Public Health funding continues to decline in Cobb and Douglas Counties while the population grows and diversifies. CDPH has been forced to leverage all opportunities to most effectively serve the citizens of the dual county district. Various improvements across the agency have been accomplished through a focused effort on measurement, evaluation and continuous improvement. Stakeholders from within Cobb and Douglas Counties, Georgia include staff of Cobb and Douglas Public Health, the Boards of Health of Cobb and Douglas counties and community partners within the local public health system. It is expected that the entire population of the counties will benefit, at least indirectly, from improvements to the infrastructure of the public health system.
Cobb County Board of Health
Center for Organizational Performance and Strategy Management
Public Health funding continues to decline in Cobb and Douglas Counties while the population grows and diversifies. CDPH has been forced to leverage all opportunities to most effectively serve the citizens of the dual county district. Various improvements across the agency have been accomplished through a focused effort on measurement, evaluation and continuous improvement. Stakeholders from within Cobb and Douglas Counties, Georgia include staff of Cobb and Douglas Public Health, the Boards of Health of Cobb and Douglas counties and community partners within the local public health system. It is expected that the entire population of the counties will benefit, at least indirectly, from improvements to the infrastructure of the public health system. Upon joining the agency in 2008 as District Health Director, Dr. Jack Kennedy identified the need to bring a more disciplined approach to the agency in areas of business administration – in building a more solid infrastructure and expanding the capacity of the entire system. A new office and positions were developed by Dr. Kennedy in conjunction with the CDPH leadership team and subsequently approved and funded as a part of the agency budget by the local Boards of Health. Simultaneously, funding was sought and obtained for the services of Dennis Barnhart, a consultant who had worked with a number of for-profit and not-for-profit organizations in Canada, the US and Europe. CDPH began developing mission, vision and values statements. The Balanced Scorecard framework was employed to provide a framework, methodology and structure to the process.
A key gap identified was the lack of a robust process of community health assessment (CHA) and community health improvement planning (CHIP). Guidance was sought from the National Association of County and City Health Officials (NACCHO) and the MAPP (Mobilizing for Action through Planning and Partnerships) framework was adopted to undertake CHA and CHIP processes. The MAPP Steering Committees kicked-off monthly meetings beginning in April 2011. After only six months, with facilitation support and logistics support from the MAPP Coordinator, the MAPP Steering Committees have completed the Local Public Health Systems Assessment and expect to have completed the remaining three assessments (Community Health Status, Community Themes and Strengths and Foces of Change) by February 2012. In early 2011, CDPH staff identified an opportunity to apply for Capacity Building funding from the Centers for Disease Control (CDC) for Community Transformation. Reviewing the CDC Request for Proposal, staff noted the strong alignment between Community Transformation activities and the MAPP process already underway at the agency. A cross-functional team of CDPH employees was identified to prepare the application. In September 2011, CDC staff announced that Cobb Public Health had been awarded a $499,000 grant to enhance those Capacity Building Activities.
Upon joining Cobb and Douglas Public Health in 2008 as District Health Director, along with the Board of Health and a strong Leadership Team, Dr. Jack Kennedy identified the need to bring a more disciplined approach to the agency in areas of business administration – in building a more solid infrastructure and a more robust system to more effectively serve a diverse and growing population. A strategic planning process was initiated at the agency utilizing the Balanced Scorecard framework. The Balanced Scorecard is a strategic planning and management system used across a variety of business and industry, government, and nonprofit organizations internationally to align business activities to the vision and strategy of the organization, to improve communications, and to monitor an organization’s performance against strategic objectives. It was created by Drs. Robert Kaplan (Harvard Business School) and David Norton as a measurement framework that balanced lead to lag measures and strategic non-financial performance measures to traditional financial metrics. The goal of the improvements to the strategy management system was to influence the entire organization to ensure that CDPH does the right things, the right way, at the right time. The system holds the agency accountable for performance and provides the information needed to continually improve.
Accreditation was identified in the agency’s vision statement: By 2014, Cobb and Douglas Public Health will be an acknowledged leader among health departments in the Southeastern United States….we will work…to obtain PHAB accreditation. In 2009, the agency began a first round of self-assessment of readiness to undertake accreditation efforts. Resources were allocated to begin addressing gaps identified in that assessment process. A key gap identified in readiness for accreditation was the lack of a robust process of community health assessment (CHA) and community health improvement planning (CHIP). Guidance was sought from the National Association of County and City Health Officials (NACCHO) and the MAPP (Mobilizing for Action through Planning and Partnerships) framework was adopted to undertake CHA and CHIP processes.
Through careful review of the agency’s ability to provide the Ten Essential Services of Public Health, Dr. Kennedy along with the CDPH Leadership Team and local Boards of Health realized that more deliberate organization and improvement of the agency’s infrastructure through provision of dedicated resources would enable delivery of better outcomes to the entire community.
The Balanced Scorecard, managed by the OPSM office, provides a comprehensive view of CDPH's overall performance by monitoring key performance indicators from four perspectives: customer, internal business processes, employee learning and organizational growth, and financial. These categories are broad and embrace activities such as accreditation, workforce development, community health assessment and improvement. By implementing initiatives to close gaps in accomplishing important objectives and frequently monitoring progress, the agency is better able to serve the community - and hold all stakeholders accountable for improved performance and outcomes.
Typically seen only in a corporate setting, this office is staffed with a Director (experienced in strategic planning, budgeting and business development) a Policy and Planning Specialist (who serves as a MAPP Coordinator) and an administrative assistant. This office also oversees a cross-functional Organizational Performance Enhancement workgroup formally chartered with responsibilities of quality improvement, environmental and policy scanning, assessment, and evaluation activities. Other agencies, including the State of Georgia Department of Public Health, have requested interviews, presentations and information about the coordination and management of the functions of the Center of Organizational Performance and Strategy Management at CDPH. Much of the contents of this application include materials shared with those organizations. Over the course of the last three years, CDPH has realized that promoting health and preventing disease in a community with less than $30 per capita of public health funding requires the agency to leverage and capitalize on every opportunity. With shrinking ability to provide direct services, the agency assessed the value of allocating funds for this function. The return on the investment in these OPSM positions has underscored the appropriateness of those decisions.
CDPH’s approach to strategic planning, quality improvement, accreditation and engaging the community in a more deliberate and focused manner is different from other approaches seen in public health due to the unique approach of creating and staffing an Office of Organizational Performance and Strategy Management (OPSM).
It is the goal of the OPSM office to identify innovation, efficiencies and resources to provide exponentially more value to the community than direct allocation to services of the invested dollars would provide (for instance, improving the delivery of mass vaccination services in the community versus during one-on-one encounters at the Health Department). CDPH has resourcefully employed and woven various tools and practices into the work overseen by the OPSM offices including:
• MAPP – two simultaneous, highly-engaged MAPP Steering Committees in the two county district - creativity is exhibited in sharing the resources of the larger suburban county (Cobb with over 700,000 residents) with the smaller, more rural (Douglas with approximately 130,000 residents). This has been achieved by combining Community Health Status workgroups that share hospital and university representatives in developing surveys to identify disparities within the communities.
• The NACCHO PARTNER tool - used to assess the strength and sustainability of partnerships – creativity of use of the tool is the inclusion of the results in an agency Balanced Scorecard metric.
• CDC Assessment Tools – Local Public Health System Assessments (the agency and community piloted CDC’s version 3.0) and Agency Contribution Assessments – innovatively used and leveraged these tools to identify pilot partners to implement improvement plans.
• Healthy People 2020 goals have been integrated into the MAPP Community Health Assessment processes and to recruit members to undertake sustainability planning – one indicator at a time.
• NACCHO fact sheets on Community Health Benefit have been used to engage and develop presentations in conjunction with the Georgia Hospital Association and local non-profit hospitals.
• NACCHO Community Balanced Scorecard guidance and resources will be employed during the Community Health Improvement planning phase of the MAPP efforts in February-July 2012. The agency has previously implemented a Community Balanced Scorecard process with a coalition focused on nutrition and activity. CDPH is in the top 5% of health departments nationally based on the size of the population served. Unique challenges are represented however, because the two counties within the district represent vastly different demographics. The agency must consistently tailor approaches to best meet the needs of each county. The magnitude of the complexity of the work of the agency has been more easily undertaken through the establishment of the OPSM office within the agency – and the ability of that office to organize and focus resources as needed.
Other agencies, including the State of Georgia Department of Public Health, have requested interviews, presentations and information about the coordination and management of the functions of the Center of Organizational Performance and Strategy Management at CDPH. Much of the contents of this application include materials shared with those organizations.
Various functions of the OPSM office are undertaken routinely at other agencies, but a large county/district local health department has not been identified that has centralized and specifically staffed and streamlined these functions, and incorporated them into an agency-wide Balanced Scorecard for management, within one department. Other agencies, including the State of Georgia Department of Public Health, have requested interviews, presentations and information about the coordination and management of these functions at CDPH. Much of the contents of this application include materials shared with those organizations.
All stakeholders within Cobb and Douglas counties, Georgia – specifically including staff of Cobb and Douglas Public Health, the Boards of Health of Cobb and Douglas Counties, community partners within the local public health system and citizens of the two-county district - have benefited from a resource dedicated to identifying needs, resources and improvements geared toward public health. At some level (advisement, serving on coalitions, providing feedback for evaluation), stakeholder groups participate and shape OPSM activities. For instance, customer survey data and related analysis is collected by the OPSM staff (as part of the regular Balanced Scorecard reporting function) and shared with internal staff to identify areas for improvement, with the Boards of Health to solicit funding for needed improvements (such as expanded waiting rooms) and with community partners to solicit assistance and sharing of resources (such as requests for the donation of medical services for those who suffer long wait times or insufficient care in the public health setting).
Role of Stakeholders/Partners
Stakeholders have contributed in various ways to the functions of the OPSM office. The Boards of Health have provided and approved sufficient funding for activities. Community leaders have provided advisement and letters of support for funding and organizing activities. Over 50 partners contribute financial and human subject-matter-expert resources for involvement in the MAPP Committee work.
Through the OPSM Office, CDPH responds to requests and engages stakeholders in improving the overall performance of the agency and the overall health of the community. CDPH initiated a MAPP process within the Cobb and Douglas communities in 2010 and has secured funding that will sustain the process for at least two years. CDPH provides logistics support for the now-active and engaged Committees. CDPH has specifically identified goals within community partner agencies that align with and support the improvement of community health. During monthly MAPP Steering Committee meetings, CDPH staff actively work to identify and demonstrate how collaboration benefits the community. During the recent Local Public Health System Assessments, CDPH invited Fit City Tyler Texas representatives to speak to participants during opening sessions, lunch and closing sessions about the successes of the collaborative efforts in their community. MAPP partners networked and planned for similar initiatives following these sessions.
If CDPH were to undertake similar efforts, a few critical lessons would be considered for improvement. First, neutral facilitation of efforts is critical. Removing barriers to quickly address root issues is the most efficient approach – whether in the community or even within the agency where various programs are competing for limited resources. Additionally, the Local Public Health System Assessments would have likely been completed over several sessions instead of in a one day setting as a kick-off to a MAPP effort. The ability to see various partners at work would have enabled the agency to identify key partners with expertise and willingness in a more efficient and effective manner than the “potential participant brainstorming” sessions actually used for initiating the MAPP efforts.
Upon joining the agency in 2008 as District Health Director, Dr. Jack Kennedy identified the need to bring a more disciplined approach to the agency in areas of business administration – in building a more solid infrastructure to respond more efficiently and effectively to a diverse, growing population. A new position, with identified core competencies, was developed by Dr. Kennedy in conjunction with the CDPH leadership team. The position, Director of Organizational Performance and Strategy Management (OPSM), was approved and funded ($80,000 plus benefits) as a part of the agency budget by the Boards of Health following a presentation and request by Dr. Kennedy. Simultaneously, funding (in the approximate amount of $10,000 plus travel and incidentals) was sought and approved for the services of Dennis Barnhart, a consultant who had worked with a number of for-profit and not-for-profit organizations in Canada, the US and Europe, providing consultation and practical advice and tools to support best practice strategic planning, enterprise performance management and organizational change programs. Guidance was sought from the National Association of County and City Health Officials (NACCHO) and the MAPP (Mobilizing for Action through Planning and Partnerships) framework was adopted to undertake much needed CHA and CHIP processes. A second position, MAPP Coordinator, was added in the OPSM office at the agency ($60,000 plus benefits).
In 2008, the OPSM director position was created and consulting services were secured for development of a robust strategic planning process. Agency strategy development ensued over the next 12-18 months. Local Boards of Health and community stakeholders were actively engaged for input and feedback. Following assessment for accreditation readiness in 2009-2010, a MAPP coordinator position and clerical support was added to the OPSM office. Through a highly organized effort program categorization (mandated/non-mandated, etc.) and summarization was accomplished by December 2010. The MAPP Coordinator oversaw the kickoff of the MAPP initiative following six months of preparation in April 2011. Strategic objectives were cascaded to agency programs in 2010 and 2011. By July of 2011, all agency personnel had developed aligned personal scorecards.
Process & Outcome
The Balanced Scorecard Strategy Management framework inherently provides evaluation of key agency objectives using financial/non-financial and lead (process) measures balanced with lag (outcome) measures. Various evaluation metrics have been identified, monitored and reported for the top 10-12 agency, program and individual strategic objectives. At an agency and program level the following measures have been developed, tracked and assessed on a monthly basis for improvement opportunities: customer satisfaction survey results, program activities targets (number of screenings, for example, program outcome targets (increased immunization rates, for instance), number of strategic partnership needs filled, number of PHAB accreditation measures fully documented, percentage of personal scorecard goals accomplished by agency employees, retention rates, dollars of traditional and non-traditional funding and number of budget revisions undertaken by programs.
More specifically, the top three following objectives were evaluated:
• Provide high quality services to our customers
• Promote health and prevent injury and disease to achieve healthy communities
• Promote, develop and evaluate community partnerships
Evaluation findings are compiled at the personal and program levels for the Balanced Scorecard processes. Results are shared in staff meetings and summarized for sharing and input with the local governing Boards of Health. The Leadership Team at CDPH meets monthly to review metrics and reports/analysis and participates in three separate annual Strategic Planning Retreats with the Boards of Health. Lastly, once per year, in May, the agency provides all-staff Continuing Education sessions at an all-day retreat-style event. Core Competencies for Public Health Officials training for all staff (as outlined in all personal scorecards) and dozens of other critical topics are slated for 2012 continuing education offerings.
Objective 1: Provide high quality services to our customers: agency targets were established for customer surveys. On a scale of 1-5, agency customer service was rated at 4.7 in May 2011 following a 27% response rate to survey requests. Space constraints at the agency were identified with improvement needs noted by an architect in 2010. Despite a challenging economic climate, agency staff undertook efforts to pursue inclusion in the county’s special purpose local option sales tax (SPLOST). The agency was eventually approved to receive funds from the SPLOST – in an amount exceeding $6 million. The option passed by a slim margin of less than 100 votes (please note there are approximately 400 employees at CDPH). Funding will be used to expand various service areas to a neighboring county facility.
Objective 2: Promote health and prevent injury and disease to achieve healthy communities: through cascading Balanced Scorecards to over 30 agency programs, activity and outcome targets have been established and monitored to ensure delivery of grant and funding requirements and to align all programs and staff to the overall objectives of the agency.
Objective3: Promote, develop and evaluate community partnerships: Over 130 total partners participated in the Local Public Health Assessments held in the counties in early October 2011. Over 40 of these partners meet monthly in each of the counties as a part of the MAPP Steering Committees. Many of these partners are currently not only engaged in CHA and CHIP activities, but are undertaking planning for sustaining the processes within the community.
Sustainability for the functions overseen by the CDPH OPSM Office has been addressed in the following manner: Strategic Management: CDPH has cascaded the agency’s Balanced Scorecard throughout the agency. Metric and initiative owners and teams contribute to the strategy management process, without overreliance on any single staff member. Each employee has developed and tracks progress toward a personal scorecard that aligns with programs/centers and the agency overall. The personal scorecard process has been integrated into the State of Georgia’s performance management system and is a key component of the agency’s Workforce Development Plan. No less than six times per year, CDPH leadership presents results of strategic efforts to the Boards of Health - and engages members in assessment and prioritization. Minimal funding required for maintenance of Balanced Scorecard Management software and administration staff will be allocated as a result of the strong support of local Boards of Health for the process.
MAPP/CHA/CHIP: To ensure continuity of community health assessment and improvement, CDPH has identified stakeholders within the community, obtained pledges of support, established a routine meeting schedules for Steering Committee members and workgroups, secured funding to develop a MAPP website and identified/leveraged similar community efforts (such as the Community Health Benefit efforts of the local non-profit hospitals).
Accreditation: CDPH has identified an owner for each document required for accreditation. A team of Domain Owners (the Accreditation Team) oversees the assessment and revisions of the documentation. PHAB Standards and Measures have been adopted as an “unofficial” supplement to the agency’s policy and procedures manuals. The Accreditation Team meets monthly for approximately one hour to discuss gaps in meeting standards and plans for remediation. Accreditation is specifically included in the agency’s Vision statement and is an effort fully supported by both local Boards of Health.
In addition to the sustainability inherently built into processes described above, CDPH has developed strong relationships with community members with vested interests in improving community health. Specific plans to sustain practices and leverage resources include:
• Cobb and Douglas Counties are fortunate to partner with several local non-profit hospitals. In addition, relationships with the Georgia Hospital Association (GHA) have been established. Once IRS guidance for Community Health Benefit has been finalized and stakeholders within the hospitals identified, CDPH has planned a series of workshops with hospital partners to determine how deliverables and improvement planning aligns. CDPH and GHA collaborated together and with NACCHO to provide feedback to the IRS on such guidance in 2011 in an effort to ensure that collaboration on improvement efforts is more easily achieved (restrictions, requirements, timeframes).
• CDPH produces a report, How Healthy Are We? (HHAW) – the latest version was issued in 2010: (http://cobbanddouglaspublichealth.org/HealthStatistics/index.php. Community Health Assessment staff are assessing the feasibility of engaging co-sponsors for specific indicators (pages) within the HHAW report. Plans include providing clear definitions of the health indicators featured, information about the importance of improvement of the indicator to the community, strategies to address inequities and information for the community about how to engage in efforts geared toward improvement. Partners from the MAPP Steering Community that may contribute to this process include the American Cancer Society, Glaxo-Smith Kline and Kaiser Permanente, among others.
• Cobb County is also fortunate to have representation on the MAPP Steering Committees of the local university, Kennesaw State University. Kennesaw boasts an excellent school of health/nursing (the WellStar School of Health and Human Services) and the A.L. Burruss Institute of Public Service and Research. These divisions are working tirelessly to provide survey data from various studies previously conducted, and to develop a new survey (to be conducted in 2011/2012) to more specifically identify disparities within the community. Burruss is dedicated to developing a survey that meets the needs of various community partners and is repeatable for purposes of measurement and evaluation.
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