CHAPTER 26
Measuring the Leader
Work experience, hardship, opportunity, education, role models, and mentors all go together to craft a leader.
—J. A. Conger, Learning to Lead
Leadership is multidisciplinary as well as multilayered, and no single measure of leadership exists. Most quantitative evaluation instruments do not have specific public health leadership dimensions and are quite general to begin with. Case studies, interviews, and stories, of course, provide qualitative information. The quantitative and qualitative information that is available can be used to evaluate the development of leadership skills and determine whether leadership development programs lead to changes in behavior.
The purpose of this chapter is not to review all the leadership assessment instruments on the market but rather to describe several instruments currently used in various public health leadership development programs. This chapter will also explore the concept of 360-degree feedback and consider recent arguments for and against credentialing public health administrators.
A LEADERSHIP COMPETENCIES FRAMEWORK
The late 1990s saw a renewal of interest in training the public health workforce, including public health leaders. The issue of leadership training was addressed by the Public Health Functions Project, which was coordinated by the Assistant Secretary of Health and the Surgeon General.1 Table 26-1 presents the 10 tasks this project undertook. A project subcommittee was appointed to:
Provide a profile of the current public health workforce and make projections regarding the workforce of the 21st century. The subcommittee should also address training and education issues, including curriculum development, to ensure a competent workforce to perform the essential services of public health now and in the future. Minority representation should be analyzed and the programs to increase representation should be evaluated. Distance learning should be explored. The subcommittee should examine the financing mechanisms for curriculum development and for strengthening the training and education infrastructure.2(p.v)
TABLE 26-1 Public Health Functions Project
The following tasks will be undertaken as part of the Public Health Functions Project:
1. Develop a taxonomy of the essential services of public health that can be readily understood and widely accepted for use by the public health community.
2. Using the taxonomy developed, assess the public health infrastructure and document the federal, state, and local expenditures on essential services of public health.
3. Propose a mechanism to ensure accountability for outcomes related to the delivery of essential public health services at the state and local levels, in return for greater flexibility in administration of federal grants to support public health.
4. Develop a strategy for communicating to the general public and key policy makers the nature and impact of essential public health services.
5. Document and publish analyses of the health and economic returns on investments in essential public health services.
6. Identify the key categories of public health personnel necessary to carry out the essential services of public health, assess the nation’s current capacity and shortfalls, and establish a mechanism for ongoing monitoring of workforce strength and capability.
7. Develop and publish a full set of evidence-based guidelines for sound public health practice.
8. Collaborate with the PHS Data Policy Committee to identify the information and data needs for the effective implementation of the essential services of public health and develop a strategy for the interface between the personal services and population-wide systems, ensuring the availability of information necessary to both.
9. Develop a process to ensure the appropriate collaboration of the public health community and adequate inclusion of public health perspectives in the development of national health goals and objectives for the year 2010.
10. Develop a strategy for regular communication among interested parties at the national, state, and local levels on progress related to these activities.
Source: Reproduced from Public Health Service, Public Health Workforce: An Agenda for the 21st Century, 1997, U.S. Department of Health and Human Services.
One of the subcommittee’s tasks was to look at the feasibility of a competency-based curriculum. In the past, learning objectives were used to evaluate educational attainment. A competency-based system is intended to be more oriented toward outcomes. Both learning objectives and competency-based outcomes can be useful for gauging a student’s or trainee’s mastery of new skills and abilities. Learning objectives define the key topics of the course or curriculum in a general way, whereas competencies define what a student or trainee is supposed to master over the long run. The critical issue is how to measure progress toward achieving the competencies and objectives.
The project subcommittee reported on six priority areas for a competency-based curriculum: cultural competency, health promotion skills, leadership development, program management, data analysis, and community organization. It identified a number of action steps for acquiring the competencies.
The development of competencies is a complex process. At the 1995 annual meeting of National Public Health Leadership Development Network (then under a different name), a project was undertaken to develop a series of leadership competencies for use in the creation and evaluation of state and regional public health leadership programs. The task groups formed at the meeting named four core categories for the competency exercise: transformational leadership skills, political competencies, transorganizational skills, and team-building skills. Over the course of 1996, the framework evolved. With the advent of a concern for competencies for leaders in a public health preparedness environment, Dr. Kate Wright and the Heartland Center for Public Health Preparedness have modified the framework to include these new competencies. Appendix 26-A presents this updated framework.3
Transformational leadership skills are needed by public health leaders because leaders are change agents. Leaders need to have a mission and vision and need to motivate and manage change effectively. As for political competencies, leaders need to understand how the political process works, how to negotiate, how to build alliances, and how to market public health and educate the community about public health issues. Because so much public health activity occurs between organizations, public health leaders need transorganizational competencies, including an understanding of organizational dynamics, interorganizational collaboration mechanisms, and social forecasting and marketing. The team-building skills they require include the ability to develop team-oriented structures for purposes of planning and implementing objectives and evaluating progress toward the objectives, the ability to facilitate team development, and the ability to mediate when a conflict occurs.
The framework presented in Appendix 26-A provides a template for learning and for making sense of the multidimensional aspects of public health leadership. No framework should be etched in stone. It must be allowed to evolve. Data need to be collected to determine if the identified competencies can be taught and put into practice. For example, Discovery Learning has developed a 360-degree public health leadership profile based on the framework that will provide these data in the future.4 The profile is based on evaluation of such skills as innovation, client service, mentoring, collaboration, team skills, and conflict and negotiation skills.
The main problem with most competency frameworks is that the competencies are not defined with sufficient specificity to permit their measurement. Take, for example, the competency “Identify, articulate and model professional values and ethics,” which is obviously very general and difficult to gauge. The solution is to break down each competency into specific components that can be measured. Discovery Learning has attempted to do this. In addition, there must be an applied research strategy to evaluate the leadership competencies routinely and revise them as necessary. None of this is to imply that the leadership competency framework is useless. The process of refining the framework has just begun and will probably take several years to complete. The end result is hoped to be a performance standards system capable of evaluating leadership outcomes.
CREDENTIALING AND ACCREDITATION
The credentialing of public health professionals became a live issue in the 1990s. In 1971, the U.S. Department of Health, Education, and Welfare defined credentialing as “the process by which a nongovernmental agency or association grants recognition to an individual who has met certain predetermined qualifications specified by that agency or association. Such qualifications may include: (a) graduation from an accredited or approved program; (b) acceptable performance on a qualifying examination or series of examinations; and/or (c) completion of a given amount of work experience.”5
The supporters of credentialing argue that it will increase the credibility of public health professionals in the political arena as well as with the public at large. Professional standards will be developed that will guide public health programs. Some supporters want to tie credentialing to licensure. The critics argue that no credentialing system is possible because of the multidisciplinary background of public health professionals. Despite this criticism, a credentialing examination for graduates of accredited schools of public health and public health programs was given for the first time in the summer of 2008 and supervised by a newly created National Board of Public Health Examiners.
Schools of public health point out that they go through an accreditation process overseen by the Council on Education in Public Health. Accreditation would be prima facie evidence that graduating students have the necessary competence to practice public health, and a master’s degree in public health from an accredited school of public health should preclude the necessity of further testing. In contrast, many public health practitioners have not been trained in public health and thus don’t have the stamp of approval conferred by graduation from a school of public health. In addition, there is a question whether schools of public health are teaching the skills that practitioners need to have. For example, leadership courses do not exist in some schools of public health.
A report to the U.S. Health Resources and Services Administration defined accreditation as follows: “Accreditation is generally used to refer to the evaluation of academic programs which prepare individuals for professional practice and to determine whether such programs meet predetermined standards. Accreditation may be carried out by public and private agencies or associations.”6(p.9)
Licensure, credentialing, and accreditation are related, although proponents of credentialing may argue that accreditation is not a guarantee that the credentialed public health professional has acquired the desired knowledge or the ability to translate this knowledge into practice. Credentialing proponents point out that a process of evaluating professional knowledge helps develop standards for professional performance, whereas accreditation is tied to an organization rather than a specific individual.
A report prepared for the Association of Schools of Public Health discussed factors that need to be included in any sound credentialing system.7 First, role delineation that distinguishes between professionals who have different skills and levels of knowledge is a requisite. Because the role of public health administrators would be distinguished from that of other practitioners in the field, the credentialing of public health leaders could occur. Second, the credentialing system must specify the knowledge, skills, and attitudes (KSAs) required to carry out the duties of a credentialed professional and public health leader. Third, the system must determine the education, training, or experience necessary to generate the required competencies. Fourth, a testing procedure or other form of assessment must be devised to determine when a practitioner has achieved entry-level competency levels as well as more advanced levels of ability and knowledge. Finally, the system must include a process for recertification and require certified practitioners to undergo recertification periodically. Because leadership tools and skills change over time, the recertification process would encourage advanced training.
In the early 1990s, the American Public Health Association looked at the issue of professional credentialing.8 The committee assigned to the task found very little information in the literature related to credentialing. To further its understanding of the issue, the committee conducted interviews with leaders in the field and with credentialing experts and also surveyed these two groups. The committee found that public health leaders generally did not support the development of a credentialing system. The leaders recognized that a credentialing system would need to be multifaceted and be able to accommodate a number of subspecialties and different education levels. The reaction of the credentialing experts was similar. The committee concluded that, despite the obvious benefits of credentialing, there was no consensus on the form credentialing should take.
One successful credentialing system was developed by the Society for Public Health Education (SOPHE) for undergraduate health educators.9 The National Commission for Health Education Credentialing (NCHEC) was organized to carry out the certification of health educators. Since 1988, more than 2,000 individuals have become certified health education specialists. The certification process, which is based on what NCHEC has determined are necessary educational and professional experiences, is voluntary. A health educator cannot take the examination unless he or she has a college degree from an accredited institution. A candidate also must have a minimum of 25 college semester hours in health education.
At the present time, there are more than 100 sites in the United States where the examination is given twice a year. Those people who pass the certification examination are seen as having met the minimal health education requirements. New criteria were introduced in 2006.10 A three-tiered model for credentialing was developed for health education practice at the entry level and two advanced levels. SOPHE also became concerned with leadership and developed a leadership program for its members.
Questions have been raised about the qualifications of local health officers. During the 1990s, the Health Resources and Services Administration gave a three-year grant to the School of Public Health at the University of Illinois at Chicago to develop procedures for credentialing health administrators. A voluntary credentialing program was developed. It is too early to evaluate the experiment, but the experience of public health management and leadership programs around the country indicates that public health leaders gain from the management and leadership development process. What they gain, however, is difficult to determine in other than a general way. The National Public Health Leadership Development Network will begin to discuss the issue of credentialing for public health leaders in 2013.
360-DEGREE LEADERSHIP ASSESSMENT AND FEEDBACK
We all have perceptions of ourselves that others around us may not share. Leaders are no exception. They may view themselves one way and be viewed by their colleagues in quite a different way. Therefore, the assessment of a leader needs to include a self-evaluation as well as evaluations by colleagues. In other words, it should be a 360-degree assessment.
The 360-degree assessment process involves a multilevel evaluation that focuses on whether the leader’s style of leadership supports or obstructs achievement of the mission and goals of the organization. In a comprehensive 360-degree assessment, all key stakeholders have a voice in evaluating the leader and assessing the direction in which the organization is moving.11
Requirements of a 360-degree assessment include the following:12 First, the leaders of the organization must determine whether sufficient enthusiasm for and commitment to the process exists in the organization and whether they are willing to institute changes based on the results of the assessment. Second, they must collect high-quality assessment data. Finally, they must identify possible responses to the results, such as the development of leadership training programs or formal mentoring programs.
There is a much-utilized 360-degree leadership assessment instrument, the Leadership Practices Inventory (LPI), which evaluates leaders based on their performance of best leadership practices.13 The five practices in the initial LPI were selected on the basis of interviews with senior and midlevel administrators and on leadership case studies. These five practices are still the major emphasis of the LPI. The practices are (1) modeling the way, (2) inspiring a shared vision, (3) challenging the way, (4) enabling others to act, and (5) encouraging the heart.
The third edition of the LPI has 30 leadership practice items, and for each item there are 10 possible responses, from “almost never” to “almost always.” (In the first edition, there were only five choices for each item, from “rarely” to “very frequent.”) The score for a given practice, therefore, can range from a low of 6 to a high of 60. One version of the LPI is used for self-evaluation, and a second version is used for evaluation by observers (colleagues and stakeholders). The LPI can be used at different times to determine whether the leader has made progress in performing the five leadership practices.
Using the original LPI, data on 43,000 leaders from around the world were collected, and means, standard deviations, and internal reliability measures were computed.14 Most of the leaders were from the business sector, but some were from academia and the public sector. The reliability rates fell between 0.81 and 0.91. Enabling others to act was seen by leaders and their observers as the most common practice, followed by challenging the process, modeling the way, encouraging the heart, and, in last place, inspiring a shared vision.
In a pilot study using the LPI, baseline leadership information was collected from 163 public health leaders selected as fellows by the Illinois Public Health Leadership Institute between 1992 and 1997. There may be a self-selection bias built into the study, because fellows are likely to have identified themselves as leaders before embarking on the leadership program and to be committed to leadership development to enhance their skills. Thus far, public health leaders have not specifically been studied. Comparisons of public health leader self-evaluations and observer evaluations have not been done thus far. Some preliminary data indicate that observers rate their leaders higher than the leaders rate themselves.
Mean scores for business leaders and public health leaders are presented in Table 26-2. The scores for public health leaders are consistently higher, but a confounder is the fact that the sample of business leaders includes academics and human service professionals. The scores for the two groups were not significantly different on the practice “challenging the process,” an indicator of orientation to change, nor on the practice “inspiring a shared vision” (both groups scored relatively low). The public health leaders scored significantly higher than the business leaders on the other three practices, all of which are associated with the quality of work-related relationships.
One of the difficulties of using the LPI in studies of leadership is that the main purpose of the instrument is to assess individual leaders through self-evaluation and observer evaluation. The aggregation of LPI data should hide the characteristics of individual leaders, but nonetheless they need to be informed of the fact that their evaluations may be used for research. The instrument also may create biases in the responses because it is tied to a conceptual model that the developers promote. Not every leader supports this model.
TABLE 26-2 Means and Standard Deviations for Public Health and Business Leaders
Note: This study was done with Elanine Jurkowski.
Another instrument used in several public health leadership programs is the Skillscope 360-degree assessment developed by the Center for Creative Leadership.15 This instrument assesses information skills, decision-making skills, interpersonal skills, personal resources, and effective use of self. The instrument is flexible to use and can be used for individual assessments tied to coaching and a part of a structured leadership program. On a group level, the Skill-scope can help to establish a group profile related to the strengths of the group and areas that need work. Another instrument developed by the Center for Creative Leadership is the 360-degree Benchmarks profile, which is one of the leadership instruments used in the National Public Health Leadership Institute.16 Benchmarks is a comprehensive tool that measures 16 success skills and five career derailers. The 16 skills fall into the four categories of meeting job challenges, respecting yourself and others, leading people, and potential for derailment.
On the negative side, a 360-degree assessment is often expensive and time consuming.17 Not only must the measurement instruments be bought, but staff need to be trained to interpret the results. Another issue is whether leaders are willing to reveal self-perceived weaknesses to their colleagues and whether subordinates feel comfortable rating their leaders. This issue is of special concern in smaller organizations. If anonymity is not maintained and the observer evaluations are negative, animosity may occur between leaders and their professional colleagues. Finally, there is the question whether the process will make any difference.18
Despite these issues, the process can result in important information. If the leadership data are linked to organizational needs, organizational efficiency and effectiveness can be improved. The results need to be communicated to the entire workforce, but with a sensitivity for the possible effect on the person who was evaluated. On the whole, the 360-degree approach offers individuals and the organization information that can improve the services provided by the organization.
QUALITATIVE LEADERSHIP ASSESSMENT
Public health programming is driven by population-based statistics, including mortality and morbidity rates. The problem is that the vitality of public health as an approach and perspective can get lost in the numbers, with the result that public health loses credibility among community residents.19 As a consequence, public health leaders need to acquire qualitative information to help them evaluate their performance and to publicize public health as a way of enhancing their credibility.
Qualitative information often comes in the form of stories and case studies. The case studies of interest to us here describe public health practitioners in action and present conclusions about what was done right and what could have been done better. As we will use the term, “case” refers to whatever is the subject of a case study (usually a single event or a series of events).
Case studies, for our purposes, can be divided into four classes: (1) specific empirical studies, (2) general empirical studies, (3) specific theoretical studies, and (4) general theoretical studies. Empirical case studies describe actual cases, whereas theoretical case studies are constructed specifically to illustrate some point. Specific case studies have definable boundaries, and general case studies are examples already available that can be used to demonstrate a perspective.
The cases chosen for research inquiry are typically different from those chosen for training purposes. In this section, we are interested in the latter, especially their potential to clarify the application of leadership principles in the real world of public health practice. Training case studies describe how professionals handle problems and thus can serve as guides to future action. Leaders can develop their own case studies in order to analyze public health community activities and evaluate their own leadership skills.
Public health case studies are used for three main purposes.20 First, they can be used to offer insights into how a public health agency carries out its activities. Second, they can be used to help public health leaders explore different scenarios as part of a problem-solving process. Table 26-3, for instance, presents a number of public health scenarios helpful for defining outcomes that might occur if a public health agency instituted a certain policy or embarked in a certain direction. Third, case studies can be used to illuminate why events unfolded in a certain way and to explore better ways to handle an emergency situation, for instance.
In regard to the last two uses, the role of leadership and the causal consequences of actions need to be interpreted carefully. It is always difficult to tease out the causal factors in a complex set of relationships and happenings. In addition, the events that make up a case rarely repeat themselves in exactly the same way.
TABLE 26-3 Public Health Scenarios Based on Schwartz Categories
Scenario 1: Winners and Losers
A health reform plan passes Congress. The plan presents a system redesign that is state based and involves local health alliances. The health plans incorporate most of the direct service functions of local health departments. Block grant funds that remain are given directly to the health alliances for distribution. This scenario initially positions the local health department as a loser.
Scenario 2: Challenge and Response
The American Public Health Association creates a strong lobbying coalition that includes representatives from all the major public health interest groups and organizations. As Congress reviews changes in the financing of health services, the public health community is able to affect legislation so that CDC and state public health agencies become responsible for collecting all data related to health care, are responsible for oversight of all health programs, become the lead agency for all government-sponsored primary prevention programs, are directly funded for health-related community programs by a block grant, and so on. Public health meets every challenge and wins.
Scenario 3: Evolution
There is a major change in the economy of the state. Several new biotechnology companies move to the state, and many new jobs are created. The state unemployment rate drops to 3%. With the increase in employment, the number of people on welfare drops significantly. With new jobs, the teenage pregnancy rate drops, as does the incidence of gang-related violence, because gang members get jobs.
Scenario 4: Revolution
Congress passes a major piece of legislation. The government decides to get out of the public health business. All public health activities are transferred to the private healthcare system.
Scenario 5: Cycle
Five years after the evolution scenario above takes place, the American economy collapses. A major depression occurs. People lose their jobs. Gang warfare increases. The teenage pregnancy rate expands significantly.
Scenario 6: Infinite Possibilities
A health reform package passes that provides universal coverage.
Scenario 7: The Lone Ranger
Through the efforts of public health professionals and researchers, a cure for AIDS is found, a chemical substance that purifies all water is discovered, and a vaccine that prevents Alzheimer’s disease is developed. Because of these breakthroughs, the American public unequivocably supports all public health initiatives.
Scenario 8: My Generation
The early years of the 21st century see a major increase in births in the United States.
The above scenarios can be looked at individually or can be combined to form more complex scenarios.
Source: Adapted from The Art of the Long View by Peter Schwartz. Copyright © 1991 by Peter Schwartz. Used by permission of Doubleday, a division of Random House, Inc.
Some case studies are merely free-flowing stories about examples of leadership, for instance. These stories nonetheless must have a message intended for a well-defined audience.21 There are three main types of leadership stories. One is the “Who am I?” story. The second is the “Who are we?” story. The third is a story of the realization of a vision. It is possible to add a fourth category consisting of “What I learned on my summer vacation” stories. These stories describe what a leader learned from other leaders or from workshops on leadership.
Case study stories have plots intended to elucidate ideas or values. They should be tested before being released to the public to make sure that their messages are clear. One variant of the personal story is the biographical portrait.22 A portrait of a historical or present-day leader, such as C. Edward Koop or Paul Farmer, can be employed for the same purposes as a personal story. Another variant is to focus on a leader whose values stand in contrast to those of a typical public health leader, such as a senator from a tobacco state.
An interview can also make up the content of a case study. Questions serve as the mechanism for getting information. For example, the author interviewed more than 130 public health leaders in four countries in order to explore their understanding of the meaning of public health, their vision of the future, and the changing characteristics of leaders. (Table 26-4 consists of a guide for interviewing public health leaders.)
An interesting variation on the interview is the focus group, in which leaders, for example, might answer questions as a team. A conversation is another variation—a variation explored in Exercise 26-l.
A case study protocol for public health practice narratives was developed for public health practitioners in a leadership development program under the assumption that structured case studies provide trainees and other lifelong learners with models of public health practice.23 Case studies can also be used to explore cutting-edge issues in public health that are in need of resolution. In other words, case studies can be based on completed events or on situations in progress.
Each case has a unique character.24 For example, even similar cases will differ in historical background, setting, or economic, political, legal, social, or cultural aspects. They also can have a different slant depending on the reason they were written.
Case studies, as stories, have characters, a plot, and a setting. Their purpose is to give insight into leadership styles and practices, personality concerns, power concerns, organizational intrigues, politics in action, media involvement, and so on. They can be effective mentoring tools; the mentor can assign a case study for the mentee to read, and then the two can discuss the issues raised in the case study. A problem-based case study can present a possible vision of the future.
The best case studies are built on real experiences. Whereas ideal cases can be constructed, most people seem to relate better to real-life situations that seem real in their unfolding. That is one of the reasons that every case study in this book is factually based, although names and places have sometimes been changed to protect the actual participants.
TABLE 26-4 Interview Guide for Public Health Leaders
1. What are the reasons you decided on a career in public health?
2. How would you define public health?
3. What is your definition of leadership?
4. What are the necessary leadership practices and skills that a public health leader needs to use?
5. Are these practices and skills different from the practices and skills of business leaders?
6. What elements of public health’s organizational system enhance or create barriers to leadership?
7. What is the role of public health in carrying out the core functions of assessment, policy development, and assurance?
8. What is your vision for public health in the 21st century? What are the three most important systems issues for the future, and what are the key health issues for the future?
9. How successful is the system in promoting community coalitions to address the health of the community?
10. Are public–private partnerships that address public health concerns possible? What is public health’s role in managed care?
11. Does the public understand public health? If not, what can you do to change this situation?
12. Should public health be integrated into the general health sector, or should public health be maintained as part of a separate governmental office?
13. What distinguishes a practitioner, a manager, and a leader?
14. Is the mentoring of future leaders important? What type of mentoring program do you recommend?
15. What is the role of politics in public health?
Most case studies are written as narratives and have a beginning, middle, and end25 (Table 26-5). The opening should present the issue that the case is intended to illustrate and describe the setting and key characters. The middle, or the body of the case study, describes the events that make up the case. If this is done properly, then the lesson of the case becomes clear. In some instances, elements of the setting and key characters may be described in more detail than was provided in the opening. Political factors that affected the outcome may be critically examined.
Many case studies include all sorts of supplemental documentation to elucidate the circumstances. The closing reviews the issue in light of the events described and analyzes the decisions made by the key characters.26 It may explore possible options that might have led to an outcome different from the one that actually occurred. (Some case studies are intended to deal with multiple issues and use a slightly different organization to address the issues in a coherent manner.)
Case Study 26-A has the classic organization described here. It deals with the issues of privatization of laboratory services and the lack of involvement by public health laboratory directors in public health policy issues. It is also based on variations of real-life situations.
TABLE 26-5 Case Study Development Protocol
Opening (first few paragraphs)
Name and title of responsible professional
Date: month and year (fix the case in time)
Synopsis of decision required or problem setting or issues presented, keeping in the forefront the core functions of health departments
Case body (no more than four to five pages)
Department/agency history, if pertinent
Environmental setting, if pertinent
Political concerns
Expanded description of the decision or problem situation
Human interaction facts, etc.
Human element
Personality impact
Public relations factor
Presence/absence of vision/enthusiasm
Organizational relationships
Other case characters or entities
Program and process
Financial concerns, where pertinent
Closing (last paragraph or two)
Conclusion of the case
Suggested methods
Setting the scene to establish a sense of urgency about the problem or decision
Setting out a range of decision options
Source: Reprinted with permission from J. Munson, Case Study Development: Guidelines and Protocols for Case Study Development, 2nd ed., 2003. © 1994, University of Illinois School of Public Health, Mid-American Regional Public Health Leadership Institute.
Case Study 26-A
Organization of Public Health and Clinical Laboratory Services in a Reformed Health Service Delivery System
Jon Counts
Introduction
In 2009, the U.S. Congress passed comprehensive legislation that would establish universal healthcare coverage by the year 2012. Congress mandated that each state would develop a strategic plan that would integrate and restructure the public and private healthcare programs. The commissioner of health, Dr. Strangelove, has designated you, Dr. Vision, to develop a plan to define the role of hospital, commercial, public health, and academic laboratories as part of the state of Innovation’s strategy for a reformed health system.
Case Body
The result of three decades of heavy clinical laboratory utilization has been the development of a fractured, duplicative, and costly laboratory system in the state of Innovation. The laboratory network in this state fits the general description of the current health system: a patchwork of private and public programs, with goals and objectives as varied as the groups and organizations represented in the system. Clinical laboratories represent a significant component of the rapidly increasing costs of health care. The Health Care Financing Administration estimates that spending on laboratory services composes 4.5% of all national healthcare expenditures.
Clinical laboratories, like the rest of the healthcare community, have been significantly affected by the nation’s health reform legislation, the Health Services Act of 1993. The primary vehicle for the implementation of the legislation is the new Health Services Commission. The Health Services Act will enable each state to control spending by:
1. shifting the state toward a system of “managed” health care
2. defining a uniform benefit package and developing standards of certified health plans through which the uniform benefits package will be provided
3. setting the maximum rate a certified health plan may charge for the uniform benefit package
4. establishing a maximum healthcare inflation rate and lowering the rate until it matches the rate of general inflation
5. setting rules for fair competition among certified health plans
6. minimizing malpractice and its costs
7. simplifying the administration of claims, billing, and information
8. promoting the use of cost-effective healthcare practices and services
9. defining the role and function of public health agencies
Dr. Vision realizes that the task ahead of him will be a challenge and very controversial.
1. First, the development of any coalition among laboratory organizations, physicians, pathologists, laboratory managers, hospital and commercial laboratories, and government will be exceedingly difficult to achieve.
a. There will be opposition to a government agency leading the discussion about the role of laboratories in a reformed system. There will be suspicion, lack of trust, and concern about the regulatory approach that government agencies might mandate.
b. For the most part, there has been little or no historical interaction among individuals/organizations who will be involved in the coalition; therefore, the plan must be carefully developed and staged, ensuring that a process for developing consensus has been established.
c. The activities of the coalition will be monitored closely; therefore, there cannot be any secrecy and they must be open to the public, outside review, and scrutiny. There must be a system for dissemination of information and recommendations to the laboratory and medical community.
d. There will be strong opposition to the possibility that the plan will lead to the re-engineering and downsizing of commercial and hospital laboratory staff.
e. The issue of competition between public health laboratories and private sector facilities will be raised as well as the need to consider the privatization of diagnostic services provided by government laboratories. This obviously will be a contentious point because Dr. Vision will have a vested interest in the outcome.
2. The nature of health problems has changed dramatically during the 20th century; chronic conditions have become predominant as well as new and re-emerging infectious diseases.
3. The utilization of managed care plans and capitation to control costs and share the risk with providers has increased dramatically. The march of managed care, new technologies, and alternative treatment settings will prompt a 34% decrease in inpatient hospital days over the five years from 2009 to 2013. Ambulatory facilities will eliminate many surgical inpatient days, use of birthing centers will increase, mental health care will be delivered more often in residential settings such as halfway houses, and home care will be the most dramatic and fastest-growing segment of the healthcare industry. These changes will have a significant effect on diagnostic laboratory testing. Hospital laboratories will undergo significant reduction in routine and inpatient testing, vertical integration will occur, and regional delivery systems will consolidate and centralize laboratory testing. Large national commercial laboratories will capture the vast majority of testing.
4. The role of laboratory medicine will be expanded into promoting health and preventing disease. Home testing will increase, as will the need to promote direct public access to preventive and screening testing. Genetic testing obviously is going to expand. Hospital and commercial laboratories will play a much more active role in the nation’s disease surveillance, promoting the need for a statewide electronic network between private clinical laboratories and the public health systems. Other anticipated changes in the future laboratory system include:
• active management of laboratory utilization, elimination of unnecessary testing, and utilization of practice guidelines
• standardization of lab instrumentation and testing methodology and increasing automation
• utilization of clinical patient outcome measures of laboratory quality
Proposal Solution
The implementation of health reform makes strategic planning imperative for all components of the health system. Historically there have been few efforts to draw the clinical laboratory community together into cooperative efforts toward long-range planning except in the area of laboratory regulation and the credentialing of laboratory personnel. This initiative has been developed to assist the leadership of the clinical laboratory community in the state of Innovation in assessing the effect of health reform and in developing recommendations for integrating the diverse segments of the existing laboratory system into a more cost-effective and efficient structure. The process will include creation of a steering committee to provide recommendations to Dr. Vision for the guidance, direction, and oversight of the initiative. The steering committee may also appoint technical advisory work groups to study and develop specific recommendations on such issues as the following:
• structure and integration of delivery system
• utilization of clinical laboratories in medical decisions or development of practice parameters
• laboratory regulations
• effect of malpractice tort reform on laboratory utilization
• utilization of new technology in laboratories
• personnel resource training and credentialing
• utilization of out-of-state laboratories
• reimbursement policies
• direct billing
• laboratory information systems—collection, analysis, integration, and dissemination of data
• surveillance of emerging infectious diseases
• point-of-care testing
• home testing
• public access to laboratory testing
The steering committee will consolidate its recommendations into a report to be submitted to the commissioner of health, Dr. Strangelove, for his consideration in establishing public policy.
Dr. Vision must first establish a process to identify and appoint members from the department and community to the steering committee, individuals who are experts in laboratory science, strategic planning, public policy, development of community constituencies, and consensus building and who are representatives of medical specialties.
Next, the steering committee must establish a strategic-planning process, including identification and prioritization of major components and issues. In order to address those issues listed, it is essential that a mechanism be developed to collect and evaluate health-related data to determine the need for diagnostic laboratory services. Finally, it must be determined by the steering committee how it will solicit public input.
Exercise 26-2 provides the opportunity to write a case study. The work of researching and writing the case study, which may take several weeks, is done using teams. The case studies presented in this text can serve as models.
QUANTITATIVE LEADERSHIP ASSESSMENT TECHNIQUES
Leadership assessment comes in more than one variety. Part of the explanation is that the standard leadership assessment instruments grow out of different theories of leadership. Another part of the explanation is that there are at least five levels of leadership and different traits and behaviors that are needed for each level. Most leadership assessment techniques are oriented toward the personal level, but leadership can also be evaluated at the team, agency, community, and professional levels.
Leadership Tip
Serve refreshments at meetings. It reduces absenteeism.
Because it is usually the individual who fills out the leadership assessment instrument, most leadership assessment relates to personal traits and behavior, and these traits and behaviors, unsurprisingly, are stressed by psychometricians. One of the best-known personality assessment tools has been adopted by a number of public health leadership programs. The Myers-Briggs Type Indicator (MBTI), based on Jung’s theory of psychological types, measures personality along four dimensions.27 The first is the extroversion (E) and introversion (I) dimension. Where someone falls along this dimension is determined by whether he or she relates more to the external world or more to his or her inner world. The second dimension, defined by the contrast between sensing perceptions (S) and intuitive perceptions (N), measures whether a person focuses on the here and now or on future possibilities and abstract theory and symbols. The next dimension, defined by the contrast between thinking (T) and feeling (F), measures whether a person responds to situations rationally or emotionally. The fourth dimension, defined by the contrast between judgment (J) and perception (P), measures whether the person tends naturally to engage in organizing, planning, and decision making or instead tends to want to keep options open.
The MBTI instrument is quite comprehensive28 and requires the person being tested to answer numerous forced-choice questions. After completing the questionnaire, the person receives a report on his or her profile. The author, who filled out the questionnaire in order to gain a better understanding of how it is used, was found to be an ENTJ. The report said that the author tends to be decisive and frank, quick to take charge of people and projects, applies logic and analysis, prefers action to contemplation, and often pays more attention to tasks than to the people.
To discover how leaders in the public sector would score, researchers tested and compared five groups of leaders in local, state, and federal government.29 The first group included 1,394 senior federal government administrators tested from 1983 to 1986. The next three groups, tested in the early 1980s, consisted of managers attending special government institutes at the University of North Carolina. The fifth group consisted of about 100 social service administrators from Nebraska. Figure 26-1 shows how these groups scored on the four dimensions. The point to note is that leaders do not score in a uniform way. Different patterns emerge. Leaders with different styles engage in different leadership practices.
The Leader Behavior Analysis II instrument differs substantially from the MBTI.30 It presents the person being tested with 20 typical job situations that involve a leader and one or more staff members. After reading each scenario, the person, putting him- or herself in the position of the leader, selects one of four possible actions. The instrument, which can be self-scored, investigates three dimensions. The first is flexibility (whether the person tends to try to be directive or supportive). There are four score categories for this dimension:
S1: high directive, low supportive behavior
S2: high directive, high supportive behavior
S3: high supportive, low directive behavior
S4: low supportive, low directive behavior
The responses to the pertinent scenarios are used to compute a style flexibility score between 0 and 30. The higher the score, the greater the flexibility. The second dimension is leadership effectiveness, and the third is diagnosis.
FIGURE 26-1 Myers-Briggs Type Indicator Percentages for Managers in Federal, State, and Local Government. Source: Reprinted with permission from M. H. McCaulley, The Myers-Briggs Type Indicator and Leadership, in Measures of Leadership, K. E. Clark and M. B. Clark, eds., p. 389, © 1990, Leadership Library of America, Center for Creative Leadership.
Scores for these dimensions are computed in roughly the same way as for the first dimension. There is also a form for others to fill out, which allows for a 360-degree personal leadership evaluation.
A study of an earlier version of this instrument found that leadership assessment tools help leaders evaluate their leadership styles and compare their self-perceptions with the perceptions of colleagues.31 The sample included evaluations of 20,000 leaders from 14 cultures (each evaluation comprised a self-assessment and assessments by others). About 2,000 leaders from industry and education were interviewed, and about 500 in-depth interviews were done. The situational leadership model was supported by the data collected.
There is a Team Leadership Practices Inventory that is basically similar to the LPI developed for leaders and colleagues.32 The Team LPI is based on the same five leadership practices used in the initial version of the LPI: challenging the process, inspiring a shared vision, enabling others to act, modeling the way, and encouraging the heart. Because the use of teams has increased in most organizations, evaluating how teams function is essential. Each team member fills out the Team LPI, which has 30 items. The scores for each practice are totaled and then averaged. By using the Team LPI, a team can determine its strengths as well as the practices that need improvement. The LPI is highly correlated with the Team LPI. Both instruments are less concerned about leadership style than about the practices of leadership.
There has been growing interest in leadership skills and practices at the organizational level. In 1984, a study of effective organizational leadership was undertaken,33 and it led to the development of the Leader Behavior Questionnaire (LBQ). The LBQ consists of 50 questions. It is intended to measure focused leadership (listening ability), communication abilities, trust leadership, respectful leadership (how leaders treat others), risk leadership, bottom-line leadership (the belief of leaders that they can make a difference), empowered leadership (sharing power), long-term leadership (visionary leadership), organizational leadership, and cultural leadership (leadership based on the values of the organization). An important underlying assumption of the LBQ is that leadership is multidimensional and that each of its dimensions must be evaluated.
An important assessment-related breakthrough occurred in the mid-1990s. The healthcare sector became more interested in the measurement of outcomes as a way of evaluating effectiveness.34 Performance measurement encompasses the measurement of program inputs, intermediate outcomes (process issues), and end outcomes.35 One goal of performance measurement is to determine whether changes in public health expenditures affect the outputs of public health agencies and the final outcomes for the community.
Two important new instruments give added clarity to the way talents affect leadership and also thinking and behavioral preferences. The Gallup Organization has been studying managers and leaders for more than 40 years. From its work has come an instrument called Strength Finder (now Strength Finder 2.0).36 This instrument measures the strengths of an individual as tied to 34 talent themes. Rath has pointed out that it is important to build on individual talents to create strengths at work and not concentrate on individual weaknesses. This instrument is easy to take and is not costly. A leader buys the book, which has a unique access code to the Gallup Organization website. The recipient will receive a profile of the top five strengths.
Leadership Tip
Use social media to expand your leadership network.
The Emergenetics instrument gives the individual a profile in color of his or her thinking preferences and behavioral attributes.37 This instrument has also been tested on individuals throughout the world. The instrument relates to four major thinking preferences of people: analytical (blue), structural (green), conceptual (yellow), and social (red). Most individuals have profiles that show some mixture of all four preferences, but they tend to have dominance in one, two, three, or four thinking domains. The three behavioral attributes are expressiveness, assertiveness, and flexibility.
An Institute of Medicine report presented a framework for improving the health of community residents. The community health improvement process is shown in Figure 26-2.38 It encompasses the identification and analysis of health issues, the development and implementation of strategies to resolve the issues, and the monitoring of the implementation process and outcomes. One of the steps is to develop an indicator set that links the implementation of strategies with their outcomes so that the effectiveness of the strategies can be determined, which is the essence of performance measurement. Figure 26-3 presents a performance measurement model consisting of six steps.39 Despite the existence of this model, public state and local agencies have been slow in adopting the performance measurement approach.40 This is beginning to change, as mentioned below.
Performance monitoring is related to evidence-based public health.41 Evidence-based public health promotes the use of traditional biostatistics measures, epidemiology, healthy communities assessment, and continuous quality improvement methods. Public health agencies and their leaders have not routinely used the tools at hand in an effective manner, nor have they routinely approached their responsibilities from a population-based perspective.
Public health leaders need to develop the competencies to carry out performance monitoring. Currently, they often assign the task of performance monitoring to other staff members. They also need to ensure that performance measurement is accepted by agency staff and that the information gained is used by the staff to improve operations. In fact, performance measures for evaluating the activities of public health leaders and their community partners utilizing a systems perspective and the essential public health services in the performance process have been developed in the National Public Health Performance Standards Program. The use of performance measurement by leaders will become more prevalent with the accreditation of local health departments, which began in 2011.
FIGURE 26-2 The Community Health Improvement Process (CHIP). Source: Reprinted with permission from Improving Health in the Community: A Role for Performance Monitoring, p. 6. © 1997 by the National Academy of Sciences. Courtesy of the National Academies Press, Washington, DC.
FIGURE 26-3 Performance Measurement Step-by-Step. Source: Reproduced from Improving the Nation’s Health with Performance Measurement, Prevention Report, Vol. 12, No. 1, p. 3, 1997, Office of Disease Prevention and Health Services, U.S. Department of Health and Human Services. Based on example of State of Maryland’s Healthy Maryland 2000.
SUMMARY
Evaluation plays a multifaceted role in public health. Evaluation techniques are used for uncovering the public health problems that exist in a given community and for assessing the implementation of the programs intended to deal with such problems. They can also be used to assess the level of a leader’s skills and abilities.
The chapter began with a description of the leadership competencies framework and listed some of the competencies that public health leaders need to have. It then discussed the question of whether a system should be put in place for credentialing public health leaders—a question over which public health leaders are divided.
Quantitative leadership evaluations are problematic at best. Each instrument incorporates a conceptual model on which the instrument is based. The organization in which the leader works is often conceptually different from the model used in the instrument. One alternative is to do a qualitative evaluation using case studies and other qualitative techniques and a battery of several quantitative tools. No matter what type of evaluation is done, however, the evaluation should include the opinions of both the leader being evaluated and the leader’s colleagues. In short, it should be a 360-degree evaluation. Furthermore, the evaluation should cover the leader’s performance at the agency level and also at the community level.
EXERCISE 26-1: Conversations with Leaders
Purpose: to learn how peers view public health and what they think about current public health leadership issues
Key concepts: core functions, evaluation of leadership, focus group, interviewing skills, leadership skills
Procedures: It is possible to learn many things from peers. The class should divide into focus groups of six to eight members. Each group engages in a discussion of leadership using the interview questions in the text as a guide (Table 26-4). The discussion should last at least an hour, although it is not necessary to go through all the questions. The group should allow the discussion to go in any direction it naturally moves. The class can repeat the exercise several times, each time concentrating on a different set of issues.
EXERCISE 26-2: Development of a Public Health Case Study
Purpose: to develop a public health case study to examine how leaders address public health issues
Key concepts: case study, core functions, essential services, leadership, team learning
Procedures: The class should divide into teams of five to eight members. Each team will be responsible for writing a case study using the Munson protocol (Table 26-5). Much of the work will take place outside of class. Select a facilitator to monitor each phase of the project. Identify a public health case worthy of being written about. Investigate the case and collect information for writing up the case. Analyze the case from a policy development perspective. Identify leadership issues involved in the case, and then write up the case (the study should be 5 to 10 pages). Finally, give an oral report on the case to the other teams.
DISCUSSION QUESTIONS
1. What is one of the problems with using competencies as a means of evaluating leadership?
2. What are the pros and cons of credentialing leaders?
3. What are five personal leadership lessons you learned during the past year?
4. What is a 360-degree assessment?
5. What are some difficulties associated with performing a 360-degree assessment?
6. What is a qualitative leadership assessment, and what are some techniques for performing such an assessment?
REFERENCES
1. Public Health Service, The Public Health Workforce: An Agenda for the 21st Century (Washington, DC: U.S. Department of Health and Human Services, 1997).
2. Public Health Service, The Public Health Workforce.
3. National Public Health Leadership Development Network and the Heartland Center for Public Health Preparedness (Dr. K. Wright, Director).
4. Discovery Learning, http://www.discoverylearning.com/products/profile-public-health.aspx
5. U.S. Department of Health, Education, and Welfare, Report on Licensure and Related Health Personnel Credentialing (Washington, DC: U.S. Department of Health, Education, and Welfare, 1971).
6. A. C. Gielen et al., Health Education in the 21st Century: A White Paper, report prepared for Health Resources and Services Administration (Washington, DC: Health Resources and Services Administration, 1997).
7. E. Carpenter, Proposed Credentialing System for Public Health Professionals: What Would It Mean for Schools of Public Health (Washington, DC: Association of Schools of Public Health, 1990).
8. W. C. Livingood et al., Perceived Feasibility and Desirability of Public Health Credentialing: Final Report (Washington, DC: American Public Health Association, 1993).
9. Gielen et al., Health Education in the 21st Century.
10. http://www.nchec.org
11. M. R. Edwards and A. J. Ewen, 360° Feedback (New York: ANACOM, 1996).
12. R. Lepsinger and A. D. Lucia, The Art and Science of 360° Feedback (San Francisco: Jossey-Bass, 1997).
13. J. M. Kouzes and B. Z. Posner, Leadership Practices Inventory (LPI): Facilitators Guide, 3rd ed. (San Francisco: Jossey-Bass, 2003).
14. J. M. Kouzes and B. Z. Posner, The Leadership Challenge, 4th ed. (San Francisco: Jossey-Bass, 2007).
15. www.ccl.org
16. www.ccl.org
17. Lepsinger and Lucia, The Art and Science of 360° Feedback.
18. Lepsinger and Lucia, The Art and Science of 360° Feedback.
19. J. M. Kouzes and B. Z. Posner, Credibility (San Francisco: Jossey-Bass, 2011).
20. H. C. White, “Cases Are for Identity, for Explanation, or for Control,” in What Is a Case? Exploring the Foundations of Social Inquiry, ed. C. C. Ragin and H. S. Becker (Cambridge: Cambridge University Press, 1992).
21. N. M. Tichy, The Leadership Engine (New York: Harper Business, 1997).
22. G. Wills, Certain Trumpets (New York: Simon & Schuster, 1994).
23. J. Munson, Case Study Manual: Guidelines and Protocol for Case Study Development, 2nd ed., Leadership in Public Health Monograph 1 (Chicago: University of Illinois School of Public Health, Mid-America Regional Public Health Leadership Institute, 2003).
24. R. E. Stake, “Case Studies,” in Handbook of Qualitative Research, ed. N. K. Denzin and Y. S. Lincoln (Thousand Oaks, CA: Sage Publications, 1994).
25. Munson, Case Study Manual.
26. Munson, Case Study Manual.
27. M. H. McCaulley, “The Myers-Briggs Type Indicator and Leadership,” in Measures of Leadership, ed. K. E. Clark and M. B. Clark (West Orange, NJ: Leadership Library of America, 1990).
28. K. C. Briggs and L. B. Myers, Myers-Briggs Type Indicator Step II Booklet (Form K) (Palo Alto, CA: Consulting Psychologists Press, 1991).
29. McCaulley, “The Myers-Briggs Type Indicator and Leadership.”
30. http://www.kenblanchard.com
31. P. Hersey et al., Management of Organizational Behavior, 11th ed. (Upper Saddle River, NJ: Prentice Hall, 2012).
32. J. M. Kouzes and B. Z. Posner, The Team Leadership Practices Inventory (San Francisco: Pfeiffer and Co., 1992).
33. W. G. Bennis, “The Four Competencies of Leadership,” Training and Development Journal 38, no. 8 (1984): 15–18.
34. G. E. A. Dever, Improving Outcomes in Public Health Practice (Gaithersburg, MD: Aspen Publishers, 1997).
35. K. E. Newcomer, “Using Performance Measurement to Improve Programs,” New Directions for Evaluation 75 (1997): 8–13.
36. T. Rath, Strength Finder 2.0 (New York: Gallup Press, 2007).
37. G. Browning, Emergenetics (New York: Collins, 2006).
38. National Academy of Science, Improving the Nation’s Health with Performance Measurement (Washington, DC: National Academies Press, 1997).
39. National Academy of Science, Improving the Nation’s Health with Performance Monitoring.
40. H. P. Hatry, “Where the Rubber Meets the Road: Performance Measurement for State and Local Public Measurement,” New Directions for Evaluation 75 (1997): 31–44.
41. Dever, Improving Outcomes in Public Health Practice.
APPENDIX 26-A
Leadership Competency Framework: Public Health Leadership Competencies for State/Regional Programs
Adapted by the Heartland Center for Public Health Preparedness, St. Louis University School of Public Health, from K. S. Wright et al., “Competency Development in Public Health Leadership,” American Journal of Public Health, 90, no. 8 (2000): 1202–1207.
I. CORE TRANSFORMATIONAL COMPETENCIES
A. Visionary Leadership
1. Articulates vision and scenarios for change
2. Facilitates development of vision
3. Encourages others to share the vision
4. Applies innovative methods for strategic decision making
B. Sense of Mission
1. Articulates and models professional values, beliefs, and ethics
2. Facilitates development of mission and purpose
3. Facilitates reassessment and adaptation of mission to vision
4. Facilitates development of strategies to achieve mission
C. Effective Change Agent
1. Facilitates development of a learning organization
2. Creates systems and structures for transformational change
3. Creates evaluation systems for change strategies
4. Facilitates strategic and tactical assessment and planning
5. Facilitates identification of emerging and acute problems
6. Utilizes change theories and models in strategic development
7. Identifies emotional and rational elements in strategic planning
8. Creates critical dynamic tension within change strategies
9. Facilitates development of effective dialogue
10. Utilizes methods to empower others to take action
11. Models active learning and personal mastery
12. Models and facilitates cultural sensitivity and competence
13. Models utilization and application of systems thinking
14. Models critical thinking and analysis skills
15. Models appropriate risk-taking behaviors
16. Models group process behaviors: listening, dialoging, negotiating, encouraging, and motivating
17. Models leadership traits: integrity, credibility, enthusiasm, commitment, honesty, caring, and trust
II. POLITICAL COMPETENCIES1
A. Political Processes
1. Directs mission-driven strategic planning at policy and operational levels
2. Articulates political processes and variables operating at federal/state/local levels
3. Identifies and assesses critical political issues and related stakeholders
4. Identifies policies and alternatives related to critical public health problems
5. Develops capability for advocacy, community education, and social marketing
6. Utilizes principles of media advocacy to support public policy change
7. Assesses political resources to address needs of diverse and underserved communities
8. Implements collaborative strategies to involve constituencies and stakeholders
9. Utilizes political action models for infrastructure development and capacity building
10. Collaborates to analyze needs and develop regulatory actions and legislative proposals
11. Facilitates analysis and development of legislative action on public health issues
12. Directs development of systems, programs, and services for policy implementation
B. Negotiation and Mediation
1. Identifies emerging public health issues and guides or mediates action to avoid crises
2. Guides and mediates the investigation and resolution of acute public health crises
3. Identifies key stakeholders and resources necessary for mediating, negotiating, and/or collective bargaining
C. Ethics and Power
1. Models use of professional values and ethics
2. Models use of principles of integrity and high ethical standards
3. Creates collaborative systems using high ethical standards
4. Describes the role of public health law and public health practice
5. Describes the role of clinical/research ethics in public health practice
6. Develops power-based alliances with a values-based and ethical perspective
7. Utilizes transitional/conditional ethics when interpreting functions of power structures
D. Marketing and Education
1. Communicates with target audiences utilizing principles of social marketing and health education
2. Communicates with target audiences regarding needs, objectives, and accomplishments
III. TRANSORGANIZATIONAL COMPETENCIES
A. Organizational Capacity and Dynamics
1. Utilizes models to assess environment, needs, opportunities, threats, and resources
2. Utilizes models of new organizational development, behavior, and culture
3. Develop structures for workforce development and organizational capacity improvement
4. Implements structures and capability as need, opportunity, risk, or threat arises
B. Trans-Organizational Capacity and Collaboration
1. Identifies and includes power brokers and stakeholders in collaborative ventures
2. Implements and evaluates collaborative and partnering strategies
3. Facilitates networking and broad and diverse stakeholder participation
4. Facilitates change with a balance of critical tensions within collaborative systems
5. Develops and evaluates collaborative strategic action plans
6. Facilitates transorganizational shared or complementary mission and vision
7. Creates transorganizational systems with an ethical and values-based approach
C. Social Forecasting and Marketing
1. Utilizes social forecasting methods and interprets emerging needs and trends
2. Creates and articulates predictions and potential scenarios
3. Communicates analysis and interpretation of information to partners and constituents
4. Utilizes social marketing for media, health and risk communications, and community relations
IV. TEAM-BUILDING COMPETENCIES
A. Team Structures and Systems
1. Develops structures for organizational learning and systems thinking
2. Creates systems for team development and evaluation
3. Creates incentive and reward systems
4. Facilitates strategic outcomes-based team activities
5. Develops team systems for customer service and quality improvement
6. Facilitates collaborative leadership and entrepreneurial spirit
B. Team Development
1. Facilitates development of shared vision, mission, and values
2. Facilitates development of clear goals and objectives
3. Facilitates group process and dynamics
4. Implements communication processes for team development
5. Develops problem-solving, conflict resolution, and decision-making skills
6. Communicates need to balance critical tensions for team development
7. Facilitates empowerment and motivation to accomplish objectives
8. Celebrates team culture and accomplishments
9. Facilitates development of cultural sensitivity and competence
10. Facilitates development of appropriate risk-taking behavior
11. Develops servant leadership; selflessness, integrity, and perspective mastery
12. Facilitates development of personal mastery and team learning
C. Facilitation and Mediation
1. Establishes team member roles and responsibilities
2. Facilitates effective workgroup processes and relationships
3. Mediates in non-productive, dissident, or demoralized team situations
4. Facilitates problem-centered coaching
5. Utilizes negotiation to mediate disputes and resolve conflicts
V. CRISIS LEADERSHIP COMPETENCIES
A. Planning for the Unthinkable2
1. Articulates the definition of crisis levels and its elements
2. Articulates the definition of crisis management
3. Articulates the definition of crisis leadership
4. Articulates the difference between crisis leadership and crisis management
5. Articulates the role of leaders before and during crisis events
6. Articulates the systemic nature of crisis leadership
7. Identifies the elements of crisis anticipation and its relevance to crisis leadership
8. Utilizes methods and processes for anticipatory thinking and “thinking the unthinkable” before and during crisis events
9. Identifies the difference between normal/abnormal accidents/events and natural disasters
10. Identifies the elements of crisis types and methods for signal detection
11. Identifies and analyzes elements of multiple, inter-related or non-related and unthinkable crises events
12. Analyzes problems that partner organizations experience during multiple crises events
13. Articulates the full range of crises that can potentially affect the organization/system
14. Articulates the range and scope of crisis for which the organization/system should prepare
15. Develops the competence and capability necessary to anticipate, prepare for, respond to, and mitigate multiple crises
16. Develops a unified planning, capability, and resource system among partner organizations
17. Develops an emergency management/unified command system prepared for multiple crises
B. Crisis Patterns and Key Elements2
1. Utilizes the concept of technical and ethical uncertainties in a crisis event
2. Articulates the concept of objectivity as a “turnoff” during crises events
3. Articulates the concept of the court of public opinion vs. the court of law during crisis events
4. Articulates the importance of no secrets and complete transparency during crisis events
5. Articulates the importance of the concept of lessons ignored and not learned during a crisis event
6. Identifies the six phases of crisis leadership
7. Identifies the set of different crisis types
8. Identifies the effect of different crisis mechanisms
9. Identifies the different crisis families
10. Identifies different crisis stakeholders in relation to crisis types
C. Risk Assessment2
1. Utilizes the four elements of the crisis framework to identify how organizations/systems responds to crisis events
2. Applies the crisis framework to human-caused crises (normal/abnormal accidents) and natural disasters
3. Recognizes the basic patterns of organizational/system response and what elements should be reinforced or changed
4. Utilizes six phases of crisis leadership to redesign effective crisis systems
D. Command Capability and Improvement
1. Develops and implements a unified chain of command for emergency response
2. Demonstrates individual functional and leadership roles/responsibilities for emergency response
3. Demonstrates ability to make critical decisions and take decisive actions during crisis events
4. Facilitates development of key values and shared vision to guide decisions and actions during crisis events
5. Implements a multiyear emergency preparedness education, training, and exercise system
6. Implements a system for performance measurement, after-action reviews, and improvement planning
7. Identifies, communicates, and retests performance and maturity levels
E. Ethics and Crisis/Emergency Response3
1. Articulates the role of ethics in crisis leadership
2. Utilizes methods to balance emotion and use of reason during crisis events
3. Identifies historical incidence of leaders who faced moral challenges
4. Utilizes professional ethics in the context of community and society during crisis
5. Models ethical decision-making during emergencies/crises
6. Utilizes ethical decision making to apply/alter use of emergency plan procedures
7. Describes the role of public health law during emergencies/crisis events
8. Describes ethical issues regarding public health challenges and emergency events
9. Describes principles of ethical leadership and caring competence during disasters
F. Personality and Emotional Intelligence4 Personality Factors and Crisis Response
1. Identifies personality styles of leaders and leadership teams during crisis events
2. Utilizes assessment methods to determine personality style/preferences and crises
3. Analyzes the relationship of personality type/preferences to functioning during crises
4. Analyzes the impact of leadership cognitive and emotional intelligence during crises
5. Recognizes and reconciles rational and emotional elements during crisis events
Emotions and Performance: Leaders
1. Identifies critical emotional intelligence competencies during crisis events
2. Analyzes how feelings affect personal performance in stressful situations
3. Describes emotions that are aroused during crises
4. Describes personal strengths and weaknesses associated with emotions and stress
5. Utilizes methods to resist acting or responding in impulses during high-stress events
6. Utilizes methods to behave calmly in stressful or emergency situations
7. Utilizes methods to stay composed and positive during crisis events
8. Utilizes methods to calm others in stressful situations and emergency events
9. Utilizes methods to change ideas and perceptions under stressful situations
10. Utilizes methods to balance emotional and rational elements for decision making and decisive action during crises
11. Utilizes methods to handle ambiguity and multiple demands associated with crises
12. Utilizes methods to chronicle individual experience for after-action analysis
Emotions and Performance: Others
1. Utilizes assessment methods to identify personality style and the relation to performance during crises
2. Utilizes methods to identify moods, feelings, and nonverbal cues of others under stress
3. Analyzes underlying causes for feelings, behavior, or concerns of others under stress
4. Utilizes factual arguments (reason or data) to persuade/influence others under stress
5. Utilizes the support of influential parties to convince others in stressful situations
6. Utilizes methods to increase perception and perspectives of others during crises
7. Utilizes methods for reducing stereotyping of and reactions to diverse populations
8. Utilizes methods for broad support for increasing persuasive effect during crises
9. Utilizes methods to promote cooperation/collaboration in stressful situations
10. Utilizes methods to reduce conflict in crisis situations
11. Utilizes methods to chronicle experience of others to prepare for after-action analysis
G. Risk and Crisis Communication5
1. Identifies leadership role/responsibilities to develop a crises communication plan
2. Utilizes theoretical methods for and stages of risk communication
3. Identifies primary obstacles for use of appropriate risk/crisis communication in emergency situations
4. Utilizes basic elements of the concept of risk and factors associated with determining magnitude of risk
5. Articulates the Environmental Protection Agency’s seven rules of risk communication
6. Utilizes the 21 guidelines for effective communication by leaders during high-anxiety, stress, or threat situations
7. Utilizes appropriate risk/crisis communication methods during crisis events
8. Utilizes problem-solving, conflict resolution, and decision-making skills using principles and methods for risk communication
9. Utilizes communication role and methods with team members during emergency events
10. Utilizes communication role and methods with partner organizations during emergency events
11. Utilizes communication role and methods with the media during emergency events
12. Utilizes communication role and methods with the public during emergency events
H. Cultural Competence and Crisis6
1. Understands the difference between cultural diversity and cultural competencies
2. Describes the process for cultural competency development
3. Identifies the role of cultural, social, and behavioral factors in the delivery of public health services
4. Describes the relationship(s) between culture and health
5. Explores and describes knowledge about worldviews, mental models, values, beliefs, practices, and/or ways of other cultural groups
6. Identifies and discusses differences within cultural groups at the community level as well as across cultural groups
7. Describes the dynamic forces contributing to cultural diversity at the organizational level
8. Interacts with sensitivity and effectiveness with persons from diverse (cultural, socioeconomic, educational, racial, ethnic, professional, age, lifestyle preferences) backgrounds in the practice setting and in crisis situations
9. Actively seeks ongoing education, consultation, coaching, and/or training experience to enhance understanding and effectiveness with culturally and ethnically diverse populations in both normal and crisis situations
10. Identifies and understands one’s own competence level when interacting with cultural/ethnically diverse populations in normal and crisis situations
11. Identifies own stereotyping attitudes, preconceived notions, and feelings toward members of other ethnic/cultural groups and how these dimensions affect decision making
12. Participates in cultural/ethnic groups in communities of practice and community settings
13. Develops strategies and adapts approaches to problems and emergency/crisis situations that take into account cultural differences
14. Identifies institutional barriers that prevent cultural/ethnic groups from seeking public health services and assistance in emergency or crisis situations
15. Facilitates understanding of the importance of and methods to increase diversity in the public health workforce
16. Recognizes that communication and related actions are culturally bound
I. Legal Basis for Preparedness7
1. Identifies the source and scope of state and federal powers to protect the public’s health, safety, and welfare in the event of emergency events
2. Analyzes and applies how public health law contributes to emergency response
3. Identifies and applies the basic legal framework for public health preparation in emergency events and the roles of federal, state, and local governmental agencies
4. Identifies and applies basic provisions of the governmental unit in the health code and regulations during public health emergencies
NOTES
1. University of North Carolina School of Public Health Doctoral Program Leadership Competencies were used and adapted in part for use in this domain.
2. Competency sets were developed by the Heartland Centers in collaboration with Dr. Ian Mitroff, Comprehensive Crisis Management, Inc.
3. Competencies were developed by the Heartland Centers in collaboration with Dr. Shugg Yagel-McBay.
4. Comprehensive Crisis Management, Inc., Therese Jacobs-Stewart, M.A., and materials from the Hay Group, Dr. Daniel Goleman, Harvard University.
5. Competencies developed by the Heartland Centers in collaboration with Dr. Vincent Covello. http://centerforriskcommunication.org/.
6. Competencies developed by the Heartland Centers in collaboration with Dr. Louis Rowitz and adaptation of the Core Competencies in Public Health of the Council on Linkages Between Public Health Practice and Academia.
7. Competencies developed by the Heartland Centers in collaboration with Jason Sapsin, JD, MPH, the Johns Hopkins Center for Law and the Public’s Health.