Health Policy And Management

Front 1

the U.S. does not have a health system, instead we

Back 1

have hundreds of thousands of health care providers and insurers providing health services in an uncoordinated manner (both private and public)

leads to inefficient delivery of care and higher costs as well as inconsistent care due to fragmentation

Front 2

why does the U.S. not have a health system

Back 2

1.) no systematic policy approach to health care delivery

2.) multiplicity of financial arrangements and payers

3.) large array of settings where medical care is provided

4.) organization developed organically over time - (1) U.S. cultural values, (2) political realities, (3) incremental legislation

Front 3

National Health Expenditures per Capita

1960-2013

Back 3

1960 - 5%

1970 - 7%

1980 - 8.9%

1990 - 12%

2000 - 13.4%

2010 - 17.4%

2013 - 17.4%

Front 4

U.S. is higher than any other country in

Back 4

health expenditure per capita

Front 5

the U.S. spends

Back 5

2.5 times more than any other country on health care, but don't have the highest life expectancy

Front 6

Life expectancy in 2010 for U.S.

Back 6

78.7 years

Front 7

health care spending per person GDP

Back 7

$8,233

Canada is next, then Sweden, United Kingdom, Japan, Mexico

Front 8

health care prices compared between U.S. and other countries

Back 8

angiogram, colonscopy, hip replacement, lipitor, MRI scan are all higher than Canada, Switzerland, Spain, New Zealand, and Netherlands

Front 9

why is the U.S. healthcare so expensive

Back 9

1.) profit driven providers (move from non-profit to profit)

2.) pricing schemes and insurance

3.) misaligned financial systems leads to over utilization of testing, drugs, procedures, etc.

4.) acute care focused (instead of prevention)

5.) administrative costs - many layers of overhead due to our insurance/reimbursement mechanisms

Front 10

distribution of National Health Expenditures by Type Service in 2010 in billions

Back 10

1.) hospital care - 31.4%

2.) physician/clinical services - 19.9%

3.) other health spending - 15.7% - admin costs

4.) other personal health care - 14.8%

5.) prescription drugs - 10%

6.) nursing care and retirement - 5.5%

7.) home health care - 2.7%

Front 11

most European and Asian countries have some kind of

Back 11

national health care system

Front 12

3 common types of health care systems

Back 12

1.) publically financed, privately delivered national health care system (Canada)

2.) publically financed and delivered national health systems (Britain)

3.) socialized insurance system with mandatory contributions and private delivery (Germany)

Front 13

Medicaid was enacted in

Back 13

1960s

Front 14

type of health insurance design relates to key issues for patients: 7

Back 14

1.) affordability

2.) differences in access by income level

3.) availability of services

4.) waiting list/wait times

5.) choice

6.) complexity of interacting with insurance system/paperwork

7.) patient satisfaction

Front 15

iron triangle of health policy

Back 15

1.) access to care

2.) cost

3.) quality

Front 16

access

Back 16

the ability to use or access needed, affordable convenient, acceptable, and effective personal health care services

Front 17

key barriers to access: 4

Back 17

1.) lack of health insurance

2.) inadequate health insurance

3.) insurance coverage limitations

4.) workforce issues

Front 18

health care access - uninsured and underinsured

key characteristics: 6

Back 18

1.) poor

2.) low education

3.) non-native

4.) racial/ethnic minority

5.) location

6.) age

Front 19

problems with being unisured: 4

Back 19

1.) less access to care

2.) less timely care

3.) less likely to follow treatment

4.) recommendations due to cost

Front 20

underinsured

Back 20

do not have financial resources to cover the gap between what their insurance covers and their medical bills: high cost-sharing, co-payments, deductibles, premiums, reimbursement and visit caps, service exlusions

Front 21

safety net providers serve many uninsured and underinsured such as

Back 21

1.) CHDs

2.) FQHCs

3.) public hospitals

Front 22

barriers to health care among nonelderly adults by insurance status, 2013

Back 22

1.) no usual source of care- u 53% for uninsured

2.) postponed seeking care due to cost

3.) went without needed care to cost

4.) could not afford prescription drug

all 4 ranked highest for uninsured, then Medicaid/public, last employer/private

Front 23

uninsured rates among the nonelderly by state 2013

Back 23

southern states, montana, wyoming, but not mississippi, and louisana, alaska= >16%

new york area, northeast, midwest = <12%

remainder = 12-16%

Front 24

most people in U.S. obtain health insurance through

Back 24

their employer

Front 25

health insurance acts as an

Back 25

intermediary between patients and providers

Front 26

an estimated 93% will be insured once the

Back 26

ACA is implemented

22 million insured through state/federal health insurance exhanges

16 million newly insured in Medicaid or CHP

Front 27

coverage changes among the nonelderly 2000-2013

Back 27

uninsured and underinsured = gone from 16.8- 12% to 17-23% from 2000 to 2013

private = from 71% to 61% from 2000 to 2013

Front 28

U.S. spends more per person on health care but often ranks poorly on

Back 28

health care measures

Front 29

IOM - Err is Human: Building a Safer Health System

Back 29

10,000s of Americans die each year as a result of preventable mistakes in their care, the report lays out a compreshensive strategy by which government, health providers, industry, and consumers can reduce errors

Front 30

key causes of errors affecting patient safety: 4

Back 30

1.) medication errors

2.) infection control

3.) injuries from falls

4.) injuries from procedures

Front 31

IOM outlines 6 areas for improvement

Back 31

1.) safety

2.) effectiveness

3.) patient centered care

4.) timeliness of care

5.) efficiency of delivery of care

6.) equitable provision of care

Front 32

quality issues in the delivery of care stem from the

Back 32

complexity of the U.S. healthcare system due to its decentralized and fragmented nature - difficult to provide coordinated, patient-focused care and leads to: variation in services, inefficiencies, and overuse, underuse, and misuse of services

Front 33

10 Essential Public Health Services

Roles of local and state public health agencies

Back 33

Assessment:

1.) monitor health

2.) diagnose and investigate

Policy Development:

3.) inform, educate, and empower

4.) mobilize community partnerships

5.) develop policies

Assurance:

6.) enforce laws

7.) link to/provide care

8.) assure competent workforce

9.) evaluate

System Management:

10.) research

Front 34

what are the roles of federal public health agencies: 5

Back 34

provides national oversight, policy, and funding for:

1.) disease control and prevention

2.) research

3.) consumer safety and protection

4.) provides resources to care for vulnerable populations (MH/SA, HIV, Disabled, etc.)

5.) emergency response

Front 35

key federal health agencies of the department of health and human services

Back 35

1.) Centers for Disease Control and Prevention (CDC) - roles/authority: lead agency for prevention, health data, epidemic investigation, public health measures aimed at disease control and prevention; ex: of structures/activities: CDC Epidemiology Intelligence Service (EIS) functions domestically and internationally at the request of goverments

2.) National Institutes of Health (NIH) - roles/authority: lead research agency, also funds training programs and communication of health infor to professional community and the public; ex: of structures/activities: 17 institutes in all - the largest being the National Cancer Institute, NIH is the world's largest biomedical research enterprise with extramural research grants throughout the world

Front 36

key federal health agencies of the department of health and human services - continued

Back 36

3.) Food and Drug Administration (FDA) - roles/authority - consumer protection agency with authority for safety of foods and safety and efficacy of drugs, vaccines and other medical and public health interventions; ex: of structures/activities - division responsible for food safety, medical devices, drug efficacy and safety pre and post approval

4.) Health Resources and Services Administration (HRSA) - roles and authority: seeks to ensure equitable access to comprehensive quality health care; ex: of structures/activities: funds community health centers, HIV/AIDS services, scholarships for health professional students

Front 37

what are the roles of global public health organizations and agencies?

Back 37

provides international oversight, policy, and funding for:

1.) disease control and prevention

2.) coordination of response to major disease outbreaks and natural disasters

3.) tracks population health across countries

Front 38

global public health organizations:

Back 38

1.) World Health Organization (WHO) - structure/governance: United Nations organizations, seven regional semi-independent components, e.g. Pan American Health organization covers North and South America; roles - policy development, e.g. tobacco treaty, epidemic control policies, coordination of services, e.g. SARS control, vaccine development, data collection and standardization, e.g. measures of health care quality, measures of health status; limitations - limited ability to enforce global recommendations, limited funding and complex international administration

Front 39

global public health organizations:

Back 39

2.) International Organizations with focused agenda, Bilateral governmental aid organizations; structure/governance: UNICEF, UNAIDS, USAID, many other developed countries have their own organizations; roles: focus on childhood vaccinations, focus on AIDS, often focused on specific countries and specific types of programs, such as the US focus on HIV/AIDS, and maternal and child health; limitations: limited agendas and limited financing, may be tied to domestic politics and global economic, political, or miliatry agendas

Front 40

how can public health agencies and the community they serve work together? 4

Back 40

1.) strategic planning - prioritize health issues and populations and identify resources for addressing them (MAPP)

2.) pooling resources to address needs

3.) coordinating service delivery

4.) educating the community (prevention campaigns)

Front 41

local public health system examples:

Back 41

police, EMS, community centers, churches, civic groups, doctors, hospitals, philanthropist, fire, mass transit, corrections, environmental health, economic development, elected officials, parks, nursing homes, employers, tribal health, mental health, drug treatment, schools, MCOs, home health

Front 42

The Anatomy of Health Care in the US by Moses et al (JAMA)

Back 42

provides trends in health care spending and utilization and looks at drivers that impacts these trends

Front 43

management

Back 43

1.) interdisciplinary compilation of concepts that is integral to all human enterprise including public health

2.) necessary to assure the goals of public health programs are met

3.) it is an integral component of the social contract between employers and employees

concepts derived from sociology, psychology, economics, statistics, and finance

Front 44

health policy and management is one of the

Back 44

core competencies areas for public health

Front 45

how health professionals learn to manage

Back 45

1.) as an add-on to their public health training and not as an integral part of their training

2.) on the job

3.) some never have any training

Front 46

management

Back 46

is the operational glue that keeps all the components of public health working together to meet the vision and mission of public health

Front 47

most employees have not had formal training in

Back 47

management and pick up what is needed through work

Front 48

management, organization, and culture are inextricably linked to organizational effectiveness, therefore

Back 48

managers are often judged by their organizations performance

Front 49

organizational philosophy

Back 49

the value of an organization can also be called this

Front 50

high-performing organizations have

Back 50

a values system that furthers the organizations goals, an organization in which all staff understand the desired values and incoporate them into their work lives will achieve its goals more effectively

Front 51

ethics audits

Back 51

are an important tool managers can use to biopsy the organizations value system

consists of:

1.) staff surveys

2.) obervations of staff and patient interaction

3.) reviews of staff recruitment

4.) training

Front 52

audits

Back 52

provide understanding of cultures

Front 53

management or managing has 4 main elements:

Back 53

1.) a process comprised of interrelated social and technical functions and activities

2.) that accomplishes organizational objectives

3.) achieves these objectives through use of people and other resources

4.) which occurs in a formal organizational setting

Front 54

senior management establishes

Back 54

organizational objectives, which have the clearest and most direct effect

Front 55

managers at all levels shape

Back 55

.organizational values and cultures

Front 56

managers can be described by

Back 56

functions performed, skills used, roles played, and competencies to succeed

Front 57

management skills: 3

Back 57

1.) technical - abilities of managers to use the methods, processes, and techniques of managing - decrease as managers become more senior

2.) human/interprsonal - cooperating with others, understanding them, and motivating and leading them in the workplace - important at all levels

3.) conceptual skills - are the mental ability to see how various factors in a given situation fit together and interact - increases as managers become senior

Front 58

management roles: 6

Back 58

1.) interpersonal - figurehead, leader, and liason

2.) informational - monitor, disseminator, and spokesperson- inside and outside organization

3.) decisional - entrepreneur, resource allocator, and negotiator - most important tool of manager

4.) designer - organizing work functions for maximum effectiveness - also important

5.) strategist - focus on how to adapt their organizational domains to external challenges and opportunities

6.) leader - the leader role is affected by how well the roles of designer and strategist are performed, more difficult because of dynamics in health field

Front 59

management functions and decision making: 5

Back 59

1.) planning - establishes objectives, first step in managing, occurs when planning new program or make changes

2.) organizing - develops tools and resources needed to achieve plan

3.) staffing - retaining human resources that are effective

4.) directing - depends on the ability to lead, motivate, and communicate with staff

5.) controlling - regulating activities in accordance to plan; has four steps: 1.) setting standards, 2.) measuring performance, 3.) comparing actual with expected results, 4.) making corrections as plan is implemented

Front 60

5 management functions of planning, organizing, controlling, directing, and staffing are connected by

Back 60

decision making

Front 61

problem solving steps: 7

Back 61

1.) problem identification, or recognizing the prescence of a problem (including gathering and evaluating info) and stating the problem - one of many functions of manager

2.) making assumptions, which uses logic to extend what is known

3.) developing tentative alternative solutions and selecting those to be considered in depth

4.) evaluating alternative solutions by applying decision criteria

5.) selecting the alternative that best fits the criteria

6.) implement the solution

7.) evaluate the results of implementing solution

Front 62

fact

Back 62

defined as an acutality, certainity, reality, or truth, obtaining facts is necessarily constrained by time and resources

Front 63

hearsay and rumor may have elements of

Back 63

truth, this makes them important to the extent that they suggest potential problems that warrant further investigation, in themselves hearsay and rumor are never the basis for action or decision making

Front 64

persons who make assertions should be asked how the assertions are supported by

Back 64

facts

Front 65

leadership

Back 65

functions of an organization such as the public health department are organized into areas of common interest, expertise, and public health priorities

Front 66

leaders or managers must have the ability to

Back 66

tailor communication and relationship building based on the interest of the individuals and key stakeholders within these functional groups, its all about relationships

Front 67

primal leadership

Back 67

these individuals have a natural way with communication (born leaders)

Front 68

taught leadership

Back 68

an art, not a science - most successful leaders lead through negotiations

Front 69

building leadership skills: 6

Back 69

1.) assess the environment for collaboration

2.) create clarity through visioning and mobilizing, shared values

3.) build trust among constituents

4.) share power and influence - developing synergy and communication

5.) develop people through mentoring and coaching

6.) self reflection

Front 70

leadership practices inventory (LPI): 5

Back 70

1.) model the way - finding a way to clarify personal values and set examples by aligning actions and shared values

2.) inspire a shared vision - imagining possibilities for the future and enlisting others in the common vision by appealing to shared goals and objectives

3.) challenge the process - seeking innovative ways to change, grow, and improve through risk-taking and experimentation

4.) enable other to act - fostering collaboration and promoting goals and trust among individuals and organization - uplifting others through shared power

5.) encourage the heart - recognizing contributions and showing appreciation for excellence by celebrating values and victories to create a spirit of community

Front 71

relationship management

Back 71

public health leaders and managers must work with individuals from many different types of organizations

while the organizations may differ in their business structure, mission, and goals - they are all staffed by people

different behaviors are necessary to effectively manage the relationships with the various types of individuals, not one size fits all

Front 72

relationship management

Back 72

1.) governing boards: need clear line of responsiblity so the governing board does not become a micromanaging group, recognizing the political nature, may have aligned or competing ideas of how the organizations should be led and manged, managing these relationships takes inpiring a shared vision, has responsibility for evaluating the performance of the leader: through experience, open communication, staying true to mission or organization; in this state, local public health departments dont have local government boards, but do in others; all non-profit public health organizations do have government boards

Front 73

relationship management

Back 73

2.) senior managers - have their own goals - advancement, retirement, maintaining the status quo, etc, share the path for success through development and implementation of a roadmap, key to managing relationships with senior management is to keeping them involved and participating in the process, be honest and upfront about the challenges and benefits of completing certain tasks and must provide the necessary resources, all five LPI behaviors are essential in this setting to manage relationships with senior mangement

Front 74

relationship management

Back 74

3.) front-line employees - face the public on a daily basis and feel the immediate reaction of implemented programs, need to know that leaders and managers are with them, understand the job they do, and are sympathetic to the challenges they face, enable others to act and model the way are two behaviors that can help front line workers better relate to the leader and/or manager

Front 75

Relationship Management

Back 75

7) Consumers:
•When consumers are happy with their services, the leader or manager may never hear anything
•When consumers are unhappy, everyone from front-line staff to the governing board usually hears about the issues
•It is a mistake to leave dealing with unhappy consumers to front-line staff or senior managers
•Managing this relationship takes courage and personal involvement
•Showing compassion and interest that may go a long way to easing unhappiness and inspiring the consumer to become more involved in their own care.

Front 76

Relationship Management

Back 76

8) Community Leaders/Other Organizations
•The best of public health happens in collaboration with those we compete against and those we depend on.
•While leaders and managers of other organizations may be willing to work with you, there is no way to know everything that motivates them – must identify common goals.
•Community leaders: Whatever their motivation, listening to their interests, their ideas, and their demands will only benefit you. A good leader listens first and reacts second.

Front 77

Importance of Teams in Public Health: 2

Back 77

1.) Limited resources
2.) Community effort

Front 78

Outstanding teams Focus on:

Back 78

. accomplishing a particular goal
•The feeling that all the members of the team are operating as a single unit where everyone knows what everyone else is to do at that time
•A willingness to set aside ego and personal ambition for the sake of the team
•High level of commitment and trust between and among team members

Front 79

Types of Groups and Teams: 2

Back 79

•Informal Groups:

•Informal groups are created to fill some sort of social or personal interest or need
•Typically no formal leader
•There are no policies and procedures
•Unwritten norms governing their behavior

•Formal Groups:

•Have boundaries
•Distinct member roles,
•Specific tasks that are performed and measured and operate within a specific organizational context.
•The leader is to understand how to craft and nurture teams that are effective, productive and satisfying to their members.

Front 80

Relationship Management: 5

Back 80

1.) governing boards

2.) senior managers

3.) front-line employees

4.) Consumers

5.) Community Leaders/Other Organizations

Front 81

Team Characteristics: 5

Back 81

•Composition – size and expertise
•Status differences – may lead to intimidation
•Psychological safety – acceptance, allow to make mistakes
•Team norms – unwritten code of conduct
•Team cohesiveness – shows commitment to the task

Front 82

Improving Team Effectiveness

Back 82

Leadership:

•Group composition
•formal leader & informal leaders

Communication networks and interaction patterns:

•redundant communication

Methods of group decision making:

•consensus
•voting

Front 83

Improving Team Effectiveness

Back 83

Group learning:

•collective skill, talent and insights of the group come together
•learn from each other and their environment in a way not available to individual members

Team development:

•Forming
•Storming
•Norming
•Performing
•Adjourning

Front 84

Improving Team Effectiveness

Back 84

Strategies:

•Intergroup training including team building exercises
•Structure the relationship between teams around mutually important goals
•Carefully examine how teams interact to determine the sources of conflict
•Reorganize the teams into new groups that can work independently of one another

Front 85

Improving Team Effectiveness

Back 85

Organizational culture:

•The resources and support systems
•Continuous training

External environment:

•Availability of funding
•Sustain relationships with outside partners is an important part of effective teams in resource poor environments.

Front 86

Principles of Organization Design: 5

Back 86

•Organization design is never static.
•Organization redesign is necessary but if done too frequently, can lead to a significant amount of employee fatigue and loss of productivity.
•While we think of organization design as a rational process, a change in leadership, shifting organization goals or changes in financial condition might dictate a particular design.
•Organization redesign is an ongoing process.
•The design process is a core part of management activities and must take into account authority, responsibility, accountability, resources and rewards.

Front 87

Organization Design

Back 87

Signals for redesign:

•Experiencing significant performance problems
•New product or service is either introduced or is discontinued
•Major shift in the organization’s policies.
•Changes in government regulation
•Change in senior leadership in your organization.

Front 88

THE FIVE BASIC PART OF THE ORGANIZATION: 5

Back 88

1.) Strategic apex

2.) middle line

3.) operating core

4.) technostructure

5.) support staff

Front 89

Forms of Organization Design: 5

Back 89

•Functional
•Divisional
•Matrix
•Parallel
•Program/Product Line

Front 90

Factors Influencing the Choice of Organizational Form: 6

Back 90

•Mission
•Environment
•Organization
•Culture
•Human Resources
•Politics

Front 91

Governing Board

Back 91

Three broad classes of boards:

•honorary
•fiduciary
•community

•Specific roles:

•Hiring, evaluating and (when necessary) terminating the CEO
•Reviewing and approving the annual budget
•Reviewing and approving major organizational decisions, commitments and plans including expenditures, loans and leases
•Evaluating progress towards strategic, programmatic and financial goals
•Select members to serve on the Board and evaluate the performance of the Board itself
•Meet on a regularly scheduled basis
•Update the bylaws as needed

Front 92

Managing Your Relationship with the Governing Board

Back 92

•Important elements that are part of this relationship and include:

•Board education
•Communication
•Engaging then in decision making
•Respect the time of your board

Front 93

Ethics

Back 93

can be defined as the standards of conduct and morality

Front 94

Law

Back 94

is a system of principles and rules for human conduct that arises from a society’s value system, is recognized by society, and enforced by public authority

Front 95

Public health employees must see their value system--their ethic--as a

Back 95

special charge and responsibility to those they serve

Front 96

In most cases, the law is the minimum

Back 96

performance expected in society. Professions demand that their members not only obey the law, but hold them to a higher standard of conduct.

Front 97

Law & Ethics

Back 97

Shows the succession of events that results in the public scrutiny of an organization’s decisions, and a judgment whether they are legal, ethical, or both

codification

manifestation

coprorate decisions

decisions exposed to public scrutiny

decisions determined to be legal/illegal and ethical/unethical

Front 98

Organizational Philosophy and Values

Back 98

•Personal ethics is a result of values imparted from family and friends; religious training; self-study, education, life experience and introspection; and professional codes of ethics.
•The values (personal ethic) of staff at all levels should be congruent with the organization’s.
•It is essential that the cores of the two value systems are compatible and consistent.
•Only by achieving a high level of congruence is the organization able to live its values by developing a strong, pervasive culture.

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Linking Theory and Action

Back 99

Four principles should guide decisions in public health. These principles should be reflected in the organization’s philosophy and culture, as well as in the manager’s personal ethic:

•Respect for persons
•Beneficence
•Nonmaleficence
•Justice

These principles should be reflected in all of the policies, procedures, and rules used by the organization.

Front 100

12 Principles of the Ethical Practice of Public Health

Back 100

1. Public health should address principally the fundamental causes of disease and requirements for health, aiming to prevent adverse health outcomes.
2. Public health should achieve community health in a way that respects the rights of individuals.
3. Public health policies, programs, and priorities should be developed and evaluated through processes that ensure an opportunity for input from community members.

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12 Principles of the Ethical Practice of Public Health cont…

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4. Public health should advocate and work for the empowerment of disenfranchised community members, aiming to ensure that the basic resources and conditions necessary for health are accessible to all.
5. Public health should seek the information needed to implement effective policies and programs that protect and promote health.
6. Public health institutions should provide communities with the information they have that is needed for decisions on policies or programs and should obtain the community’s consent for their implementation

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12 Principles of the Ethical Practice of Public Health cont…

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7. Public health institutions should act in a timely manner on the information they have within the resources and the mandate given to them by the public.
8. Public health programs and policies should incorporate a variety of approaches that anticipate and respect diverse values, beliefs, and cultures in the community.
9. Public health programs and policies should be implemented in a manner that most enhances the physical and social environment.

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12 Principles of the Ethical Practice of Public Health cont…

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10. Public health institutions should protect the confidentiality of information that can bring harm to an individual or community if made public. Exceptions must be justified on the basis of the high likelihood of significant harm to the individual or others.
11. Public health institutions should ensure the professional competence of their employees.
12. Public health institutions and their employees should engage in collaborations and affiliations in ways that build the public’s trust and the institution’s effectiveness.

Front 104

Conflict of Interest

Back 104

•Conflicts of interest arise when someone has two sets of duties or obligations (differing interests) and meeting one set makes it impossible to meet the other.
•These differing interests become a conflict of interest because the individual cannot meet the duty of loyalty to both entities when a decision that affects both is needed.
•A common source of differing interests occurs when a decision maker in an organization has personal gain from outside relationships

Front 105

Patient Consent

Back 105

•Consent is obtained after benefits, risks, and alternatives to the services to be rendered have been explained.
•Three elements are necessary for consent to be ethical:

•Voluntary - Consent must be given freely, without coercion or other interference with the decision.
•Competent - Consent can only be given by someone who is mentally capable of knowing the nature and consequences of the decision
•Informed - Consent must be based on information that is provided

•Obtaining consent for clinical decisions that is voluntary, competent, and informed is the legal responsibility of health care practitioners

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Consent & Public Health Practitioners

Back 106

•Must have patient’s informed consent to be treated by someone in a public health agency.
•Those in training roles must be clearly identified and their status must be known to all with whom they have contact.
•Research - Regardless of legal requirements, public health managers have independent ethical duties to protect research subjects under the principles of respect for persons, beneficence, nonmaleficence, and even justice (fairness).

Front 107

Preventing and Solving Ethical Problems

Back 107

•Ethics committees can provide consultation on a number of issues that arise in clinical programs. They can also:

•serve as a repository of expertise
•educate staff
•prospectively consider the ethical implications of policies and procedures, and resource allocation

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Leadership

Back 108

Leadership

“Leadership is a process through which an individual attempts to intentionally influence human systems in order to accomplish a goal.”
There are a number of attributes of leadership that cut across all leaders regardless of their organizations:

•The focus of leadership is on other individuals or groups
•Leadership means influencing
•The objective of leadership is goal accomplishment
•Leadership is intentional rather than accidental
•Requires a significant degree of personal courage
•Leadership is highly situational

Front 109

Leadership Roles and Power

Back 109

5 forms of power commonly used by leaders to influence others:

•Legitimate – this form of power comes from one’s official position in the organization.
•Reward – in this case, power results from the ability to reward certain behavior by pay, bonuses, promotions, gifts, etc.
•Coercive –use their ability to punish followers for not doing what the leader wants. Examples might be demotion.
•Expert – this form of power is derived from the specific knowledge required by the organization.
•Referent – sometimes called charismatic power, these individuals create admiration, loyalty and the desire to copy the actions of the leader among followers

•These five forms of power are

complementary and should be part of the skill set of every leader.

Front 110

Leadership Styles

Back 110

Three primary leadership styles:

•Authoritative style is used when leaders tell their employees what they want done and how they want it accomplished, without getting the advice of their followers
•Participative style involves the leader including one or more employees in the decision making process
•Delegative style allows the employees to make the decisions – occurs in organizations with highly skilled employees or professionals such as health care settings.

Front 111

Evidence Based Leadership

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Kouzes and Posner found 5 similar patterns of behavior when leaders were at their best:

•Model the Way: Leaders create standards of excellence and then set an example for others to follow
•Inspire a Shared Vision: Leaders passionately believe that they can make a difference
•Challenge the Process: Leaders search for opportunities to change the status quo.
•Enable Others to Act: Leaders foster collaboration and build spirited teams
•Encourage the Heart: Leaders recognize contributions that individuals make – celebrate accomplishments

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Alternative Leadership Perspectives: Transformational Leadership

Back 112

•It has four components:

•Charisma or idealized influence
•Inspirational motivation
•Intellectual stimulation
•Individualized consideration

•Being charismatic involves possessing a dynamic, energetic and commanding presence.
•Transformational leadership works to upset the status quo rather than playing by the rules. Often they are trailblazers, foraging new paths for their organization and their followers.

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Alternative Leadership Perspectives: Servant Leadership

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•There are a number of important attributes of servant leaders and they include:

•Listening receptively to what others have to say
•Acceptance of others and having empathy for them
•Foresight and intuition
•Awareness and perception
•Highly developed powers of persuasion
•Ability to conceptualize and to communicate those ideas
•Ability to exert a healing influence upon individuals and institutions
•Building community in the workplace
•Recognition that servant-leadership begins with the desire to change oneself

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Public Health Funding Sources

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•There are four major sources of funding local health departments: local taxes, state grants, federal grants, and fees for service.
•Over the years the federal government has taken over an increasing role in the financing of public health especially with the growth of emergency preparedness and infectious disease management (HIV).
•The two largest public health care programs are Medicare and Medicaid.

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Public Health Funding

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•Public Health agencies lack of adequate funding to support ongoing services, and have inflexible sources of funds.
•Most federal funds are designated for specific purposes (for example, bioterrorism preparedness)or to serve specific constituencies (for example, Maternal/Child Health)
•Some state funding is also designated but also provide “general revenue”
•This form of “silo” or “stovepipe” funding cannot sustain a permanent infrastructure and discourages evidence-based planning, policies, and programs.

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Funding Priorities

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•Federal funding of public health is determined by Congress who provides states with categorical funding (immunizations, emergency preparedness etc.)
•State funding of public health is determined by the legislature, governor and Department of Health
•Local funding is determined by county commissions, city councils and community needs.

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Health Economics

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•Economics involves the utilization and management of scarce resources
•Economics is concerned with the way in which resources are allocated among alternative uses
•Health Economics addresses the choice a society and its individuals make about health care

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Measures of Health Status

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Life expectancy measures used in economic analysis:

•QALY: Quality-adjusted life years calculates life expectancy adjusted for quality of life, where quality of life is measured on a scale from 1 (full health) to 0 (dead).
•DALY: Disability-adjusted life years combines years of life lost (YLL) through premature death (before 82.5 years for a woman and before 80 years for a man) plus years lived with the disability (YLD).

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Economic Analysis

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•Can be used to determine the burden of a disease or cost effectiveness of a treatment.
•To estimate a disease burden, you need to know:

•The prevalence of the disease in a population
•Assessment of the effect on health status (QALY)
•Quantify direct and indirect costs associated with these effects.

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Economic Analysis

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•Economic evaluations must take into consideration the difference between efficacy and effectiveness.

•Efficacy is the maximum possible benefit, often achieved with controlled trials
•Effectiveness is the actual decrease in disease achieved when the intervention is applied over a large, non-homogeneous population

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Methods of Economic Analysis

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Cost-benefit analysis (CBA):

•The objective of cost-benefit analysis is to maximize net benefits (benefits minus costs in monetary terms).

Cost-effectiveness analysis (CEA):

•Similar approach by calculating the monetary value of the intervention costs. The difference is that cost-effectiveness considers the effects produced by an intervention, which are not measured in monetary terms (lives saved, illnesses prevented or years of life gained).
•Used more in healthcare since it is hard to put a monetary value to a life.

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Examples

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•CBA:

•Immunizations save $8.50 in direct medical costs for every $1 spent
•ER diversion program - saved $3.26 of ER costs for every dollar of program costs

•CEA:

•Colon cancer screening $20,000 per 1 QALY saved
•coronary artery bypass surgery $25,000 per DALY averted

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The gains and losses of providing public health programs

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.apply not only to the people who are receiving the services but to the population as a whole (allocation of scarce resources).

•Using economic analysis methods helps society determine the best use of these scarce resources and allocate funding to the most effective intervention.

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Diverse Base of Funding Sources

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•Health service organizations must be attentive and open to all possible funding sources outside of their usual business revenues (fees for services).
•Public health agencies receive the bulk of their revenue from state, local and federal government sources; however, some of this revenue is through competitive grants (HRSA, CDC).
•Other revenue sources include grants and donations from foundations and private parties. Some examples of these include:

•Robert Wood Johnson Foundation
•Annie E Casey Foundation
•Kellogg Foundation

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Revenue Types

With revenue that is considered philanthropy, there are three general categories:

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1.Restricted Revenue: support specific projects and programs (usually has a defined budget)
2.Unrestricted Revenue: support general work and capacity. Most difficult for which to fundraise.
3.Endowment: principal of the gift is preserved in perpetuity and annually (only a percentage of interest earned is used to support the specific project or program)

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Fundraising Basics

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•Financially successful organizations create varied, unique philanthropy road maps that include both short and long term goals.
•Understand basic fundraising approaches (i.e. grants, events, direct giving campaigns).
•Determine which funding sources are better organizational matches than others (based on programs, needs).
•Anticipate potential bottom-line impacts – don’t want to spend more then you will make in the fundraising process.

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Federal and State Agency Contracts and Grants

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•Largest source of revenue for public health organizations

•There are important distinctions between a grant and a contract

•Grants usually have broader expectations, no legal ramifications if project not accomplished (may be paybacks or blacklisted for future grants)
•Contracts are for specific services; can involve legal ramifications if not provided within specifications/timeframes.

• Competitive process

•“Request for proposals” outlines all of the information required in proposal.
•Scoring criteria and process for selection
•Grant or contract award provides details on expectations, timeframes etc.

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Foundations

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•Play important philanthropic role in supporting non-profit organizations

•Private Foundation: An organization created from designated funds from which the income is distributed annually as grants to not-for-profit organizations, groups and/or individuals.
•Corporate Foundation: foundation funded by a profit-making corporation that has as its primary purpose the distribution of grants according to established guidelines.

•Foundations tends to want to build relationships with their grantees - initially make small steps until the organization “proves” itself

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Individual Donors

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•Greatest source of philanthropy in the United States

In order from most effective to least effective:

personal - face to face

personal letter on personal stationary

personal telephone call

personalized letter

direct mail

phon-a-thon - impersonal

special event

door to door

media advertising

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Fundraising Staffing

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•All members of an organization play a part in fundraising - every staff member understands how they help promote a culture of philanthropy within their broad community (spokesperson for the organization)
•Fundraising staff – in-house or outsourced
•Not simply a staff responsibility; it is also supported through a volunteer network - broadens base of donors

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Fundraising Ethics

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•Need to be vigilant about how to engage with fundraising prospects and donors:

•“Friend raising”

•Public health and health service organizations need to have self-monitoring processes in place to focus on areas such as:

•Accounting standards
•Organizational accountability
•Organizational policies, including gift acceptance, investment policies and spending policies
•Gift agreements
•Fee-based fundraisers
•Donor privacy
•Conflict of interest policies

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Strategic Project Management

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•Organizations that have successful fundraising programs tie fundraising strategy to the organization’s strategic plan, mission and vision.
•Project management tools help donors visualize the links between the strategic plan and the gifts they give

1.What are we trying to accomplish and why?
2.How will we measure success?
3. How do we get there?

•Also help the organization and the donor better understand possible partnerships available to help execute the organization’s vision and plans

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Setting Organizational Strategy

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•To build your fundraising infrastructure and to set fundraising dollar targets, health services managers must consider several interrelated areas:

•Staffing: fundraising budget allocation (employees or contracted services)
•Organizational senior leadership and governance volunteers/Board: ownership of fundraising goals
•Donor readiness: donors and funders understanding of the organization’s goals and priorities

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Long-term Process

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•Not a quick fix to an organization’s financial difficulties.
•Requires an upfront investment in building the infrastructure and skills necessary to be successful.
•Need to develop and nurture relationships with donors and funding agencies.
•Not a single person’s responsibility but rather part of everyone’s job in the organization.

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Strategic Thinking

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Strategic thinkers:

•Acknowledge the reality of change
•Question current assumptions and realities
•Builds an understanding of systems
•Envisions possible futures
•Generates new ideas
•Considers the fit of their organization with the external environment

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Strategic Planning

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•Provides a sequential, step-by-step process for creating a strategy
•Involves periodic brainstorming sessions
•Requires data and information but also builds in consensus and judgment
•Establishes an organizational focus
•Facilitates consistent decision making processes
•Reaches consensus on what is required to help the organization fit with the external environment
•Results in a documented strategic plan

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Environmental Assessment

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•External Environmental Analysis - examines the external forces impacting an organization including demographic, economic/fiscal, and political factors and trends

•Environmental scanning - systematically scanning for changes in your environment – political, technical, economic, societal etc.
•Issue monitoring - tracking issues or trends over time
•Forecasting of future issues – how will you respond given different scenarios
•Issue assessment - understand the effect an issue will have on your organization

•Used to formulate the opportunities and threats faced by an organization

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Environmental Assessment

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•Internal Environmental Analysis and Value Creation

•Identifying internal strengths and weaknesses
•Evaluating your relevance in the community

•Value- services valued by the community?
•Rareness – are you the only one capable of providing this service?
•Imitability – is it easy to duplicate the services you provide?
•Sustainability – can you maintain services over time?

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SWOT Analysis

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•Strengths: characteristics of the business that give it an advantage over others. - internal and helpful
•Weaknesses: characteristics that place the it at a disadvantage relative to others - internal and harmful
•Opportunities: elements that the business could exploit to its advantage - external and helpful
•Threats: elements in the environment that could cause trouble for the business - harmful and external

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Strategic Choice

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•Strategies need be aligned with your Mission, Vision and Values

•Strategic Goals

•Relate to attributes critical to your mission
•Connect to critical success factors and what is needed to carry out specific objectives
•Stated in terms that the whole organization can understand

•Strategic Alternatives

•Growth strategies
•Contraction strategies
•Maintenance strategies

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Strategic Plan Implementation

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•Assign tasks and timeframes
•Develop dashboard indicators to collect the needed data for monitoring
•Review on a regular basis the progress being made to achieve the goals and objectives
•Revise as the internal and external environment changes

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Strategy and Organizational Culture

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•Implicit, invisible, intrinsic, and informal consciousness of the organization
•Made up of shared assumptions, shared values and shared behavioral norms
•Culture is learned, shared and is both subjective and objective.
•The creation of an organizational strategy embodies a level of change that is dependent on the type of strategy being enacted.

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Change Management

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•Four attributes that specifically determine the outcome of any change process:

•Duration – the length of time needed until a change process is completed
•Integrity – the ability of the team to complete the change process on time
•Commitment – the extent to which senior management is committed to change
•Effort – the amount of time that the change process demands over and above the usual work that still needs to get done.

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Marketing

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•Marketing is another tool used in strategic management.
•Public health programs must compete with other public priorities for funding.
•Public health practitioners must convince policy makers and the public about the value they provide to the community.
•How you tell the story about local public health and the role of local health departments will vary depending on who you are talking to -- peers, policymakers, community groups, the media, and the general public.
•Health Departments must be their own advocate.

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Marketing Strategies

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•Build relationships with local media - provide them with information about new programs or initiatives, trends or public health threats.
•Regularly providing information to your local and state policy makers about the value of your services.
•Reach out to the community and inform them of your programs and services as well as any public health threats that may arise.
•Make sure your employees are your best advocates. What they tell their neighbors and friends can impact the image of the Health Department.

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U.S. Demographic Trends

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•The percent speaking a language other than English at home went from 17.9 percent in 2000 to 19.7 percent in 2007, while continuing upward to 20.8 percent in 2011.
•Of the 60.6 million people who spoke a language other than English at home in 2011, almost two-thirds (37.6 million) spoke Spanish.
•The percent speaking English "less than very well" grew from 8.1 percent in 2000 to 8.7 percent in 2007, but stayed at 8.7 percent in 2011.

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U.S. Demographic Trends

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•In addition to English and Spanish, there were six languages in 2011 spoken at home by at least 1 million people:

•Chinese (2.9 million)
•Tagalog (1.6 million)
•Vietnamese (1.4 million)
•French (1.3 million)
•German (1.1 million)
•Korean (1.1 million)

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What is Culture?

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•Culture - integrated patterns of learned beliefs and behaviors that is shared among groups and includes thoughts, styles of communicating, ways of interacting, views on roles and relationships, values, practices, and customs.
• Through culture, people and groups define themselves, conform to society's shared values, and contribute to society.
•The cultural bond may be ethnic or racial, based on gender, or due to shared beliefs, values, and activities.
•Culture is dynamic in nature, and individuals may identify with multiple cultures over the course of their lifetimes.

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Culture and Language

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Culture and language may influence:
•health, healing, and wellness belief systems;
•how illness, disease, and their causes are perceived;
•the behaviors of patients/consumers who are seeking health care and their attitudes toward health care providers;
•as well as the delivery of services by the provider who looks at the world through his or her own limited set of values, which can compromise access for patients from other cultures.

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Cultural Competency

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Definition: Cultural and linguistic competence is a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations.
•Cultural Competence is NOT
•Stereotype or Generalization major subpopulations
•Bilingualism or Biculturalism
•Acculturation - adopting the beliefs and behaviors of another group

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Need for CLC Services

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There are ethical and practical reasons why providing culturally and linguistically appropriate services in health and health care is necessary, including the following:

1.To respond to current and projected demographic changes in the United States.
2.To eliminate long-standing disparities in the health status of people of diverse racial, ethnic and cultural backgrounds.
3.To improve the quality of services and primary care outcomes.
4.To meet legislative, regulatory and accreditation mandates.
5.To gain a competitive edge in the market place.
6.To decrease the likelihood of liability/malpractice claims.

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National Policy

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•In 2001, DHHS‐OMH (Office of Minority Health) released the National Standards on Culturally and Linguistically Appropriate Services (CLAS) to emphasize the need for a health system‐level response to language access.
•The enhanced National CLAS Standards were released in 2012 - are intended to advance health equity, improve quality, and help eliminate health care disparities by providing a blueprint for individuals and health care organizations to implement culturally and linguistically appropriate services.

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National CLAS Standards

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Principle Standard: Provide effective, equitable, understandable and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy and other communication needs.
Standards fall into 3 categories:
1.Governance, leadership and workforce
2.Communication and language assistance
3.Engagement, continuous improvement and accountability

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Governance, Leadership and Workforce

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• Advance and sustain organizational governance and leadership that promotes CLAS and health equity through policy, practices and allocated resources.
•Recruit, promote and support a culturally and linguistically diverse governance, leadership and workforce that are responsive to the population in the service area.
•Educate and train governance, leadership and workforce in culturally and linguistically appropriate policies and practices on an ongoing basis.

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Communication and Language Assistance

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•Offer language assistance to individuals who have limited English proficiency and/or other communication needs, at no cost to them, to facilitate timely access to all health care and services.
•Inform all individuals of the availability of language assistance services clearly and in their preferred language, verbally and in writing.
•Ensure the competence of individuals providing language assistance, recognizing that the use of untrained individuals and/or minors as interpreters should be avoided.
•Provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the populations in the service area.

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Engagement, Continuous Improvement and Accountability

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•Establish culturally and linguistically appropriate goals, policies and management accountability, and infuse them throughout the organization.
•Conduct assessments of the organization’s CLAS-related activities and integrate CLAS-related measures into assessment measurement and CQI activities.
•Collect and maintain demographic data to monitor and evaluate the impact of CLAS on health equity and outcomes and to inform service delivery.
•Conduct regular assessments of community health assets and needs and use the results to plan and implement services that respond to the cultural and linguistic diversity of populations in the service area.
•Partner with the community to design, implement and evaluate policies, practices and services to ensure cultural and linguistic appropriateness.
•Create conflict and grievance resolution processes that are culturally and linguistically appropriate to identify, prevent and resolve conflicts or complaints.
•Communicate the organization’s progress in implementing and sustaining CLAS to all stakeholders, constituents and the general public.

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Linking the Pieces

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1.) cultural competence

2.) linguistic competence

3.) community engagement

4.) patient and family centered care

5.) health literacy

6.) partnerships between patients & health professionals

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Individual Awareness

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•One’s perceptions of other cultures are influenced by one’s own world view
•Cultural biases may be at a conscious or subconscious level
•Values, beliefs, and practices related to health, health care, illness, and well-being:
•One’s own
•Prevailing society norms
•Among culturally diverse individuals, groups, and communities
•Within health care systems and institutions
•Social, economic, and environmental factors that impact the health and well-being of communities
•Self-assessment and reflection can have a positive impact on capacity for cultural and linguistic competence, for individuals and organizations

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BELIEF Model

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The BELIEF model is based upon several of the interviewing instruments and is intended for use by clinical personnel.

•B - Health beliefs (What caused your illness/problem?)
•E - Explanation (Why did it happen at this time?)
•L - Learn (Help me to understand your belief/opinion.)
•I - Impact (How is this illness/problem impacting your life?)
•E - Empathy (This must be very difficult for you.)
•F - Feelings (How are you feeling about it?)
Dobbie

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Workplace Diversity Defined

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•Nondiscrimination in the workplace on basis of race, ethnicity, primary language spoken, religion, disability, sex, or age.
•A diverse workplace respects and values differences among people and points of view and fosters environment in which many views and perspectives flourish is a management ideal
•Capacity to produce positive outcomes in relation to a host of performance measures

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Health and Healthcare Disparities

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•The overall health of the Americans has improved over the past few decades, but not all Americans have benefited by these improvements.
•Among nonelderly adults, 17% of Hispanic, and 16% of black Americans report they are in only fair or poor health, compared with 10% of white Americans.
•Infants born to black women are 1.5 to 3 times more likely to die than those born to women of other races.
•Health disparities - differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups.
•Healthcare disparities - differences among population groups in the availability, accessibility and quality of health care services.

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Racial and Ethnic Workforce Diversity

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•The IOM stresses the evidentiary basis for health workforce diversity:
•evidence of improved access to care
•evidence of greater levels of patient satisfaction
•evidence of improved health care utilization leading to better health outcomes and the reduction of disparities in health
•more dynamic and high performing research enterprise

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Diversity in the Public Health Workplace

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•Three core functions characterize the public health enterprise: assessment; assurance; and policy development.
•A public health workforce that is diverse and emphasizes diversity is essential to the performance of these three functions.
•Important to identify and address health disparities as part of the health department’s role in assessment, assurance and policy development.

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The Legal Basis of Workforce Diversity

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•The laws that govern non-discrimination in the workplace are complex and are broadly summarized as follows:
•Prohibits intentional discrimination against certain protected population subgroups.
•Does not compel any particular diversity outcome, only that discrimination not be intentional or as a result of workplace practices.
•Prohibits the use of hard quotas to achieve workplace diversity; however, the law favors the use of well designed and narrowly tailored practices in recruitment, workplace employment, and the conditions of employment, that can help promote a diverse workplace that is reflective of the community it serves.

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Categories of Non-Discrimination Laws: Legally Protected Populations

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•Federal civil rights laws prohibit workplace discrimination:
•Title VII of the 1964 Civil Rights Act
•The Age Discrimination in Employment Act (ADEA)
•The Americans with Disabilities Act (ADA)
•Some have basis in constitution, others lawmakers have created to enact specific protections and include race, national origin, skin color, sex, religion, disabilities, age (older workers).
•State laws may recognize certain additional populations as deserving legal protection (sexual orientation, HIV/AIDS)

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Civil Rights Act of 1964

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•Federally protected under Title VI of the Civil Right Act of 1964
•Sec. 2000d. Prohibition against exclusion from participation in, denial of benefits of, and discrimination under federally assisted programs on ground of race, color, or national origin
•No person in the United States shall, on the ground of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance.

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Laws compelling diversity as a condition of federal funding

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•Beyond federal civil rights laws, various federal programs that provide funding may contain specific conditions that create diversity obligations.
•Medicare and Medicaid
•Grants from CDC, HRSA, NIH
•Limited English Proficiency (LEP) Guidelines
•Require presence of formal interpreter services in larger facilities
•Interpreter services are required by managed care organizations and accrediting bodies (JCAHO, AAAHC, CARF)

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Managing for Workplace Diversity

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•“Corporate compliance” – oversees employment practices, contractual obligations and legal obligations.
•Diversity has a rationale that extends well beyond legal compliance – essential business practice for healthcare providers to ensure the accessibility and quality of care for the community it serves.
•Proactive and insightful public health leaders will make diversity one of the core values upon which their organization functions.

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Four Diversity-centric Business Strategies

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•Think broadly about diversity - not just what is required by law
•Reflect on the diversity of the population – staff should reflect the population it serves
•Better meet the needs of clients – increases accessibility and quality of services
•Enhance organizational performance – increases trust and brings value of your services to the community

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mission

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statement of organization's purpose or reason for being

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vision

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seeks to describe what the organization wishes to become and its hope for the future

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values

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the core principles that organizations and the people within them stand for and that serve to make the organization unique

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strategic goals

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the mission, vision, and values of an organization provide the focus and direction for the choice of strategic goals