You are to put yourself in the place of Diane Hudson, MPH management consultant who has been tasked with doing the initial assessment for a larger analysis designed to diagnose and recommend solutions tomanagement issuesfacing the Sleepy Mountain Health Department (SMHD).

Note that your boss, Kathy Campbell, to whom you must submit this report, is very demanding in requiring fact-based recommendations. She requires specific reference to management concepts upon which you base your recommendations (e.g. span of control, etc.) Be specific paraphrases will not do. Assessment should be FIVE PAGES and it should follow the pattern below and answer each question below:-

1. Identify what you consider the five (5) most important management challenges facing SMHD.
2. Designate one page for each challenge and address each challenge with a series of bullet points as follows:
3. Bullet Point # 1. State the management challenge identified and the page number in the SMHD case where this challenge(s) is exposed.
4. Bullet Point # 2. Present your recommendation as to how management should approach this challenge/solve the management problem.
5. Bullet Point # 3. Specifically list the management concept(s) we discussed that you used in making your recommendations. Be specific in calling out the concept(s)/theory.

Case:-

Sleepy Mountain Health Department

Diane Hudson, MPH was making her way back from Sleepy Mountain, West Virginia to the Morgantown airport and a thousand thoughts were going through her head. Diane was well on her way to a successful career at Acceleration Associates International (AAI) a management consulting firm with a number of clients in the public sector. She started out five years ago as an intern with AAI while she was completing her MPH. Soon after graduation she was offered a job with AAI and began working her way up the corporate ladder. She just became a Senior Consultant with AAI and Sleepy Mountain was her first assignment as a project leader. She felt a great deal of pressure to make this project a success.

Sleepy Mountain

Before she left for Sleepy Mountain her colleague Joe Dyer told her Sleepy Mountain and its health department "were nothing to write home about!" Joe went to college in Morgantown and told Diane Sleepy Mountain, West Virginia had a bad reputation. Not many people wanted to live there. In his words "no body except old timers would live in Sleepy Mountain and they would move if they had the money or somewhere to go." Local government was known for its ongoing financial troubles. The people in Sleepy Mountain were friendly, proud, and honest but poor. The economy was built around coal mining and most of the mines closed a decade ago. The few that remained opened were run my multinational corporations who acted as absentee landlords and pulled what meager profits the mines made out of the country and certainly out of the community. Years ago the mines were automated so most of the good paying jobs disappeared and even the automated equipment was rapidly depreciating.

In spite of the depressed economy, the demands on the health department had increased dramatically. The population of Sleepy Mountain was made up primarily of the elderly who would not move and young families whose head of household had less than a high school education and could not move because they had few if any marketable skills. There were also a large number of young children. Many families were uninsured except for Medicaid of West Virginia and Medicare and a large percentage of the population relied on the health department for their primary medical care. The nearest hospital to Sleepy Mountain was in Snowden, West Virginia. This hospital had 200 beds, was run by the Sisters of Charity, and was known primarily as an urgent care hospital that frequently had to stabilize patients and send them to more comprehensive facilities in Morgantown, WV or Pittsburg, PA.

The Sleepy Mountain Health Department, although not wealthy by any means, was well funded compared to other operations in the area. Many years ago the county passed a law that designated a portion of the property tax to the health department and local schools. Although property values had decreased over the years the taxes provided the health department with relatively predictable and stable funding. In addition, because of the coal mining history the local community had received a substantial sum from the federal and state government as well as the United Mine Workers Union to care for individuals with chronic diseases caused by working in the coal mining industry. The health department also received grants from time to time to fund special projects designed to address specific needs.

Sleepy Mountain Health Department (SMHD)

The SMHD was the largest employer in Daniel Boone County. The health department employed approximately 600 employees. About 100 of the employees were "professional" including physicians, nurses, disease control specialists, laboratory personnel, and community health workers. Environmental health was not a part of the department. Environmental health had been moved from the health department 20 years ago and put under the jurisdiction of the West Virginia Environmental Services Department after a rather nasty confrontation between public health officials and mine owners relating to air and water pollution. The other 500 employees were nonprofessional employees such as maintenance staff, secretaries, data entry personnel, laboratory technicians, etc.

Diane found herself involved with the SMHD because of a grant the health department had received from the Appalachian Trust Foundation. The Foundation had awarded the grant to the SMHD because of the importance of the department to the local region and the evident managerial challenges the SMHD was presently experiencing. Specifically, the proposal awarded to AAI outlined that the responsibility of the consulting firm was to do a comprehensive assessment of the managerial and organizational challenges that were preventing the department from achieving its greatest potential.

Why SMHD Needed a Management Audit

A job at SMHD was considered a prized accomplishment for most of the citizens of Sleepy Mountain. No employer in the county and few in the entire state offered a benefits package that compared to that of the health department. Although there was occasional discontent about the pay levels no one complained about the benefits which included employer paid health insurance for the individual employee and very reasonable rates for family plans. Employees also enjoyed membership in the county employees retirement system which was totally noncontributory. Employees had a generous number of paid holidays and four paid personal days.

Despite the generous benefits, employees appeared to Diane as complacent and unenthusiastic about their jobs. Patients complained that waiting times in the clinic and at vital records were extremely long and gaining access to a provider was complicated. Processing personnel (e.g., receptionists, etc.) were rude and condescending. No one would do anything not required by their job description.

Professional employees had a similar benefits package but there were greater discrepancies in pay levels. Clinical workers were offered professional supplements to bring their compensation more in line with the private sector. However, the salary levels continued to lag significantly. Although recruiting and retaining nonprofessional workers was not a problem (everyone wanted the benefits) the health officer often complained that it was extremely difficult to recruit professional employees like doctors and nurses. Since all employees were subject to the regulations of the Boone County Personal Board the hiring process was complicated and slow. Positions had to be "posted" on the County Web Site for a minimum of 30 days, candidates were required to go through a very detailed "eligibility process" by the Personnel Board and virtually all the hiring was done by the centralized staff at County Headquarters. Health department employees often complained that the first time they met their new employee was when they showed up for work. All the interviews, evaluations and hiring was done by the Boone County Personnel Board. Even the job specifications written in the health department were edited and altered by Personnel Board employees without consultation with or notification of health department HR.

SMHD supervisors were sent a list of individuals who had been prescreened by personnel in the Headquarters and managers often felt they were not offered the best candidates for positions. Most often when feedback was provided the advice of the health department was not taken. Some suspected the Personnel Board played favorites and gave preference to family members and friends in constructing the list. The average time from the posting of a SMHD position and the hiring date was 8 months. The health officer and other SMHD managers agreed that many of the best candidates were simply "no longer available" by the time the list reached the health department. The counter strategy used by the health officer was to continuously request clinical positions in the hope that someone would be available when a position opened.

In addition to the recruitment problem turnover was a very difficult issue with professional positions. If the department was lucky a doctor would graduate from medical school that grew up in Sleepy Mountain and would want to "return home." This was particularly true of nurses. In fact, one of the most important "community partners" of SMHD was the Northern West Virginia Community College (NWVCC). The NWVCC was one of several community colleges in the state that offered a two year nursing program. Virtually all of the graduates for the program were employed either at the SMHD or the Snowden Hospital. The few who did not work for the health department or the hospital were quickly employed by one of the family doctors located in adjacent areas. Frequently, when a nurse who was on the Personnel Board's list was referred to the SMHD he/she had already accepted a job from another employer. One nurse related that he had accepted another job, quit that position for a better one, and was considering taking another job all during the time he was on the Personnel Board list.

The average tenure of a doctor at SMHD was seven months. Many moved to the community only to discover that there were a number of limitations - the quality of public schools was suspect, there was practically no cultural life any closer than Morgantown, and there were few employment opportunities for spouses. The average tenure for nurses was not much better. However, rather than moving out of the community the nurses seemed to rotate from the SMHD to the hospital to a doctor's office and back again to the health department. The only nurses who had significant longevity at the health department were those who had the "golden handcuffs" and were held in place by the vesting of the retirement system.

Inside the SMHD

The first contact Diane had with the SMHD after AAI got the consulting contract was the department's web page. The web page was less than helpful. Essentially, it had an "About" link that gave a brief description of the department and a "Contact Us" link that provided a local phone number. There was no SMHD directory available. There was a listing of the Board of Health members which was comprised of four local doctors, a pharmacist, a nurse, and the superintendent of education. There was no contact information for the Board Members.

When Diane followed up with a telephone call to get some needed information she was greeted with an electronic answering system that stated "if this is a medical emergency call 911 for all other issues please enter your party's extension." However, with no directory it was impossible to know any extensions. When Diane finally arrived at the department on her first visit she was greeted with what looked like an abandoned army base. Paint on the walls was not fresh, the waiting area for Vital Records was austere, and she was literally afraid to take the elevator for fear she "might get stuck and never heard from again." She decided to take the stairs to the third floor where the administration was located and that was a mistake. The stairs apparently had not been cleaned in several weeks, there was evidence that some employees had been smoking in the stairway, and perhaps some ate their lunch there.

The Health Officer at the SMHD was Dr. Howard Heinz. Dr. Heinz was 70 years old and was retired from the United States Navy. Dr. Heinz had a very distinguished military career which spanned 32 years. He was the first young person ever to be appointed to the United States Naval Academy from the Sleepy Mountain area and was a first-generation college graduate. After graduation, he attended medical school at Johns Hopkins and entered the Navy to fulfill his mandatory obligation. Navy life suited him and his wife so he made the Navy a career. His fondest wish was to retire to Sleepy Mountain and "give back" to the community that had given so much to him.

Everyone seemed to like Dr. Heinz, who preferred to be called "The Captain" and liked to point out that he was "running a tight ship at the health department." It was observed that Dr. Heinz was "slowing down." Last year he went to Pittsburgh for open heart surgery and never seemed to regain his energy. He bragged that over the last year he had become a "very effective delegator." The Captain's only real problem was his preference for "sticking to the book." He never criticized any employee for following procedures but would become very upset if someone "violated a policy and things went wrong."

As a result, most employees had adopted the practice of always following the rules even if it meant longer waiting times in the clinic or losing good people because the hiring process. Even when things finally arrived at the health department processes faced slow down after slow down with everyone making sure they didn't make a mistake. Employees told Diane they constantly had to "navigate this culture of NO." It was said that no matter what the merits of a request were, the first answer you got was "no." This seemed to have gotten significantly worse since the Captain learned to delegate. Then you had to step back and "figure out a way to work around the system or just give up and go on your way." When people raised questions about the shabby condition of the waiting rooms and elevators Dr. Heinz would say "I am working on it" but nothing ever happened.

Organization of SMHD

The SMHD was organized much like any local health department. The department was divided into five major divisions - Clinical Services, Community Outreach, Disease Control, Vital Records, and Finance and Administration. Clinical Services was responsible for the operation of three primary care clinics located throughout Sleepy Mountain. Generally speaking each clinic was operated by a clinic manager, a doctor, a nurse practitioner, a RN, a social worker, a pharmacy tech, and two secretaries. Clinic managers reported to the Director of Finance and Administration. The doctors and nurses were evaluated by the Clinic Managers but reported to the Medical Director on medical matters.

Disease Control was headed by a nurse practitioner specializing in infectious diseases and staffed by two disease control specialists, an epidemiologist and a secretary. Community outreach was led by a licensed social worker and consisted of three social work assistants, a public relations administrator and a secretary. Vital Records was headed by a Public Health Program Director/Statistician with a staff of two data entry specialists, a receptionist, and a secretary. Finance and Administration was directed by Alex Horton, MBA, CPA. Alex reported directly to the health officer along with the Medical Director. Finance and Administration was by far the largest unit in the health department and contained a personnel specialist who primarily interfaced with the County Personnel Board and administered the department's benefits program. The Accounting Unit was responsible for the receipt and distribution of health department funds including purchasing. This unit employed four accountants who were responsible for fund accounting, accounts receivable, accounts payable, and payroll. The Information Technology unit employed ten employees who interfaced with the accountants for business matters, the clinic and administered the EMR, and provided all the IT support for the department. There was also a full time lawyer in Finance and Administration who dealt primarily with contracts and risk management.

The management structure was Balkanized and was comprised of what appeared to be five independent fiefdoms. The budget was tightly controlled by Alex and competition was intense for available funds. In fact, Alex encouraged competition and frequently stated in management team meetings that "healthy competition for the budget was the key to departmental efficiency." Clinical Services complained that there was just too much overhead in Finance and Administration and Community Outreach and Finance and Administration maintained that the clinics and vital records should be more "productive" and generate more revenue since the major sources of funds to the department were for clinical services and vital record fees. Management team meetings often ended when participants "came close to blows" and the Captain seemed incapable of settling things down. Most of the time he just adjourned the meeting and said, "let's all cool down and talk again next week."

Alex was always producing reports that compared the clinics to one another in terms of patient visits and was careful to highlight the "laggards" in bright red. Vital Records was under constant pressure to generate more fees. Alex and the Medical Director rarely talked to one another except in management team meeting and these interactions were usually contentious. The Medical Director complained that Alex was trying to run the health department like a business and had lost sight of the "real mission of public health." Alex delighted in smugly stating that if there is "no money there is no mission."

Your Assignment

You are Diane Hudson. This is Friday afternoon and your boss Kathy Campbell, Managing Partner of AAI, wants your assessment completed according to the form and format you were supplied in the Instructions. You have worked for Kathy for several months and you know her slogan "say it straight and say it fast." Everyone knows Kathy will not read more than five pages of anything. If you want to impress her you have to get to the point. KATHY IS EXPECTING YOUR REPORT. DON'T DISAPPOINT HER!