residents cannot be improved with only medical and public health interventions.

Recommendation #2: A comprehensive Strategic Plan for this health system must be developed. This plan should promote a unifying conceptual framework that: (a) outlines the vision of the health system and DHS’ critical functions, strategic goals and objectives, operational approaches, and performance benchmarks; (b) serves as the basis for the planning, management, and evaluation of programs and services implemented by all stakeholders, and (c) is understood, supported and continually enhanced by the health workforce.

Recommendation #3: The DHS must assume the technical and managerial leadership for the development and promotion of recommendations #1 and #2 above, since the ultimate responsibility for the performance of LAC’s health system lies with the government.

This leadership responsibility should be focused on the principal activities of policy dialogue and resource mobilization, and be expressed through: (a) optimal utilization of multidisciplinary staff, (b) partnerships

Problem Statement II:

Current DHS strategies focus primarily on cost-cutting measures to maintain its fiscal stability. Plans based on economic considerations unintentionally disregard the overall goals and vital functions of the health system.

Recommendation #4: Current programming must be reinvigorated with new goals for DHS. Managers should keep staff focused on a few key strategic goals (business objectives). The following three overarching goals developed by WHO to measure health system performance of countries worldwide are recommended: Goal #1: Good Health Goal #2: Responsiveness to the expectations of the population Goal #3: Fairness in Financial Contribution

The WHO Rationale: “Better health is unquestionably the primary goal of a health system.

Health care can be catastrophically costly and the need for it unpredictable. Mechanisms for sharing risk and providing financial protection are important. The second goal of health systems is fairness in financial contribution. The third goal is to enhance the responsiveness of the system to the legitimate expectations of the population reflecting the importance of respecting people’s dignity, autonomy and the confidentiality of information.”4

Recommendation #5: Current programming must be aligned to new vital (core) functions for DHS. Managers must keep staff centered on a few key vital functions. The following four vital functions developed

by WHO to measure health system performance of countries worldwide are recommended: Service Provision: delivering public, personal and private health services.

Resource Generation: creating resources through investment and training including investing in people, buildings, and equipment and generating the human and physical resources that make service delivery possible.

Financing: revenue collection, pooling of resources, and strategic purchasing of interventions/services.

Stewardship: oversight, acting as the overall stewards of entrusted resources, powers and expectations, setting and enforcing the rules of the game and providing strategic direction for all the different actors involved.5

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Discussion and Recommendations

Recommendation #6: The current DHS organizational structure and functions should be aligned with the overall goals and vital functions outlined in recommendations #1 and #2, i.e.: (a) the specific strategies and objectives of divisions, programs and Service Planning Areas (SPA) of DHS must be brought into alignment to demonstrate how their work connects to and impacts the overall DHS goals and vital functions, and (b) the proposed new vital functions must be specifically assigned to existing divisions and/or new structures created for such purposes.

Problem Statement III: Cost

effective healthcare for the entire population must replace current health care delivery thinking.

Recommendation #7: Incorporate WHO’s twofold objective of good health into DHS thinking, values, and guiding principles; that is, “the best attainable average level of health (goodness), and the smallest feasible health differences among individuals and groups (fairness).”6 Recommendation #8: Implement the current worldwide trend to reform health systems based on the fundamental principle of delivery of high quality essential care for everyone. Lessons learned from previous reforms of health care systems --founding of national health care systems, extension of social insurance schemes, promotion of primary health care to achieving affordable universal coverage-- are paving the way to the current health sector reform trend. Rather than all possible care for everyone or only the simplest and most basic care for the poor, the aim is to deliver high quality essential care to everyone defined

by criteria of effectiveness, cost and social acceptability.7 Consequently, DHS should re-examine what essential services should be available to LAC residents based on local priorities, burden of disease and cost effectiveness.

Rather than all possible care for everyone or only the simplest and most basic care for the poor, the aim (of a health system) is to deliver high quality essential care to everyone defined by criteria of effectiveness, cost and social acceptability.7 Problem Statement IV:

Health care systems have traditionally concentrated almost exclusively on the presumed needs of individuals. Too little attention has been given to people’s demand for health care. In addition, health promotion and disease prevention and control are affected by individual, structural (social), environmental and economic (super-structural) factors within and beyond communities that must be viewed comprehensively. Protecting and improving the health of a population is a shared responsibility among residents, public institutions, private for-profit and non-profit organizations, key stakeholders, opinion leaders and policymakers.

Recommendation # 9: A Community Liaising Program is needed to consolidate and lead an expanded response aimed to strengthen, expand and diversify public, personal, and private health programs and services. Unlike previous liaising staff or efforts in the past, the goals of this program should be to:

5 Improving DHS Performance: SPA 4 ViewPoint

Increase awareness of and generate more support for health promotion and disease prevention and control programs.

Identify and secure additional/potential resources (human, material and financial) aimed to integrate public, personal and private health programs and services through, but not limited to, the following strategies: (a) Community Networking. (b) Strategic Alliances & Partnering, (c) Community Mobilization, (d) Private Sector Leveraging, (e) Resource Development, and (f) Policy Development and Advocacy.8

At first people refuse to believe that a strange thing can be done, and then they begin to hope it can be done, then they see it can be done, then it is done, and all the world wonders why it was not done centuries ago.”

-Frances Hodgson Burnett Recommendation #10: The future DHS direction must deliver services that are demand-driven rather than supply-oriented. New mechanisms and strategies must be created to be responsive to expressed community needs including the Community Liaising Program described in Recommendation #9.

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Discussion and Recommendations

Problem Statement V:

Performance measurement and improvement is the key to DHS’ longterm competitive advantage, success, effectiveness, stability and survival.

Managing for improved performance requires an objective assessment of three organizational building blocks.

These components are the worker, the workplace and the work itself.9

Recommendation #11: Institutionalize a DHS-wide performance measurement and improvement plan shifting the focus from a process-oriented oversight to an insight-oriented outcome (results oriented).

This plan should include but not be limited to the following: Immediate attention to growth and development of human resources at every level.

Specific training in measurements of attainment (what is achieved with respect to established goals) and performance (how to compare attainments with what the system should be able to accomplish, i.e., the best that could be achieved with the same resources)10 keeping in mind that measurement drives behavior and behavior creates culture.

A commitment to create a self aligning organization that keeps all the vital elements of DHS aligned and headed in the same direction at the same time. In other words, a culture and systems that keep everyone in DHS doing the right things right, i.e., Service Quality Index, Customer Service, Process Quality Indicators, Leadership Index, etc.11 (Please refer to Problem Statement VIII).

linked to rewards and recognition including a system of applied sanctions due to evidence of failure to meet expectations or lack of productivity.

Recommendation #12: Implement a sound quality assurance capability.

A commitment to quality reduces expenditures. Research on the cost of quality has repeatedly showed that 20% to 30% of a typical organization’s expenses are the result of redundancy of effort, rework, error, inefficiency, recurrent problems, untrained personnel and cumbersome systems.12 Recommendation #13: Conduct thorough technical, management and financial performance audits prior to the contracting of services including sound monitoring and evaluation. Lessons learned from work with the non-profit sector have shown both excellent and poor outcomes. In the absence of a strong quality assurance mechanism the risk for fraud, abuse, malpractice, underperformance, inflated workload figures or understated costs increases. In addition, many grants are awarded to organizations without a track record because they relied on staff with strong writing skills or consulting writers.

Research on the cost of quality has repeatedly showed that 20% to 30% of a typical organization’s expenses are the result of redundancy of effort, rework, error, inefficiency, recurrent problems, untrained personnel, and cumbersome systems.12

Problem Statement VI: Despite

the best efforts to date to integrate services, integration has not been achieved effectively within (intra) DHS and outside (inter) DHS (other LAC Departments and Community Based Organizations). Consequently, the LAC health system is characterized by fragmentation of services, compartmentalized programs, an excess of implementing units, and lack of decentralization. The word integration has been used with a variety of meanings and in different situations, i.e., a new organizational structure merging various disease control programs, regular coordination through information sharing among decision makers of existing programs, adding tasks to unqualified and already overburdened staff, and sharing of resources, such as transportation, among different programs. The Harvard School of Business used the term integration to describe the state of collaboration that exists between departments that are required to achieve unity of effort by the demands of the environment.13 However, integration is more than coordination, collaboration or sharing of resources.14

Recommendation #14: View integration as sharing of responsibilities by programs, SPA’s, CBO’s, departments and people involved in implementing health care at all levels.

Through such sharing of responsibility, broader access to health services can be achieved in an environment where stigmatization can be minimized, earlier access to services is facilitated, and easier continuation of services is guaranteed.

Performance measures that are 6 Improving DHS Performance: SPA 4 Viewpoint

July 2001

Discussion and Recommendations Recommendation #15: Incorporate coverage and quality as the cornerstones for an integrated approach.

The DHS should promote an integration concept that enhances cost-effectiveness through the provision of appropriate and better services at an early stage of disease development.

More providers would administer these services to a greater number of people closer to those in need. This should be done in an environment where educational, preventive and clinical activities take place, referrals are ensured, and patients feel at ease.15 Recommendation #16: Develop a decentralized operational structure where Area Health Offices and/or a Regional Structure are entrusted with a larger number of technical, management and financial decisions based on guidelines, criteria and procedures promoted by central units. These central units should be responsible for developing policies and training materials, ensuring technical guidance and initiating relevant audits, evaluation and research (please refer to Problem Statement X).

Recommendation #17: Carry out an organizational alignment assessment to set the future DHS direction (strategic planning), link processes and systems (vertical and horizontal alignment), and make constant adjustments. The need for companies to re-engineer is in many respects a consequence of past failures to make small manageable adjustments on an on-going basis16 (please ref er to Problem Statement VIII).

Problem Statement VII:

Previous DHS re-engineering, downsizing, rightsizing, cascading and reduction-in-force efforts have created a culture in which managers end up pushing rather than leading staff, and subordinates are characterized by low morale, unbelief, fear, insecurity, and lack of motivation.

Recommendation #18: Priority training of DHS executive, senior and middle managers and supervisors is needed to develop a new leadership competence and culture. Human Resource Development (HRD) objectives should include the acquisition of knowledge and skill sets that enable managers to: (a) connect their staff’s behavior to the DHS mission, turning intentions into actions, (b) shape DHS strategy linking teams and processes to the changing needs of customers, and (c) create a culture in which all elements work together seamlessly.

The following HRD programs are recommended: The Six Key Functions of Top Management developed by the American Management Association (AMA): “leadership, managing culture, developing people, change management, organizing and deploying resources and formulating strategy.”17 The Four Core Categories of Public Health Leadership Competency Framework developed by the National Public Health Leadership Network: “Transformational Competencies: systems thinking including analytical and critical thinking processes, visioning of potential futures, strategic and tactical assessment, communication and change dynamics.

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Legislation and Political Competencies: skills to facilitate negotiate and collaborate in an increasingly competitive and contentious political environment.

Transorganizational Competencies: skills to be effective beyond public health workers (PHWs), organizational boundaries, i.e., single stakeholder group, community unit, profession or discipline, organization or government unit.

Team and Group Dynamics: effective communication and practice are accomplished by PHWs through team building and capability, i.e., team-oriented structures and systems, facilitation and mediation roles.”18 A Culture Change Strategy comprising of new and practical management principles such as those listed below and promoted by the SPA 4 Area Health Office during the last year.

Let’s [1] become problem solvers, [2] go where we have not been before, [3] become tomorrow thinkers, [4] succeed as a team, [5] set SMART goals, [6] acknowledge the necessity for rest and relaxation, [7] become pre-active and proactive planners, [8] take the time to delegate, [9] guard our priorities and our personal and professional schedules, [10] keep in mind that when we want something we have never had, we have got to do something we have never done, [11] permit the correction of mistakes, [12] avoid unnecessary confrontations, [13] educate our down-line, 7

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Discussion and Recommendations

[14] do not permit down-line to show disrespect, [15] believe in our product, vision, mission, goals and strategies, [16] become a performance-based and a learning SPA , [17] expect better performance, [18] aim to increase our best and reduce our worst managerial qualities, [19] develop a passion for our vision, mission and goals, [20] recognize that every great achievement requires a willingness to begin small, [21] remember that what we hear repeatedly, we will eventually believe, [22] master the approaches of a successful working leader and manager, [23] accept the responsibility for the mistakes of our down-line, [24] become follow-through people and finish what we start, [25] learn to think possibilities, [26] do not allow what others say about us to change our focus, goals, course or personal opinion about ourselves, and [27] become a team of inspiration.19,20,21,22,23

“If you always do what you always did, you will always get what you always got” -Arthur R. Tenner & Irving J. DeToro

Problem Statement VIII:

The DHS cannot afford to maintain the negative impacts of a misaligned organization. The following issues reflect a misaligned organization: reactive versus proactive orientation, repeated deployment of short-term fixes, recurring/chronic issues and problems, failure to identify and correct the root cause and systemic problems, reduced productivity and

employee satisfaction, increased expenses and loss of revenue, decreased customer satisfaction, retention or loyalty, routine business does not go finished, fixes that do not produce intended effects, objectives and goals are not achieved, signals of various sorts go undetected, opportunities for improvement are missed and performance and growth are hampered.24

Recommendation#19:Move from the old linear approach to management to one of simultaneity-alignment. Alignment is the degree to which all elements of an organization’s infrastructure are tightly integrated and working in concert to enhance performance and growth.25 Alignment links the five key elements of an organization. This includes strategies and people (vertical alignment), processes and customers (horizontal alignment), and leadership to keep all the vital elements and staff headed in the same direction at the same time.

Recommendation#20: Change the conventional thinking of running DHS operations from assigning priority first to stakeholders Board of Supervisors (BOS), second to customers, and third to Employees to Employees first, customers second, and stakeholders (BOS) last. World-class businesses today acknowledge the new thinking of a well-run business; that is, well trained employees deliver quality products (programs or services) and maintain customers’ happy, thus pleasing shareholders/stakeholders (BOS) and increasing profitability (constituency satisfaction and support).26

Recommendation #21: Develop better programs to educate stakeholders (community members, gatekeepers, opinion leaders, policy influencers, political leaders, and key decision makers) about public health, preventive medicine and health care delivery. Stakeholders wish to make correct decisions and improve life for their constituents.

However, the absence of good decisions is due to lack of, or incorrect information, or the inability of the stakeholder to interpret the information.27 Recommendation #22: Enrich DHS strategies with ideas that come from employees at all levels of the organization, thus avoiding problems like: (a) strategy that is owned by the top but ignored by everyone else, (b) good employees who fail to focus on key goals, and (3) lack of commitment and momentum in the organization.28 Recommendation #23: Utilize the people closest to the action to elicit ideas for improvement, identify pitfalls and get a reality check for critical DHS issues in addition to, as a complement of, or instead of external consultants.

World-class businesses today acknowledge the new thinking of well-run business; that is, well-trained employees deliver quality products (health programs and services) and maintain customers’ happy (patients and clients), thus pleasing shareholders/ stakeholders (Board of Supervisors) and increasing profitability (constituency satisfaction and support). 26

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Discussion and Recommendations

Problem Statement IX:

The DHS should incorporate sustainability thinking into any strategic plan, reengineering program, cost reduction measure, public/private partnership or capacity building efforts. Increasing capacity at this level not only represents the cumulative effects of capacity building initiatives at the individual organization levels, but also attempts to change the environment, structure and needs that define how organizations and initiatives are conceived and implemented.

Recommendation #24: Improve organizational sustainability by incorporating Family Health International’s four complementary types of sustainability into all DHS programs and services -technical, management, financial and political sustainability. An organization without any of these components will either be ineffective (lacking technical or managerial sustainability), unproductive (lacking financial sustainability) or irrelevant (lacking political sustainability).29 “Technical sustainability: the ability of an organization to provide technically appropriate, state-ofthe-art, high quality services.

Management Sustainability: the ability to plan and manage all aspects of the operations.

Financial Sustainability: the ability to generate sufficient working capital to continue to produce goods or provide services.

Political Sustainability: the ability to maintain the support and involvement of the community

members, gatekeepers, opinion leaders, policy influencers, and key decision makers which can affect the viability of the organization.�30

Recommendation#25: Develop performance contracting mechanisms that require. counterpart contributions, cost-sharing quotas and resource diversification plans from the program, grant or partnership inception. This will ensure continuity of activities and benefits in the absence of DHS funding.

An organization without sustainability strategies will either be ineffective (lacking technical or managerial sustainability), unproductive(lacking financial sustainability) or irrelevant(lacking political sustainability).29 Problem Statement X:

The Cluster Network System in Personal Health Services and the Area Health Offices in Public Health Services contribute to compartmentalized and disintegrated DHS operations and structure.

Optimal utilization of a single regional managerial structure could better increase efficiencies and reduce costs, reconfigure and reduce specific services, integrate and align public, personal and private health services.

Recommendation #27: Utilize the personal and private health care delivery systems for prevention measuring and assigning priority to health outcomes, quality and cost effectiveness rather than access, quantity and cost. Access is only a process measure that provides no assurance of better heath in itself. A focus on health outcomes has been shown to address service utilization.

Prevention provides the best quality of life, and the most cost-effective approach should be the goal of any health system.31 Recommendation #28: Rationalize and maximize the utilization of resources from personal health services. The following example provides evidence of the persistent challenges of health systems. The health determinants of people and their contribution to the reduction of mortality were documented back in 1976. Almost 90% of this mortality was attributed to lifestyles, human biology and the environment. Expenditures for these areas accounted for 10% of the budget.

Conversely, personal health services absorbed 90% of the budget but contributed only 11% to mortality reduction.32

Recommendation #26: Create strengthened and more cost effective Service Planning Area Health Offices by merging the capabilities and

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resources of the Cluster Network and the Area Health Offices. There is a need to reconcile DHS personal and public health services at the operational level focusing priority on prevention and public health over personal health and clinic services due to the reasons described in recommendation #28.

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Summary Table

PROBLEM STATEMENTS

RECOMMENDATIONS

I. The health of LAC residents cannot be improved with medical and public health interventions alone.

1. Adopt a Health System Approach.

2. Develop a comprehensive DHS-wide Strategic Plan.

3. Assume technical and managerial leadership for Items I and II.

II. Plans based primarily on economic considerations disregard (unintentionally) the overall goals and vital functions of DHS.

4. Adopt WHO’s three (3) new goals for health systems: Good Health, Responsiveness to the Expectations of the Population, and Fairness in Financial Contribution.

5. Adopt WHO’s four (4) new vital (core) functions for health systems: Service Provision, Resource Generation, Financing, and Stewardship.

6. Align functions and structure of DHS according to Items IV and V.

III. Cost effectiveness for all, rather than all possible care for the whole population or the simplest and most basic care for the poor, must replace current health care delivery thinking.

7. Incorporate WHO’s twofold objective of good health –goodness & fairness.

8. Reform the health system based on the fundamental principle of delivery of high quality essential care for everyone.

IV. Health care systems have traditionally concentrated almost exclusively on the presumed needs of individuals. Too little attention has been given to people’s demand for health care.

V. Performance measurement and improvement are the key to DHS’ long-term competitive advantage, success, effectiveness, stability and survival.

VI. Integration of services has not been achieved effectively both within (intra-DHS) and outside DHS (Inter-Departments and Community-Based Organization) despite extensive efforts.

VII. Previous DHS reengineering, downsizing, rightsizing, cascading and/or reduction-in-force efforts have created a culture in which managers end up pushing rather than leading staff, and subordinates are characterized by low morale, unbelief, fear, insecurity, and/or lack of motivation.

9. Institutionalize a Community Liaising Program.

10. Develop and deliver services that are demand-driven.

11. Institutionalize a DHS-wide performance measurement and improvement plan.

12. Create a sound quality assurance capability.

13. Conduct thorough technical, management, and financial performance audits prior to contracting out services, including effective monitoring and evaluation.

14.

15.

16.

17.

View integration as sharing of responsibilities.

Incorporate coverage and quality as cornerstones of an integrated approach.

Develop a decentralized operational structure.

Implement an organizational alignment strategy.

18. Create a new leadership competence and culture through training of staff in the Six Key Functions of Top Management, The Four Core Categories of the Public Health Leadership Competency Framework, and a Culture Change Strategy.

VIII. The DHS cannot afford to maintain the negative effects of a misaligned organization.

19. Move from the old linear approach to management to one of simultaneity. This preferred approach is alignment.

20. Change conventional priority thinking to the new thinking of well-run businesses.

21. Develop better programs to educate stakeholders.

22. Enrich DHS strategies with ideas that come from employees at all levels.

23. Utilize the people closest to the action to elicit ideas for improvement, identify pitfalls, and get a reality check on DHS operations.

IX. The DHS should incorporate sustainability thinking into any strategic plan, reengineering program, cost reduction measure, public/private partnership or capacity building effort.

24. Improve organizational sustainability by incorporating Family Health International’s four complementary types of sustainability: technical, management, financial, and political.

25. Develop performance-contracting mechanisms that require counterpart contributions, cost-sharing quotas, and resource diversification plans.

X. Optimal utilization of a single, regional management structure could better increase efficiencies and reduce costs, reconfigure and/or reduce specific services, and integrate/align public, personal and private health services.

26. Create strengthened and more cost-effective Service Planning Area Offices by merging Cluster Network with Area Health Offices.

27. Utilize the personal and private health care delivery system for prevention.

28. Rationalize and maximize the utilization of resources from personal health services.

“Rather than saying it cannot be done, let’s find a way to get it done” —M. Ricardo Calderón

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References

1. Department of Health Services/ Public Health Goals, Los Angeles County, 2000

(Organizational Dynamics, Inc. USA 1997).

2. World Health Organization.

TheWorld Health Report 2000: Health Systems: Improving Performance (WHO, Geneva, Switzerland, 2000).

12. W. Leebow and C.J. Ersoz, The Health Care Manager’s Guide to Continuous Quality Improvement (Chicago: American Hospital Publishing, 1991), pp. 3-4.

3. Office of the Director of HealthServices, Rathgar Retreat Minutes (Los Angeles County Department of Health Services, August 22-23,2000).

13. Labovitz, George & Rosansky, Victor. The Power of Alignment (Organizational Dynamics, Inc. USA 1997).

4. World Health Organization.

The World Health Report 2000: HealthSystems: Improving Performance (WHO, Geneva, Switzerland, 2000).

14. Dallabeta, Gina et al. Control of Sexually Transmitted Diseases: A Handbook for the Design and Management of Programs (USAID/ Family Health International, Arlington, VA, 1995), pp. 43-56.

5. Idem.

15. Idem.

6. Idem.

16. Labovitz, George & Rosansky, Victor. The Power of Alignment (Organizational Dynamics, Inc. USA 1997).

7. Idem.

8. SPA 4 Area Health Office.

Community Liaising Program: A DHS Restructuring and ReinvigorationInitiative (Los Angeles County Department of Health Services, 2000).

9. Gilbert, Tom, Behavioral Engineering Model.

10. Family Health International. The AIDS Control and Prevention [AIDSCAP] Project Evaluation Tools: Introduction to AIDSCAP Evaluation (USAID/FHI, Arlington, Virginia,1993).

11. Labovitz, George & Rosansky, Victor, The Power of Alignment

22. American Management Association.

The Management Course for Presidents. AMA, Coronado Island, San Diego, CA, 2000).

23. Gilbert, Tom, Behavioral Engineering Model.

24. EnTarga, Approaches to Planning (EnTarga Business Planning).

25. Lawrence, Paul and Jay Lorshc, Organization and Environment (Homewood, Ill.: Richard D. Irwin,1969), pp. 11.

26. Labovitz, George & Rosansky, Victor. The Power of Alignment (Organizational Dynamics, Inc., USA 1997).

27. Idem.

28. Idem.

17. American Management Association.

The Management Course for Presidents (AMA, Hilton Head Island, South Carolina, 1998).

18. Wright, Kate et al. Competency Development in Public Health Leadership (American Journal of Public Health, August 2000) Vol. 90, No. 8, pp 1202-1207.

19. Schuller, Robert H., 365 Positive Thoughts (Crystal Cathedral Ministries, Garden Grove, CA, 1998).

20. Maxwell, John C., Leadership 101 (Honor Books, Tulsa, OK 1994).

11 Improving DHS Performance: SPA 4 ViewPoint

21. Murdock, Mike, The Double Diamond Principle (The Wisdom Center, Denton, TX, 1995).

29. Calderón, M. Ricardo. HIV/AIDS Prevention and Control SYNOPSIS Series: Capacity Building (Family Health International, Arlington, VA, 1997), pp. 5-12.

30. Idem.

31. Foege, William H., The Scope of Public Health: Challenges to Public Health Leadership (Oxford University Press, 1997), vol. 1, pp. 402-417.

32. Dever, G.E.A.: An Epidemiological Model for Health Analysis (Soc. Ind. Res. 1976), Vol. 2.

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Metropolitan Service Planning area (SPA 4) 241 North Figueroa Street, Room 312 Los Angeles, California 90012 Tel: (213) 240-8049 Fax: (213) 202-6096 www.lapublichealth.org Š 2001 SPA 4

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