Chapter 9

Leading and Managing Change in Public Health Organizations

Learning Objectives

• Identify characteristics of complexity and servant leadership
• Describe the public health system's need for change
• Articulate the need for public health leaders to achieve the Millennium Development Goals
• List the elements of the Model for Improvement
• Discuss system models of health

Public Health and the Urgent Need for Change

Public health is “the science and art of preventing disease, prolonging life, and promoting health” through organized efforts of society (Charles-Edward A. Winslow, quoted in Turnock, 2009, p. 10). The mission of public health organizations is to fulfill society's interest in ensuring conditions in which people can be healthy (Institute of Medicine [IOM], 1988). The broad spectrum of issues that public health must address to accomplish its mission calls for public health leaders throughout an organization who are capable of adapting to a world in which economic, social, environmental, political, and health challenges are ever changing. Unprecedented rates of emerging diseases pose substantial threats to planet Earth and can be attributed in great part to population growth, intensive farming, environmental devastation, climate change, and the misuse of antimicrobials. Our environment is contaminated with chemicals that threaten the health of all plants and animals inhabiting Earth. The increased mobility of the world's populations and growing economic interdependence facilitate the rapid spread of dangerous diseases and contaminated products. These complex threats require action by public health organizations that moves beyond the types of programs and services traditionally offered to improve population health. Public health organizations must now lead efforts to assure the public's health through broader initiatives involving numerous stakeholders and partners and addressing multiple determinants of health. For example, the World Health Organization (WHO, 2007) leads a campaign to promote global public health security, a call to reduce the vulnerability of populations to acute threats to health. WHO recommends the integration of public health into economic and social policies and systems, global cooperation in surveillance and alerts and response for disease outbreaks, and cross-sector collaboration (agriculture, commerce, tourism, and health) within governments. Another example can be found in the work of local public health agencies (LPHAs) located in counties and cities across the United States who work with partners to conduct surveillance of communicable diseases and prevent the spread of these diseases across community populations. The efforts to prevent and contain the spread of H1N1 also exemplify the work of public health agencies to monitor and control disease. This chapter explores the opportunities for public health practitioners to lead and manage changes in the delivery of public health services that are most likely to produce improved health outcomes for communities in the twenty-first century.

Challenges Facing Local Public Health Leaders

The challenges a public health leader will face in his or her career are too numerous to list. In spite of this overwhelming prospect, public health leaders can be found at different levels of government, within community-based organizations, and in nonprofit nongovernmental organizations (NGOs). Much has been written about the qualities of a successful leader—able to catch the crest of a wave and ride it with strategies in hand, value driven, technically competent, tenacious, personally credible, self-aware in regard to strengths and weaknesses, persuasive, and politically savvy (Grainger and Griffiths, 1998). Add to this the qualities that are deemed essential for a leader—visionary; ethical; having a sense of mission; being an effective change agent, political navigator, negotiator, mediator, power broker, collaborator, capacity builder, forecaster, marketer, team builder—and it is stunning that so many professionals sign on to direct their community public health efforts. Courage and a thirst for knowledge would seem to be the essential and initial traits for any person seeking greatness in public health leadership.

Public health organizations face a world that has become more interconnected and more interdependent, and in which the rate of change is unprecedented. As so aptly stated by the scientific leader and luminary Stephen W. Hawking, the twenty-first century will be the century of complexity (Sanders, 2003). Studying complex adaptive systems, or systems in which the parts are strongly interrelated, self-organizing, and dynamic, is an endeavor within the larger field of complexity science (Sanders). Rain forests, societies, human immune systems, and the world economy are all considered complex adaptive systems. Certainly the field of public health practice falls into this category as well. In order for public health organizations to thrive, they must be responsive to community needs, which are intrinsically affected by local, state, national, and global economies; emerging and reemerging diseases; and environmental pollution. To thrive, public health agencies must adapt to changes that occur in the larger environment in which they operate—locally, nationally, and globally. These are the types of adaptations that public health agencies must make to remain a relevant part of a broad effort to improve global health, which includes the health of all nations, through health care and public health services.

In this chapter we discuss the skills that our public health leaders require to assure conditions that protect and promote health in this era of complexity, and we offer recommendations to advance global public health security. Better security means stronger global, national, and regional partnerships that perform surveillance, continuously learn about emerging events and risk factors, develop processes and changes that address problems early on, and conduct primary prevention efforts by reducing exposure to risks and promoting well-being on a broad scale.

Millennium Development Goals

In 2005 members of the United Nations established goals and commitments to work together to promote the economic and social advancement of all peoples (United Nations [UN] General Assembly, 2010a). Noteworthy is this group's dedication to achieving these noble Millennium Development Goals by 2015 (UN General Assembly, 2010b):

• Eradicate extreme poverty and hunger
• Achieve universal primary education
• Promote gender equality and empower women
• Reduce child mortality
• Improve maternal health
• Combat HIV/AIDS, malaria and other diseases
• Ensure environmental sustainability
• Develop a global partnership for development

Achieving these wide-reaching goals means intensifying national responsibility and leadership. The problems they identified and their proposed solutions require leaders with the following (UN General Assembly, 2010b):

• Skills to communicate and to transform the current public health systems at the local, state, and national levels into active partners in assessing the broad settings in which our health and social issues reside
• Courage, compassion, and spirit to reignite new and old partnerships to help redesign the current system of public health

The authors of the Millennium Development Goals report acknowledge that each nation must define its own social and economic policies and resources, and especially work on building the political will for achieving the 2015 targets. However, in such an interconnected global economic system, finding ways to effectively lead and develop partnerships to leverage the world's trading and investment opportunities has great potential to reduce and eventually eliminate the poverty that plagues many nations around the globe and disrupts their opportunities for improving the health of countless people.

Urgent Need for System Change

Today's public health practitioners not only are concerned, as were their predecessors, with controlling communicable diseases and epidemics but also must recognize and address the health effects of a vast array of new health problems associated with the built environment, climate change, pandemics, natural disasters, bioterrorism, and poverty. U.S. public health practitioners must also focus on the relatively poor health of Americans when compared to inhabitants of other developed countries. Ironically, while the overall health of Americans declines, the nation grapples with excessive health expenditures, a warning sign for other developing countries to keep an eye on the evolution of their health care systems and the associated costs.

The United States ranks highest in per capita spending for health care among all countries in the world. However, in recent reviews of health care systems, the United States ranked thirty-seventh in preventable deaths, forty-third in mortality for adult females, and forty-second in adult male mortality (Murray and Frenk, 2010). The U.S. population has a shorter life expectancy, a shorter quality of life expectancy, and a higher infant mortality rate when compared with other developed Western countries (RAND, 2006). Evidence also establishes that health performance in the United States not only is poor but also is improving at a slower rate than that of other developed countries (Murray and Frenk). The U.S. rates of obesity, a known risk factor for diabetes and cardiovascular disease, are among the highest in the world. In 2009 adult obesity rates increased in twenty-three states and did not decrease in a single state, an obvious indication that public health policies and services are not addressing a clear and present danger for the American populace (Trust for America's Health, 2010a). A recent analysis of the effect of obesity on longevity predicts that the steady rise in life expectancy in the United States over the past two decades will soon come to an end, and today's generation may not live as long as their parents (Olshanksy et al., 2005).

This information should be an alarming wake-up call to public health agencies who are just now beginning to address the problem, while at the same time the skills of the public health workforce remain focused on the provision of personal health care services and not on population-centered primary prevention services. The U.S. health care system is adept at treating particular diseases and illnesses, such as cancer and cardiovascular disease. We spend over $2 trillion each year to pay the costs of health care (Urban Institute, 2009). Almost 80 percent of these health care costs are attributed to treating preventable chronic diseases. The health care system is made up of health care providers and institutions, such as hospitals, that treat sick or injured patients and provide clinically based preventive services. Less progress has been made to prevent risk factors and promote policies and behaviors that reduce the rates of chronic diseases, which are linked to the smoking and obesity that are widespread throughout the nation (United Health Foundation, 2009). Local public health systems continue to emphasize personal health care services over population-centered health services. Personal health care services involve the treatment of disease and the provision of clinical services to individuals or families to address and resolve their individual health problems. The lack of knowledge about population-centered health services on the part of key public health practitioners, as well as the current mandates for public health agencies to provide personal care services, such as maternal and child health care, are barriers for a needed redesign of the public health system.

Investing in public health services that seek to reduce tobacco use through education, regulations, and taxes, or that involve communities in campaigns to promote physical activity by increasing access to safe recreational areas, are highly effective when compared to the curative model predominant in the U.S. The curative model has as its primary function the treatment of illnesses, such as lung disease or diabetes, and it costs more than $3 trillion annually (Trust for America's Health, 2010b). Millions of Americans suffer from such preventable diseases as cancer and diabetes. Their quality of life is diminished, and for some their retirement years become a nonstop series of visits to various providers of health care. Underinvesting in preventive care and population health is the norm, although evidence continues to show that the nation's health would improve with such investments (Kindig and Stoddart, 2003; McGinnis, Williams-Russo, and Knickman, 2002). The 2009 Trust for America's Health report determined that an investment of 10 dollars per person in evidence-based community health programs to promote physical activity, improve nutrition, and expand smoking cessation would amount to a savings of $16 billion annually in health care costs within five years.

Most public health agencies have changed little over the past decades. Among the ten most frequent services LPHAs offer, according to a review conducted by the National Association of County and City Health Officials (NACCHO, 2008), are adult immunizations provision, communicable disease surveillance, childhood immunizations provision, tuberculosis (TB) screening, food service inspections, environmental health surveillance, food safety education, tuberculosis treatment, tobacco use prevention, and inspections of schools and day care programs. Tobacco use prevention is the only new program added to the top ten list during the past decade, a result of the master settlement of a class action suit in which tobacco companies agreed to pay $365.8 billion over twenty years to compensate states for treating smoke-related illnesses as well as to finance anti-tobacco programs.

NACCHO's profile (2008) of LPHAs, based on agency-reported data, states that most primary prevention services, including programs to address tobacco use, nutrition, chronic disease, unintended pregnancy, physical activity, injury, substance abuse, violence, and mental illness, are being provided by NGOs, not by LPHAs. In a comparison of providers of primary prevention services in various communities, just fewer than 40 percent of LPHAs, some in partnership with NGOs, were shown to provide chronic disease prevention services. The report does not specify the amount or type of primary prevention services offered by LPHAs or LPHAs in partnership with NGOs. Twenty-five percent of LPHAs deliver home health care, and 11 percent offer comprehensive primary care services. When LPHAs provide primary prevention services, they mainly focus on tobacco use, nutrition, chronic disease, and physical activity. Nutritional services are largely organized around the federal program Women, Infants, and Children (WIC) to ensure access to healthy foods for low-income mothers and their young children up to age five. LPHAs serving smaller populations generally offer a smaller percentage of primary prevention services than do their larger counterparts. NACCHO also reports that although a large percentage of LPHAs conduct surveillance and epidemiological services for communicable diseases, fewer than half of LPHAs apply these skills in the area of chronic illness.

Because every system is perfectly designed to achieve exactly the results it gets (Berwick, James, and Coye, 2003), the current public health system is a prime candidate for change that redesigns the system to support public health services that are population-centered, address the principle causes of disease through primary prevention, and incorporate a global health focus. Much work remains to be done to reduce the occurrence of preventable diseases. Experts in the field of cancer, for example, maintain that 40 percent of cancer cases worldwide could be prevented. Relatively simple population-centered strategies shown to be effective at reducing cancer cases include policies and campaigns that lower the rates of tobacco use, limit exposure to secondhand smoke, and decrease alcohol consumption; that encourage people to avoid getting too much sun and maintain a healthy weight through good nutrition and exercise; and that seek to protect against infections that cause cancer through vaccines (Union for International Cancer Control, 2010).

A number of public health agencies are engaged in quality improvement projects to address gaps in performance. Some use standards to identify gaps, such as the Centers for Disease Control and Prevention (CDC) National Public Health Performance Standards Program (www.cdc.gov/od/ocphp/nphpsp/) or public health accreditation criteria (for example, the Public Health Accreditation Board standards, www.phaboard.org/index.php/accreditation/standards/). Often the scope of changes undertaken to improve the performance of local public health agencies is limited. Efforts by LPHAs trying to improve current services, such as by reducing clinic wait times or reworking billing practices, amount to more of the same. Although these endeavors can achieve some improvements in organizational performance and community health outcomes, the resulting improvements generally do not accomplish the level of change that is fundamentally necessary for the public health system to grapple with today's complex and global health problems. What is needed is change of the system, not changes in the system. Producing great health outcomes requires great systems of care for health, including public health, and a will to improve, along with methods for systematic change (Berwick, 1996). An interesting exercise for most LPHAs would be for each one to check the alignment of its community health assessment priorities, established in partnership with community stakeholders, with its strategic plan, a current report of its services over the past two years, and the agency's strategic budget. Our recent review of a rural local public health agency revealed significant misalignments among the community health assessment priorities, the organization's strategic plan, its report on current activities, and financial documents about funded programs. The vision for local public health agencies involves community partnerships that guide the selection of priority health outcomes and the budgeting of and advocacy for adequate resources to meet community expectations for health improvement—known as customer service in other industries.

Visioning the New Public Health

The ultimate concern of public health practitioners is with the underlying structures that create the society in which we live and that have an impact on whether we are a healthy or unhealthy community, state, or nation. “Because fundamental social structures affect many aspects of health, addressing the fundamental causes rather than more proximal causes is more truly preventive” (Public Health Leadership Society [PHLS], 2002, p. 4). Whether protecting the public during a disaster or epidemic or reducing exposure to risk factors that lead to chronic illness and suffering, public health leaders must work collaboratively across community groups to form partnerships, as well as taking stock of state, national, and global health perspectives to identify and promote the fundamental requirements for health that contribute to global public health security. These requirements extend beyond access to quality health care and include the effects on health that originate from lifestyles, social relationships, economies, policies, and the built and natural environments—components of the ecological model of health.

The vision for public health reaches beyond the traditional provision of personal services and community health education, and includes advocacy and actions at the local, state, national, and global levels to encourage the sustainable use of finite resources; to reduce the impact of climate change; to protect the world's natural resources; to create built environments that promote and sustain healthy lifestyles and reduce the spread of chronic diseases; to sponsor policies that foster healthy local economies, reducing the impact of poverty on health and the social dimensions of life; and to update and expand regulations and controls that reduce the opportunities for the spread of toxic threats and infectious and chronic diseases.

The public health services of the future will routinely incorporate a system model of health with the major determinants of health for addressing the profound changes in the way we inhabit our planet, such as the growing use of intensive farming practices or rapid urbanization in parts of the world. Models incorporating the determinants of health, such as the ecological model of health, are valuable tools for action by local, national, and global public health leaders (Centers for Disease Control and Prevention [CDC], 1999a; IOM, 1996; Schneider, 2006). Employing such models facilitates thinking about and working simultaneously on the multiple dimensions of the system that create the incredible threats to all forms of life on our planet today. Newer versions of the ecological model of health are more expansive and include the global ecosystem, acknowledging problems associated with climate change and biodiversity, and with the macroeconomy, politics, and global forces that represent the significant interrelationships and interdependence among societies across the globe. An example of the interdependence of societies around the world can be found in the financial crisis in the U.S. banking system in 2007, which created significant risks for world economies, many of whom experienced decreasing economic growth, recessions, and growing unemployment and poverty. Earlier versions of the ecological model of health included individual characteristics (such as age, sex, race, and hereditary factors); lifestyles; community (social capital); the local economy (wealth creation and markets); activities (such as walking, shopping, moving); the built environment (buildings, places, roads, and so on); and the natural environment. Developing local strategies for reducing health inequalities and merging that work with sustainable environmental and economic determinants of health included in current models of health can be part of a global effort to improve the health consequences of poverty, crime, wars and conflicts, climate change, natural catastrophes, and man-made disasters. Preventing infectious disease epidemics and pandemics and avoiding other acute health events are equally critical areas for emerging public health leaders.

Leadership for the New Public Health

Modern day problems are just too complex for traditional leadership thinking formed during the Industrial Age and based on top-down management principles. The multifaceted challenges facing human organizations today call for a range of new skills among public health leaders that transcend the conventional view of leadership in which one person, the leader, exerts sufficient influence over another, the subordinate, to achieve an intended outcome. The traditional view of leadership is based on a role rather than a behavior, a role occupied by a person with the responsibility of regulating the behavior of others toward the achievement of some end.

Conventional views of leadership conceptualize the leader as a visionary who is charting the course for the future. The traditional view of leadership implies certainty, influence, and control. Leading an organization, according to the conventional view, requires a leader's vision and direction to create the necessary changes, removing any and all obstacles until the goal is met. The emphasis is on one individual's skills and capabilities. Further, the vision for the organization is created based on one leader's ability to scan the external environment and his or her adeptness at making changes, motivating employees, and including strategic partners (Uhl-Bien and Marion, 2008). A public health leader formed by the teachings of these traditional leadership models would have a vision and a story, and would be an able communicator and formidable strategic planner. These conventional models of leadership maintain that effective leaders control organizations and direct employee behaviors to achieve specific outcomes.

Alternatively, we can think of leadership as a behavior that emerges from the continuing interactions of different and multiple persons engaged in a wide variety of activities, a “roving leadership” (Max De Pree, quoted in Plowman and Duchon, 2008, p. 131). This emerging view expands the concept of leadership beyond one person, a formal leader, and considers the manifestation of leadership behavior across multiple persons in an organization. “Leaders emerge, not from self-assertion, but because they make sense” (Plowman and Duchon, 2008, p. 131). Fostering teamwork, engaging communities in decision making, and being ethical and authentic are additional competencies of leaders who help to get the right things done.

Complexity Leadership

The theory of complexity leadership is based, in part, on the uncertainty of events and the nonlinearity of relationships, which affect our ability to predict or even fully understand outcomes. This view of leadership is also based on the observation that most actions, regardless of how well they are directed and targeted, will have multiple effects. Complexity leadership theory asserts that ongoing interactions among entities at lower levels of an organization (front-line employees, information system personnel managers, and so on) result in emergent order at the higher levels of that organization (organizational outcomes), creating a new order, an emergent state of the organization. Proponents of complexity leadership believe that traditional leadership based on control and regulation to reduce conflict or disorder drains the energy from leaders and their followers. The challenges for today's public health system under these conditions of uncertainty and unintended effects are beyond the capabilities of a handful of people at the top who are “in control.” Leaders alone cannot direct all the changes, because they do not know what changes are necessary. The questions we face as a society are too big for any one discipline alone to answer. The key to solving complex issues is the emergence of leadership throughout and across the organization and the different disciplines within the organization, allowing the whole system to adapt to the myriad of changes that occur routinely in the organization and the surrounding environment. Leadership is specifically concerned with adapting organizations and employees to change, creating the capacity to thrive.

Complexity leadership theory helps answer the question of how leaders participate in developing an organization that can thrive in a complex environment (Uhl-Bien and Marion, 2008). The nonlinear, dynamic, and emergent aspects of ensuring conditions that keep people safe and healthy create challenges for public health leaders who are concerned with organizational structure and processes. Leadership is necessary to develop and guide processes by which public health solutions emerge to address complex issues, enabling rather than controlling fundamental change. To illustrate, controlling increasing rates of tuberculosis among migrant farmworkers is possible through leadership across an LPHA to accomplish

• Adherence to evidence-based practices that address the multiple determinants of health
• Continual assessment of farmworkers' living conditions and travel
• Cultivation of trust and engagement of the farmworker community leaders
• An understanding of transmission paths that include domestic and foreign travel
• A willingness to extend case finding and treatment across borders
• Attention to nutrition and safe living conditions
• Empowering staff to plan, perform, refine, and develop policies for managing the multiple services required of community members exposed to or with an active case of TB
• Employing information systems to track and report on each patient's risks, care, and contacts with possible exposure to the disease

The complex nature of the disease as well as the migrating characteristics of population members, many of whom travel between countries, are best addressed when leadership is shared and barriers to controlling the disease are removed by those who work successfully with the population and are most knowledgeable about their needs and assets.

In the complexity leadership model, the leader's role is one of making sense of a variety of factors and being a catalyst for change, altering the functioning of the entire system by introducing or removing elements, thereby loosening up the system to be adaptive. This is accomplished by integrating three key leadership functions: adaptive, enabling, and administrative leadership (Uhl-Bien and Marion, 2008). Adaptive leadership is the source of change in an organization. Adaptive leaders scan across disciplines and industries to see emerging conditions, paradigm shifts, and opportunities for innovation. Enabling leadership fosters or supports adaptive leadership, and adaptive and enabling leadership can be found at multiple levels of an organization. Administrative leadership is the function of administering, planning, and organizing the bureaucracy toward flexibility and allocation of the resources needed for the organization to adapt to and implement the changes. Administrative leadership is found in formal managerial roles within an organization. The tendency for an organization to become stagnant and nonresponsive to events due to leadership by a handful of people can be offset by the distribution of leadership across an organization. The emergence of such talent is termed collective intelligence, or distributed intelligence, and is a cornerstone of complexity leadership (Uhl-Bien, Marion, and McKelvey, 2008).

In this environment, leadership development shifts from a sole focus on individual development to an emphasis on fostering leadership capacity throughout the organization. This broadened approach to leadership development enhances the ability of the organization to practice emergent and collective leadership. For example, one way to foster emergent or collective leadership is to coach leaders to shift their thinking away from a controlling role and toward a catalytic or facilitative role. Another key principle of complexity leadership theory is the deliberate creation of aggregates, small groups or teams with a shared identity who interact with other groups or teams in the organization, creating networks of teams. Leadership capacity increases as opportunities for leaders to emerge multiply based on the expanded interaction of individuals within and across teams. A primary goal of leadership development in complexity theory is to promote more interaction and leadership across various roles, organizations, and locales, which inevitably leads to new connections and innovative relationships for solving complex problems (Van Velsor, 2008). Improving these connections increases the social assets and learning potential of an organization. In this modern era, organizational IQ and learning capacity have become more important than physical assets because they generate flexibility and the necessary knowledge to adapt to new conditions.

Tension is an accepted characteristic of the complex organization and its leadership, given the dynamics of multiple and diverse groups working together on common problems. The diversity and number of organizations that could potentially form a public health partnership to tackle one or more major health issues would no doubt result in many voices, not always harmonious, defining the health problems to be resolved and identifying solutions to be implemented (Gray, 2009). This tension or disequilibrium is not necessarily viewed as a bad thing within the framework of complexity leadership. In this state, a system is injected with energy and information that spread throughout the system and break up existing patterns, creating disturbances and presenting opportunities for new, emergent system order and solutions (Plowman and Duchon, 2008). Some claim that it is only in such conditions that emergent ideas surface, new adaptations are possible, and innovation and creativity arise. Leaders in this instance must support and facilitate the environment for adapting to such changes, busting up the equilibrium now and again to allow for continual innovation.

Leading and Serving

The tenets of servant leadership blend well with many of those of complexity leadership, and also embody the principles laid out in the Principles of the Ethical Practice of Public Health (PHLS, 2002). Servant leaders have a strong desire to serve, and they achieve organizational results by placing high priority on the needs of their colleagues and the customers of the organization (Greenleaf and Spears, 2002). Successful public health practitioners who serve their communities and fellow employees possess many of the competencies of the servant leader: listening, empathy, healing, awareness, persuasion, conceptualization, foresight, stewardship, commitment to the growth of people, and building community. A servant leader is one who promotes the growth of other persons in areas including health, wisdom, freedom, autonomy, self-worth, and willingness to serve (Greenleaf and Spears, 2002).

The servant leader works to clarify the thoughts and will of a group, listening to as well as reflecting on those thoughts through the experience of body, spirit, and mind, becoming an empathetic listener (Greenleaf and Spears, 2002). The ability to heal oneself as well as others is a strength found in servant leaders. Servant leaders rely on persuasion rather than command-and-control models of leading. They nurture great dreams, and they are able to think beyond day-to-day tasks; they can see the whole of the organization and the dynamic nature of the organization and the environment that surrounds it, as opposed to seeing only the parts. The servant leader is skilled at foreseeing potential outcomes or likely consequences of decisions, and makes decisions based on the commitment to serve the needs of others. Such a leader is committed to the development of others—professionally, personally, and spiritually—and creates real opportunities for people to grow. Lastly, the servant leader creates the culture that supports a sense of community among employees and engages the larger community with the work of the organization.

Similar to proponents of the emerging and collective intelligence tenets of complexity leadership, servant leaders are strong believers in the power of a group-oriented approach to decision making. In the case of public health, this type of approach strengthens organizations through a process that ensures wide participation and commitment to solving problems and improving community health. Leaders have a responsibility to build socially responsible products, progress, and services for the betterment of their community and ultimately the world. Engaging multiple partners and disciplines provides the knowledge—the system IQ—to do just that. The interconnectedness of today's global societies requires that leaders make informed decisions, undertaking an ecological or systems approach to monitoring events and detecting problems early on. Leaders derive such knowledge from diverse sources or groups of individuals working on the same, related, or even different perspectives of the system. The successful public health leaders for the twenty-first century are developers and facilitators of processes that promote interaction across units within and beyond their organization. In this way they promote service and increase the organization's flexibility to adapt to the ever-emerging complexities of improving the public's health.

Changing the Public Health System for the Future

We have celebrated ten great accomplishments of public health from 1900 to 1990: vaccinations, motor vehicle safety, safer workplaces, the control of infectious diseases, a decline in deaths from coronary heart disease and stroke, safer and healthier food, healthier mothers and babies, family planning, fluoridation of drinking water, and recognition of tobacco use as a health hazard (CDC, 1999b). Looking forward, what will be our top achievements? How will our public health agencies and leaders help communities stay healthy in the midst of major changes emanating from a world undergoing climate change; reeling from an international economic meltdown; facing threats from terrorists; and experiencing ongoing poverty, hunger, and increased rates of disease? What role can local public health systems plan to take in promoting local and global public health security?

In the United States, the governmental arm of public health at the local level, the local public health agency, is frequently referred to as the backbone of the public health system (see, for example, IOM, 1988; IOM, 2002). The limited research on local public health agency performance indicates that the bulk of public health expenditures continue to be related to personal health care services and treatments for preventable diseases, and not population-centered services (Brooks, Beitsch, Street, and Chukmaitov, 2009). The obesity epidemic is an indicator that the public health system must become more alert to new risk factors and undertake changes to prevent new diseases and epidemics, adapting to emerging health events. Public health agencies do this by conducting surveillance to monitor health status for community health problems; informing, educating, and empowering people about health issues; and engaging community members and organizations to address the primary causes of disease, thereby improving health and preventing excessive health care costs. Public health officials alert to the growing rates of obesity and informed about the emerging determinants contributing to this epidemic have broad community support, committed funding streams, and evidence-based interventions under way (see the Guide to Community Preventive Services, www.thecommunityguide.org/index.html). Public health agencies must transform into providers of population-centered health services, supporting interventions aimed at disease prevention and health promotion. Ideal public health services have an effect on entire community populations, for example by reducing exposure to risk factors with a negative impact on health (such as alcohol and tobacco use); supporting policies and services for promoting healthy diets and active lifestyles (such as workplace wellness programs); and reducing environmental pollution and degradation (such as by supporting small and local farming efforts).

The primary services found in most LPHAs are inadequate to address the expanded determinants of health and the threats to the public's health. Changes are needed in the current public health system to improve the health status of communities and to make progress toward global public health security. Theories of complexity and servant leadership offer guidance for creating processes that will help organizations thrive in today's complex environments.

Managing Change

Strong public health leaders are effective change agents, developing their creative capacities as well as expanding opportunities and support for other practitioners of public health to assume leadership roles. Leadership is primarily about managing change and creating processes that facilitate change. Complexity leadership concepts offer a dynamic means of understanding and explaining social phenomena and methods by which public health officials may improve organizational IQ. Complexity leadership concepts are aimed at enhancing motivation through employee empowerment, and they create ways to speed up the emergence of distributed intelligence across an organization (McKelvey, 2008). Accelerating the emergence of organizational IQ is accomplished through the deliberate creation of small groups or teams interacting with other teams and establishing networks of human capital—the knowledge, skills, health, and values of individuals. The goal is to increase the presence of these interacting groups throughout the organization, rather than confining such knowledge networks to upper management alone. Employees then become responsible agents for adaptive capability rather than individuals who merely carry out orders.

Improving the process by which we identify and undertake changes is a catalyst for loosening up the system to be more adaptive, introducing elements, methods, and new processes that move the system closer to its goals (Dodder, 2000). The obvious purpose of improving organizational processes is to increase the quality of operations and services. In the field of public health, quality is defined as “the degree to which policies, programs, services, and research for the population increase desired health outcomes and conditions in which the population can be healthy” (U.S. Department of Health and Human Services, 2008).

As mentioned earlier, the efforts to improve quality in public health agencies have focused on fairly specific goals, changes within the system, rather than undertaking a change of the system. Programs to change the public health system, including standards promoted by the CDC based primarily on the ten essential services, have not brought about such a shift. Change of the system is desirable if we are determined to contain the threats present today as well as achieve greater improvements in health outcomes, reducing health and environmental inequalities.

Within the field of health care, Don Berwick is the Administrator of the Center for Medicare and Medicaid Services, past president and CEO of the Institute for Healthcare Improvement (IHI) and national leader in and authority on health care quality and improvement. IHI is an example of an organization that operates primarily through the development of networks, which in this instance comprise IHI professionals partnering with motivated groups within organizations and applying the scientific method to build knowledge—with an ultimate goal of spreading changes that result in improvement across the health care system. To accomplish their goals for improving health care, a simple and elegant model for achieving changes that lead to improvement was devised—the Model for Improvement (Berwick, 1996). In addition to the Model for Improvement, those seeking credible improvements in their system of care are introduced to a system model for considering change, the Chronic Care Model, which is aimed at assuring fundamental change of the system, not only changes in one program or one division. The Chronic Care Model identifies the essential components of a quality system of chronic care, which include the community, the health care system, self-management support, delivery system design, decision support, and clinical information systems. Each component of the model incorporates evidence-based change concepts to improve the quality of care and the patient's interaction with the health care provider and the larger health care system (Improving Chronic Illness Care, n.d.). The ecological model of health is a comparable model for ensuring quality public health services. Both models identify the essential areas of the system in which work is needed to ensure high-quality services that lead to improved health outcomes. Improving the organizational performance of an LPHA also requires the identification of major components of the organization. We suggest the following categories, which represent common organizational domains: the customer (community and employee), financial management (stewardship of public funds and adequacy of resources for community and global priority health issues), internal processes (evidence-based services and quality improvement), and learning and growth (employee education and widespread opportunities for leadership) (Kaplan and Norton, 2001).

Using the Model for Improvement is a method for undertaking change that has the highest likelihood of achieving organizational goals. The initial step is establishing an aim. The aim should be measurable, time-specific, and clear in regard to the community or other population to be served. The model requires measures to establish that changes made result in improvements—measures that have value beyond focusing on the past. Reported measures create focus for the future because they communicate what is important to the organization. Reports on the performance of changes through the use of measures become a management tool, providing ongoing information about whether or not the change process is progressing and allowing the organization to adapt to the changes' resulting effects. Selecting changes that are the most likely to result in improvement will increase the likelihood of progress toward the organization's goals. Evidence-based practices are new to LPHAs, and their use must be emphasized by developing workforce skills, by linking evidence-based practice with funding for current and future public health programs, and through leadership.

Effective leaders of improvement maintain that frequent challenges to the status quo are needed by actively testing promising changes to the organization—an argument supported by complexity leadership theory (Berwick, 1996). The process for testing changes in real work settings is the Plan-Do-Study-Act (PDSA) cycle. Using the PDSA cycle, ideas for changes in work settings are planned, tried, studied, and acted on based on what is learned. Metrics are an important part of the study process, helping to inform the leader of any progress that is being made. The PDSA cycle is designed to allow a leader to swiftly test a change in a real work setting before fully implementing that change across an entire department or organization.

Summary

Public health organizations addressing current and future complex health issues understand that change is a basic principle of public health work. Systems and cultures that support and adapt to the shifting environment and cope with the uncertainty of events are needed. The following conditions should be present in the new world of public health practice:

• The network of groups working both independently and collaboratively on overlapping public health issues set the mission, vision, and strategy of public health.
• Leaders throughout an organization have an active willingness to foster change for improvement by establishing a plan for improvement, setting aims and allocating resources, employing a performance measurement system, and fostering leadership at various levels of the organization.
• Leaders encourage ideas for positive change throughout the organization, employing evidence or the best available knowledge attained through listening to community members and stakeholders.
• Employees throughout the organization contribute to a culture of emerging knowledge that is managed and shared.
• Such methods as using the Model for Improvement are employed to manage change, study results of initiatives, spread ideas, and sustain levels of performance improvement.
• Values surrounding the empowerment of employees, the development of knowledge and organizational IQ, relationship building, and broadly based leadership development are evident.

Theories of complexity and servant leadership offer new strategies for public health practitioners leading change of the public health system. Solving complex problems relies on the development of collective intelligence; the ability of practitioners to study and adapt to the changing environment while challenging the status quo and listening to the thoughts and will of groups created throughout the organization and community; the linking of groups to create networks that share knowledge as they work on common public health issues; and the ongoing practice of applying system models.

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Discussion Questions