Essay 5



One issue that gives many public officials trouble is accountability. There is a general perception that trying hard, or feeling good about a product, is all the accountability that is necessary.  Health directors are managers as well as policy-makers.  They are accountable to many different groups but particularly the public.  Chief executives and managers, at all levels of government and private enterprise, are held publicly accountable for their decisions.  It is not acceptable to pass blame for failure to a subordinate.  Professionals cannot hide behind their M.D./R.N./MBA degrees and blame an administrator for fiscal mismanagement.  Department and program directors are held accountable for staying within a budget.  There is no excuse for spending unallocated funds.  When I was a state health commissioner I was more likely to remove health directors from their positions for mismanaging their budgets than for any other cause.

Fiscal Accountability

The health director is responsible for the department's mission, goals and supporting programs.  The budget is a tool that defines priorities and provides a means to track fiscal performance, program by program.  It must be reviewed at least monthly to be sure that program costs stay inside their allowable totals with minimal deviation.  This does not mean one twelfth of a program's budget must be spent each month, but that you must have a spending plan for each budget item.  For instance, all capital equipment for a program may be bought in the first quarter and 50% of the program's budget spent in that quarter.  Or, a major training course in the last quarter may spend 30% of the program's funds in that quarter.  What is important is that you have a spending plan for which your supervisor can hold you accountable. If you have to deviate from this plan, do so in a timely manner with explanations to your supervisor. Mismanaging a budget is a serious failure and warrant's removal or retraining, or in the worst case, prison time!

In addition to careful fiscal management, accountability includes having a plan of work for immediate, mid-term, and long-range time periods.  It requires understanding how management fits into the department's entire operation, and the external world.  You are expected to understand a city or county manager's explicitly (derived from, a County Board of Supervisors or a City Council) stated goals for your department, as well as the implied ones necessary to support the locality's mission statement. Accountability includes a responsibility to treat people as humans, to expect the best rather than the worst from them.  This does not excuse you from guiding staff and holding them accountable.  It does not excuse you from taking necessary remedial action to correct poor performance.

Personnel Accountability.

Personnel management is a major area of accountability.  Failure to pay adequate attention to personnel management is likely to lead to legal action.  How much of the department's budget is set-aside for staff?  How much of this will be used for raises, merit increases, or part-time staff during peak periods and vacations?  Many organizations fail, or appear to fail, to administer their personnel system fairly.  Staff often perceive promotion or benefits given as based on favoritism, not performance. This is usually a misunderstanding caused by lack of clarity when setting standards to reward performance, or failure to communicate such standards to all who might be affected.  Standards of performance are often expressed in terms such as "above the average" but no one ever explains what the "average" is.  For a public health nurse the standard may be "completion of six home visits a day with a clear, complete, written description of the patient's condition and actions taken by the nurse."  More vaguely, it may be simply "performs at the same level as peers."

Physicians, nurses, and human service specialists such as social workers and case managers are trained to be concerned about their patients and clients, usually with little regard to cost. Unfortunately, this training rarely covers accountability for the results of providing care, let alone the cost.  Public accountability is changing from measuring numbers of visits made to a clinic, to concern about whether the service made any difference to a patient's health (think of examples of such measurements).  Due to the increasing cost of health care, health departments are expected to show that the care they provide, with public funds, makes a difference to the patient's health.  Additionally, many health departments are expected to show that a patient's dependency on public services is reduced, or the cost decreased, as a result of services provided.  Measurement of results is important to demonstrate accountability.

Physicians and nurses report through a medical chain of command during their training, and in most jobs.  If they work in a clinic or hospital setting they tend to consider only what their patients need without regard for the administrative structure or the various support services assisting them.  Physicians are used to writing "Doctor's Orders" and having a ward supervisor or house staff carry them out.  Rarely have they been taught, or motivated, to think seriously of the non-medical players on the team. Their priority is to make sure that patients get all the care and technology that might help them. Few physicians have any kind of management experience.  Those trained in public administration or business management have less difficulty adapting to results-oriented accountability.

Accountability to Supervisors.

When managing a local health department, one is accountable to a state, regional or district health department or jurisdictional manager. Depending on how a local health department fits into a local, regional, state or national organization, the line supervision of a health department may be a technical supervisor such as a regional or district environmental or nursing director, or directly from the state health commissioner. Supervision may also come through a non-technical administrative or political superior such as a city or county administrator, or in large population centers through a deputy or assistant city or county manager.  If the local health director is a physician reporting to a non-physician supervisor, it is often difficult for both.  Health directors must learn how to work within a large organization as a member of a team.  No one works in a vacuum.  Everybody in an organization must be held accountable.  Most jurisdictions today hire administrators trained in management of public organizations such as cities and counties, who serve at the pleasure of the elected mayor, city council, or board of supervisors [managers, selectmen, judges].   Occasionally, health directors report to a politically appointed Board of Health.

Health directors should have frank discussions with their immediate supervisors about the performance standards for which they will be held accountable.  The first discussion should take place during the job interview.  Regular periodic discussions about performance should be held at least semi-annually.  This avoids any question about your own performance, and whether the health department is making satisfactory progress.  You need to know whom you can hire and fire, particularly when you work in a civil service or a patronage system.  Most health directors work in a civil service system where all individuals are hired under personnel standards that include formal job descriptions and pay steps.  Such positions must be advertised and selections made from the best candidates. The director is held accountable for ensuring equity in hiring practices and must be alert to any effort to work around the system. One's staff learns rapidly whether people are hired on merit or because they `knew someone'.  Any perception of such behavior has a bad effect on morale that is very hard to overcome.  It is also important that the staff's profile represents the community as a whole by sex, age, and race.  To some extent this depends on the work force available locally. The larger the department, the higher the expectation will be that its staff reflects the population from which they are drawn.

Cross-cultural accountability.

If immigrants come to your health department, as is common along the US-Mexican border or near major ports, appropriate representation is especially important to avoid language and cultural difficulties.  Sensitivity to cultural and semantic differences are necessary to communicate recommendations to such groups.  In some cultures it is taboo for a male to examine a female.  If you have someone on your staff sensitive to the practice, a female physician or nurse can be assigned to that patient.  Many immigrants from Caribbean or South American cultures have a deep-seated belief in Curanderos or "witches".  Understanding such beliefs and using indigenous practitioners can help new immigrants accept the American way of providing care.  Failure to understand different beliefs and values can be a barrier to improving health care in both immigrants and some of our own neighborhoods that have developed from other than western European immigration.  Similar words among the romance languages may have very different meanings when translated to English, due to syntax, context or inflections of speech.  Asiatic languages do not have any way of expressing certain American values. 

Staff accountability and resources. 

It is important not only that you hire staff fairly, but that your supervision promotes coordination to carry out the department's goals. One of the essential chief executive's skills is delegation.  Although the health director is the chief executive of the health department, he or she still has a limited range and depth of skills. It is necessary to delegate both responsibility and resources to your staff to help carry out activities. Staff should not be held accountable for failing to reach an objective if they were not given the authority and resources to complete it. The health director should have a "management team" to help set priorities and to allocate staff to tasks. Team members are usually willing to be responsible for decisions they made as part of the team. They know the other team members that took part in making the decision will help them carry out the necessary actions. Allowing staff to make decisions in their area of expertise improves their willingness to solve problems. This technique allows you to guide staff members toward the goals you wish them to achieve without their feeling the task was force on them arbitrarily.

Monitoring subordinates.

Despite a team members' acceptance of a task, the health director must still monitor progress. If staff are falling short of your expectations intervene early by providing additional recommendations. Your staff may be making bad decisions. They may not be telling you everything because they think you do not want to hear bad news. You may be seen as a blamer, rather than a facilitator. This deters staff from holding themselves accountable to you. There is a fine line between holding a staff member accountable for a task and taking over for them. A manager may argue that sufficient resources such as people, money, or time were not provided. You should review the task given initially and make sure the manager remembers the discussion at the time the task was given, including resource limitations. You may need to agree on changes to your expectations. But you must hold the manager accountable for the task given.

Being Monitored

You should expect your own supervisors to hold you accountable to them just as you hold staff accountable to you. A director may have to change both short and long-term goals and objectives if supervisors change their goals and objectives. Directors may be in a position where their supervisors fail to listen or agree with their recommendations. If this happens discuss the issue with your staff and see if the department can and should modify its goals to meet the new challenges.  If this is completely impossible it becomes your responsibility to go back to your supervisors. If they still refuse to acknowledge the department's inability to meet their demands it may be necessary, as a last resort, to consider resigning! This should only be a final option. Never use the threat of resignation as a bluff, it will be called quickly. There are, however, times when accountability requires offering your resignation, as seen in early 2013 when the State Health Commissioner resigned rather than accept responsibility for the legislators’ Bill to require hospital standards for outpatient abortion centers.  If it is accepted, you can sit back and watch your successor make a mess of things!  If your successor thrives on the challenge and meets the expectations of your previous supervisors, you will have learned an important lesson: don't accept advice about what is or is not achievable without making sure the facts are accurate. 

Executive summaries

Just as you will be held accountable for performance (outcome) and for providing correct and timely factual information to your supervisors, you should demand such information yourself.  A large element of accountability relates to the way you present information, whether written or oral. Your supervisors are usually as busy as you are.  They need easily digested information. Provide succinct answers to their questions in the form of executive summaries, no more than one to two pages long. Cover only the facts they need to know to make decisions.  Don't preach when summarizing. Be prepared to provide backup material to the executive summaries. Present data as graphics whenever possible. If possible, delegate the bulk of the preparation of your presentations. The presentation developed for you shows how well the staff understand the department's goals and objectives, how well they research their material and how much additional training and guidance they need. This is another way to hold your staff accountable for meeting the department's goals and objectives.

Public Accountability.

Another concern for accountability at the policy level is credibility. Many organizations perform well in their chief executive's view, yet the public may not have great faith in the enterprise. This often happens with government programs, where people are served well but the policymakers don't consider the programs as being effective. This may be because the director and senior staff have been poor salesman. When public health does its job well, and often quietly, there are no disease outbreaks, no children disabled by mumps or measles meningitis, no-one affected by sewage overflow or made ill by E. Coli contaminated water, or foods containing large numbers of staphylococci.  Part of public health's accountability is also for providing public education about improvements in the public's health from good programs.  Departments of public health had their heyday before and around World War II.  They concentrated on providing pure water, uncontaminated food, adequate sewage systems, and case management for pregnant women, and immunizations for children.  We still do these things and do them well. We also work to control environmental hazards, to prevent developmental disabilities and, as a last resort, provide primary care.  Due to the excessive claims by various activist groups about food safety (the "Alar scare"), about poisoning water (fluoridation), about weekly cancer scares (coffee one week, barbecued steak the next) it has been difficult to sell less glamorous programs such as family planning, immunization, lower fat in diets, or prenatal care. The hard sell by the TV media has been for vaguely useful tertiary care. The 1988 report of the Institute of Medicine, "The Future of Public Health" indicates clearly that one of the main problems of public health, since the end of World War II, has been its failure to promote the effectiveness of public health programs. We have also failed to take a "systems approach" to evaluating our effectiveness and thus have been seen as poorly accountable. A clear example is the failure of many public health departments to get funds for prenatal care and care of young children. We have used such slogans as "$1 invested saves $3.00 otherwise used for intensive perinatal care." This sounds good to us but fails to recognize the small cost of a statewide program for perinatal and prenatal care compared with the long-term future cost savings. In a state with 1000 infant deaths a year and several thousand premature infants, the cost of prenatal care may be several hundreds of thousands of dollars, and the savings may appear to be only $1-2 million. When state budgets run into billions of dollars, these sums seem irrelevant. However, the cost of prenatal care for a single individual, up to $1000, should be compared with the $100,000 or more spent on intensive neonatal care for a very small desperately ill infant. The picture should include the costs of caring for a retarded child in the mental health/mental retardation system, the costs of special education services, and the costs of support in a sheltered workshop or a special home for the retarded. Instead of talking about $1 vs. $3 dollars for intensive care when you fail to spend the funds for prenatal care and delivery, you should focus on the same small sum spent for prenatal care vs. the millions of dollars of potential savings over the lifetime of this same child. Another way of presenting the same data is to draw a map of your community by neighborhood or census tracts showing the distribution of potential problems and potential savings. This will show each elected official that these problems exist in his or her district. Rather than making it look as though you are picking on the politicians who fund your programs, identifying the costs and numbers of individuals still affected by lack of services can result in additional funds for your programs. Such a presentation can demonstrate accountability for the health problems in the community and involve elected officials in a constructive way that leads to additional resources. When planning such presentations it is helpful to involve the TV, radio and newspapers. Political accountability can be just as important as accountability for budgeting, planning and personnel. You should also look at the Local Public Health Performance Evaluation Instrument


Finally, accountability is a two way street. Just as health directors are accountable to their supervisors, they are also accountable to the staff that works for them, and the public they serve. Directors who value two-way accountability have staffs of high performers who excel in difficult times, and make the department shine at all times.

Recommended Reading:

  1. Public Health Management. Chapter 21: Fallon and Zgodzinski. 3rd  edn. Jones & Bartlett. 2012
  2. Goldsmith S. & Eggers WD: Governing by Network, Chapter 6, Accountability.
  3. Rowitz, Louis. Public Health Leadership. Jones & Bartlett 2009 (A little verbose but an excellent reference.)
  4.  buckle National Public Health Performance Standards - Review Chapter 9
  5. The Future of Public Health, Future of Public Health Washington DC, National Academy Press, 1988 Review Chapter 2.
  6. Public Health in the 21st Century, Washington DC, National Academy Press, 2003
  7. Public Health Competencies - 2001, consider how these competencies can add to accountability.