CONTROL BOARD REPORT ON THE DC DEPARTMENT OF HEALTH
(Summarized from University Research Corp. report of October 8, 1997)
In what may well be the world's longest executive overview, this report treats all aspects of DC's Department of Health (DOH). Unlike many other consultants' reports, this one finds a department "rich in professional talent and commitment, with a need for fundamental change in both strategic and operational areas". It finds, however, a "vacuum of leadership" resulting in "an environment of stress and confusion". In fact, a unified DOH--with a total of 924 employees-- has only recently been established for DC, and the very new director has yet to establish his presence at the agency. He does have ambitions to develop his newly created agency into a public health model for the nation based on the current US vision of "healthy people in healthy communities". The report assesses five factors affecting all DOH programs:
1. Management of grants and contracts is improving, but much further progress is needed. There are classic difficulties in executing contracts and hiring personnel. Programs are having trouble getting renewals of continuing contracts; managers and staff circumvent the official processes to achieve their goals; and the staff does not have confidence in the grants management process--which is not well understood or codified in writing. There is also some indication here that the Control Board is contributing to these problems by adding yet another layer to an already cumbersome process.
2. Personnel management is an area with a "tremendous potential for improvement" according to the assessment team. On the encouraging side, job descriptions are being written, as well as procedures for performance appraisal. The team also found "a great deal of talent and expertise at all levels in DOH". However it remains difficult to fill staff positions even when they are approved and funding is available: many essential staff positions remain vacant. Compensation is inadequate and inconsistent--DOH employees have received no cost of living increases for six years, and no performance-based salary increases for five years.
Opportunities for promotion are very limited, locking professional staff into one position with little opportunity for growth. DOH is still paying little attention to management and staff development. Staff morale is low; managers have difficulties taking actions against poor performers; and staff has little access to training and professional conferences, unless they use their own money. Written guidelines for hiring, performance review, promotion and termination are not widely understood by managers, and recruiting efforts are inadequate.
3. Communications and information technology is primitive although the staff appears willing and anxious to learn new data processing and computer skills. But at this time, interoffice mail is not reliable, and the telephone system is not only inadequate, but frequently does not work at all.
4. The budget process is being improved, but in many cases, basic budget information is not available to program managers and staff. But more important, the importance of the budget process is not well understood or consistently followed--leading to mistakes, delays, and budget overruns and underspending.
5. The procurement process in DOH, as virtually everywhere throughout the DC government is totally inadequate. Despite some improvement in the ability to track orders and to develop a fast-track approval process, significant problems remain. Shortages of basic office supplies are common, with staff members often buying needed items with their own money. Cleaning supplies and services are in short supply in health care delivery settings. There are extensive delays in procuring equipment, and there are problems with staff access to vehicles: one specialized vehicle has been out of service for a year awaiting repair parts.
These shortcomings appear in one form or another in all five of DOH's operating divisions. If for no other reason, it is worth noting the scope and complexity of DOH operations and responsibilities:
In Administration, Management, and Planning, payment of vendors has become more timely ("the dark days are over"); a new strategic planning process is being initiated; a new financial management system is being developed; the budget process is being improved; and job descriptions, policies, and procedures are being codified in writing. Nevertheless, budgets, roles, responsibilities, and reporting lines are still unclear; job security still outweighs recruiting better skills; and the staff still circumvents established procedures. There is still very little "customer-feedback" to the staff, and little staff feedback to DOH administrators.
In the State Health Affairs Office, some progress is reported in the State Health Planning and Development Agency, the State Center for Health Statistics (not including automation), the Office of Emergency Health and Medical Systems, and the Service Facility Regulation Administration--which is still (unwisely) located in the DC Regulatory Administration. It might be noted that these are all normally state-level functions that are difficult at best for an inner city government to handle.
The Commission on Health Care Financing hopes to increase its staff from 66 to 78 persons to administer an $835 million federal cost-sharing program which finances health care services to approximately 127,000 individuals (in a city of less than 600,000). They are charged with developing and implementing a plan to provide health care for the District's (110,000) uninsured and indigent residents (mostly children); supporting the Mayor's health goals; and meeting the federal requirements of the Social Security Act. To its credit, this commission has reduced expenditure growth rate from 10-20% annually to 2% in FY97. It has eliminated 20,000 Medicaid ineligibles, and eliminated serious (45%) overpayment of hospital costs.
The Public Health Service employs 548 staff to administer seven programs: Addiction Prevention/Recovery, HIV/AIDS, Maternal and Child Heath, Nutrition, Preventative Health, Medical Affairs, and School Health. All suffer from problems with personnel, procurement, and information technology, but according to this consultants' report are still achieving their basic program objectives with a staff committed to their clients. The morale of that staff is very low, however, due to understaffing, insecurity about the future, basic sanitation problems, and lack of management and leadership training.
Finally, the new Environmental Health Division, whose functions are now carried out by the Environmental Administration within the DC Regulatory Administration, will use 100 employees organized into four divisions Air Quality Control; Hazardous Substances; Water Quality, and Soils. Here again, the assessment team found some positive elements, but a world of problems. The position of Administrator has been vacant for two years; there is no strategic plan; over $200,000 in grant funds remain unspent each year; legal and enforcement areas need strengthening; community outreach and relations are not done effectively; and the staff is unsure about its impending transfer. As is reported throughout the DC government, there is virtually no management training, all personnel functions (hiring, firing, raises, travel money, etc.) are inadequate; and productivity is hampered by lack of supplies, equipment, maintenance and information technology.
To a greater or lesser extent, these same problems in management, personnel, procurement, and basic technologies impact other smaller agencies as well, such as The Family Administration, The Mental Retardation and Developmental Disabilities Administration, and The Rehabilitative Services Agency--all spawned by federal and local legislation, and primarily funded from federal resources over and above the DC budget.