Building a Better a Public Health Response System in Los Angeles County

BUILDING A BETTERPUBLIC HEALTH RESPONSE SYSTEM

IN LOS ANGELES COUNTY

Los Angeles County Department of Health Services • Public Health

San Gabriel Valley and Metropolitan Service Planning Area Health Office (SPA 3 & 4)

SPA 3 & 4 CASE STUDY

November 2004

SPA 3 & 4 BEST PRACTICE COLLECTIONRELIABLE INFORMATION FOR EFFECTIVE COMMUNITY HEALTH PLANS, PROGRAMS AND POLICIES

M. RICARDO CALDERÓN, SERIES EDITOR

November 2004Building a Better Public Health Response System

SAN GABRIEL VALLEY SERVICE PLANNING AREA (SPA 3) METROPOLITAN SERVICE PLANNING AREA (SPA 4)241 North Figueroa Street, Room 312Los Angeles, California 90012(213) 240-8049

The Best Practice Collection is a publication of the San Ga-briel Valley (SPA 3) and Metropolitan Service Planning Area (SPA 4). The opinions expressed herein are those of the edi-tor and writer(s) and do not necessarily reflect the official position or views of the Los Angeles County Department of Health Services. Excerpts from this document may be freely reproduced, quoted or translated, in part or in full, acknowledging SPA 3 & 4 as the source.

Internet: http://www.lapublichealth.org/SPA 3 Internet: http://www.lapublichealth.org/SPA 4

LOS ANGELES COUNTY BOARD OF SUPERVISORS

Gloria Molina, First District Yvonne Brathwaite Burke, Second District

Zev Yaroslavsky, Third District

Don Knabe, Fourth District Michael D. Antonovich, Fifth District

DEPARTMENT OF HEALTH SERVICES Thomas L. Garthwaite, MD.Director and Chief Medical Officer, Department of Health Services

Jonathan E. Fielding, MD, MPH, MBA.Director of Public Health and County Health Officer

AUTHORS Deborah Davenport, RN, PHN, MS. Area Health Officer, SPA 1 & 2

Sharon Grigsby, MBA. Executive Director, Public Health BT Program

A. Belinda Towns, MD, MPH. Medical Director, Public Health

BEST PRACTICE COLLECTION TEAMM. Ricardo Calderón, Series EditorManuscript Author & SPA 3 & 4 Area Health Officer

Carina Lopez, MPH. Project Manager, Information Dissemination Initiative

Photos: Courtesy of photosearch.com

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The SPA 3 & 4 Best Practice Collection fulfills the Los Angeles County Department of Health Services (DHS) local level goal to restructure and improve health services by “establishing and effectively disseminating to all concerned stakeholders comprehensive data and information on the health status, health risks, and health care utilization of Angelinos and definable subpopulations”.1 It is a program activity of the SPA 3 & 4 Information Dissemination Initiative created with the following goals in mind:

To highlight lessons learned regarding the design, implementation, management and evaluation of public health programs

To serve as a brief theoretical and practical reference for program planners and managers, community leaders, government officials, community based organizations, health care providers, policy makers and funding agencies regarding health promotion and disease prevention and control

To share information and lessons learned in SPA 3 & 4 for community health planning purposes including adaptation or replication in other SPA’s, counties or states

To advocate a holistic and multidimensional approach to effectively address gaps and disparities in order to improve the health and well-being of populations

The SPA 3 & 4 Information Dissemination Initiative is an adaptation of the Joint United Nations Program on HIV/AIDS (UNAIDS) Best Practice Collection concept. Topics will normally include the following:

1. SPA 3 & 4 Viewpoint: An advocacy document aimed primarily at policy and decision-makers that outlines challenges and problems and proposes options and solutions.

2. SPA 3 & 4 Profile: A technical overview of a topic that provides information and data needed by public, private and personal health care providers for program development, implementation, and/or evaluation.

3. SPA 3 & 4 Case Study: A detailed real-life example of policies, strategies or projects that provide important lessons learned in restructuring health care delivery systems and/or improving the health and well being of populations.

4. SPA 3 & 4 Key Materials: A range of materials designed for educational or training purposes with up-to-date authoritative thinking and know-how on a topic or an example of a best practice.

At a Glance

Building a Better Public Health Response System November 2004

“The need for leaders is too great to leave their emergence to chance.”

The Future of Public, Institute of Medicine, 1988.

PREFACE:

The National Public Health Leadership Institute (NPHLI) is an innovative, 12-month, residential and long-distance leadership development program founded by the Centers for Disease Control and Prevention (CDC) in 1991. It is offered by the University of North Carolina at Chapel Hill (UNC) School of Public Health, the UNC Kenan-Flagler Business School, and the nonprofit Center for Creative Leadership, Greensboro, NC.

The NPHLI was developed in response to the recognized need for enhanced leadership in public health. “Many authorities assert that public health improvements will require the sustained actions of coalitions and partnerships and frequently call for leaders with the vision and skills to foster them”.1 Accordingly, the NPHLI mission is “to strengthen the leadership competencies of senior public health officials and to build inter-organizational teams so that community health status improves”2 and the Institute “seeks to develop collaborative leaders who convene or participate in partnerships, and to strengthen national networks of leaders who trust one another, share knowledge, and work together to improve public health”.2

The NPHLI enrolls multidisciplinary teams of 2 to 4 senior leaders responsible for strategic issues, major policy development, and boundary-spanning in their agencies or organizations. “The scholars' ability to think from a system's perspective, to create and implement a vision, to facilitate meaning and to empower followers is enhanced to assure they can shape responses to public health challenges in the twenty-first century”.1 The program curriculum requires intensive teamwork-based learning projects and learning methodologies include, but are not limited to, leadership style assessments, personal feedback and coaching, assigned readings, self-directed study, interactive lectures and discussions, case studies, monthly conference calls with experts, residential training at UNC and, most importantly, a collaborative project highlighting the effects of NPHLI on scholars’ leadership understanding, perspectives and practices and leadership project achievements during the program and after graduation.

The NPHLI highest award is the “Martha Katz Award”. It is presented annually to the scholar team whose collaborative leadership project is judged to best represent the innovative, strategic and systems thinking and action that Martha Katz demonstrated during her career at CDC and Healthcare Georgia Foundation. Criteria for selection comprises of report quality, community impact, evidence of partnership or boundary spanning activity, use of strategic thinking and demonstration of leadership learning”.3 The following pages describe the NPHLI 2003/2004 Best Team Leadership Project awarded to the Los Angeles County Scholar Team for the project entitled “Building a Better Public Health Response System in Los Angeles County.”

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PREFACE

“We must be led by those who have mastery of the skills to mobilize, coordinate and direct broad collaborative actions within the complex public health system...these skills need constant refinement and honing.”

The Future of the Public’s Health in the 21st Century, Institute of Medicine, 2002.

THE MARTHA KATZ AWARD CRITERIA FOR SELECTION:

Report Quality Community Impact Evidence of Partnership or Boundary Spanning Activity Use of Strategic Thinking Demonstration of Leadership Learning

University of North CarolinaNPHLI, 2004


i. Preface 2

I. NPHLI Time Distribution of Activites in Action 4

II. Introduction and Final Problem Statement 5

III. Problem Statements and Goal Revision Model 6

IV. Goals, Objectives, Action Steps and Results 7

V. Impact of the Project:

Impacts on Team 10

Impacts on Organization 10

Impacts on Partnerships 11

Impacts on Policies 11

Impacts on Communities and Community Health 11

VI. Outcomes Approach Logic Model 12

VII. Lessons Learned About Leadership 13VIII. References 15

IX. Appendix:

Los Angeles County, DHS: Overview of Public Health Incident Command System 16 DHS Incident Command System System Chart 17 Service Planning Area (SPA) Incident Command System Chart 18

Table 1: Goals, Objectives and Action Step 19

Table of Contents

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BUILDING A BETTER PUBLIC HEALTH RESPONSE SYSTEM


“Action Learning is a powerful training and problem-solving tool for developing individuals, teams and organizations. It is used for strategic planning, for developing managers, for identifying competitive advantages, for reducing operating costs, for creating high-performing teams and for becoming learning organizations. Simply described, action learning is a dynamic process that involves a small group of people solving real problems, while at the same time focusing on what they are learning and how their learning can benefit each group member, the group itself and the organization as a whole.

Developed by Professor Reg Revans in England in the middle of the 20th century, action learning was slow to be understood and applied until Jack Welch began using it at General Electric. Over the past 20 years, various approaches to action learning have appeared, but the model that has gained wide-spread acceptance is the Marquardt Model, which incorporates the successful elements of both European and American forms of action learning. This model contains the following six interactive and interdependent components that build upon and reinforce one another.

Problem ResolutionProblem Clarification

Continous Reflection and Learning

Early on, the group spends time trying to make sure they understand the real problem at hand. Others in the group or from elsewhere (organizations, stakeholders, community) ask questions and help clarify the problem. As the process goes along, the group then takes actions (see figure below). Learning continues throughout.

NPHLI Time Distribution of Activities in Action Learning (adapted from Marquardt, 1999, p. 45)

NPHLI Time Distribution of Activites in Action

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1. A problem (project, challenge, opportunity, issue or task) 2. An action learning group or team 3. A process that emphasizes insightful questioning and reflective listening 4. Taking action on the problem 5. A commitment to learning 6. An action learning coach

Action learning, when systematically implemented, can effectively and efficiently solve problems with innovative and sustaining strategies, develop teams that continuously improve their capability to perform and apply valuable knowledge at the individual, group and community levels”.


I. INTRODUCTION

The NPHLI Year 13 Scholars of the Los Angeles County Department of Health Services envisioned the cre-ation of a fully integrated disaster event response system in Novem-ber 2003. Given the size of Los Angeles County and the potential impact on its target rich communi-ties, our NPHLI Leadership Team initiated efforts to develop a well-coordinated public health system response to the full range of 21st century threats, be they a result of natural disasters, bioterrorism acts, or newly emerging infectious disease outbreaks. The inherent challenge to our project was the recognition and integration of local Service Planning Areas (SPAs) as critical components in disaster response, including engagement of SPA staff in preparedness and response and, in turn, how they would engage local communities.

Our group selected this topic in advance of the Program Launch and in complete innocence of all the leadership theories and best practices to which we would subsequently be exposed. Not surprisingly, over the course of the year our perspectives on our project goal, objectives, approach and, particularly, on our team, all changed markedly. We did persist on the essence of our vision and made great progress toward its achievement. We believe we have come to understand the complexi-ties of systems thinking and change and the corresponding intricacy of approach and process necessary to

address them. Action learning was evident throughout the year as the team re-thought and re-defined our understanding of the challenge and of the ways we needed to adapt our project to meet it. While the task is not yet complete, we believe the year has shown us how the action learning approach can create a path to successful broad system change. Our team, our staffs and our com-munities are the beneficiaries. We appreciate this incredible opportunity to learn so much and to describe our story in the following pages. Of the changes to everything else is the substance of this report.

II. F I N A L P R O B L E M S TAT E -M E N T

The model on page 12 demonstrates how the questioning and reflec-tion of our team evolved over the last year in order to conceptualize an approach to effectively manage Public Health disaster event plan-ning. We list in Page 6, the problem statements and goals included in our reports during the last twelve months, starting with the initial problem statement and goal from the Post Launch Report and pro-gressing to problem statement and goal of the Final Report. We moved from a mental model of a Public Health agency looking internally and outside of itself to a model of “connections and collaborations” as a means of improving our system. The initial approach of our team did not effectively address how Pub-

Introduction & Final Problem Statement

OBSERVE, QUESTION AND

REFLECT ONPROBLEM ANDPRIOR ACTIONS

TAKE ACTION

PLAN THENEXT STEPS DRAW CONCLUSIONS

OBSERVE, QUESTION AND

REFLECT ONPROBLEM ANDPRIOR ACTIONS

TAKE ACTION

PLAN THENEXT STEPS DRAW CONCLUSIONS

Action Learning

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“We are what we repeatedly do. Excellence then is not an act, but a habit.” Aristotle

“Management is doing things right; leadership is doing the right things.” Peter Drucker

The Action Learning Cycle

lic Health would truly integrate the Incident Command System (ICS) and the Community into the process of disaster planning and management. What we came to recognize is the need to create an inter-sectoral system that no longer sees “out and over”, but rather creates a framework that operationalizes effective communica-tions and collaborations. Consequently, we have acknowledged that our work is to create a network of critical roles across Los Angeles County communi-ties instead of trying to structure how others interact with us.


Problem: “The Los Angeles Public Health system is not prepared to provide a coordinated seamless response to disaster events (Post-Launch Report, November 2003).”

Goal: As a result of the leadership of this team, the Los Angeles County Service Planning Area Health Offices will collaborate with the leadership of the Bioterrorism Program and Emergency Management System to reorganize, integrating the Incident Command System model into Service Planning Area mainstream.

Problem: “Our ability to effectively and efficiently carry out our role is hindered by our failure to fully integrate the community and our community-based infrastructure (Service Planning Areas [SPAs]) into this system (Mid-Term Report, February 2004).”

Goal: To protect the health, safety, and well-being of individuals, families and communities by providing a coordinated, seamless and efficient Public Health System response to disaster events.

Problem: “…our ability to effectively and efficiently carry out our role is hindered by our failure to fully integrate the community and our community-based infrastructure (Service Planning Areas [SPAs]) into this system (Post-Retreat Report, May 2004).”

Goal: To strengthen Public Health’s ability to protect the health, safety, and well-being of individuals, families and communities by providing a coordinated, seamless and efficient Public Health System response to disaster events.

Problem: “Los Angeles County Public Health must create an inter-sectoral public health system that ensures optimal communication, information transfer, and collaboration, both within its physical operational structure and as a community-based partner, in order to assure its capacity to prepare for, protect and respond to population health disaster events (Final Report, September 2004).”

Goal: To create an inter-sectoral public health disaster planning and response system in Los Angeles County that includes an internal and external system partners in a manner that ensures optimal communication, information transfer and collaboration.

Problem Statements and Goals Revision Model

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Inside Looking Out and Across

Recognizing Need for FullCollaborationInternally and Externally

RecognizingNeed for an Inclusive Approach

Recognizing Need for a Complex Network of Critical Public Health Roles

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While our problem statement and goal are “final” for the purpose of this report, we believe that through continuous Action Learning com-mitment to questioning and reflec-tion, action, and learning as well as results—our problem statement and goal may undergo revision and restatement as we move through and enhance restructuring and partnering processes.

III. GOALS, OBJECTIVES, ACTION STEPS AND RESULTS

GOAL:

To create an inter-sectoral pub-lic health disaster planning and response system in Los Angeles County that includes internal and external system partners in a man-ner that ensures optimal commu-nication, information transfer and collaboration.

OBJECTIVE 1:

Implement reorganized and inte-grated Service Planning Area (SPA) emergency response structures by September 2004.

Action Step 1.1: Establish a work-group to develop infrastructure plans.

Results: The PHLI project team formed the core of this workgroup and was aided by a Los Angeles

PHLI leadership change project which is working on extending pre-paredness planning to community groups working through the SPA staff.

Action Step 1.2: Conduct educa-tion and training of SPA based staff regarding their roles in the new emergency response structures, including: (1.2.1.) ICS Training of Public Health leaders, (1.2.2.) Train Public Health staff for mass vaccina-tion clinic roles and ICS roles, and (1.2.3) Mass Clinic Exercise.

Results: Since most Incident Com-mand System training programs are designed for traditional first re-sponders, police and fire personnel, we had to create an Incident Com-mand System adapted for Public Health. A contract was written, us-ing Bioterrorism funding, with UCLA School of Public Health, Center for Public Health and Disaster, to design and teach a two-day seminar on Incident Command Systems for 160 Public Health leaders. This seminar was offered four times over a five month period from May to Sep-tember, 2004 for all of our public health senior managers including the SPA Area Health Officers and key staff who would play a role in a public health emergency. While these trainings were underway, a parallel effort began to train staff from the SPAs and the programs to respond to a bioterrorist emergency by opening and operating mass clinics. Command and control poli-cies were developed and approved. Job Action Sheets were developed for each of the roles necessary to staff a mass clinic (approximately 100 staff per shift per clinic site). A day of training was scheduled for

approximately 50 facilitators and breakout group leaders. Then, over two days, approximately 1,000 staff received eight hours of training cov-ering these roles. From this group, some 200 individuals were selected to exercise a daylong mass clinic including a shift change transition. Eight teams from the SPAs received an additional day of training in leadership roles at the mass clinic exercise including ICS. They, then, participated in a table top exercise at the end of their training to practice their ICS roles. On June 23, 2004, the 200 individu-als staffed a clinic site which pro-cessed 750 “victims” for smallpox vaccinations using ICS principles.

Action Step 1.3: Technical advisory group discussions and meeting with subject matter experts within Public Health, DHS, and other public safety sector providers to assure com-munication systems are compatible with SEMS/ICS, ongoing, at least monthly between March 2004 and June 2004.

Results: In terms of acquiring public safety and other partners’ input on our Public Health ICS Plan, we met monthly with members of the Los Angeles Terrorism Early Warn-ing (TEW) Group. This group is comprised of members from Los Angeles Police Department, Los An-geles Sheriff Department, and the Los Angeles City and County Fire departments. In addition to police and fire, the Department of Health serves on the policy governing body for the TEW. Coordination with the TEW had given Public Health input from senior law and fire of-ficials on how the Public Health ICS would link up with the County-wide

Goals, Objectives, Action Steps and Results

“Things do not happen. Things are made to happen.” John F. Kennedy



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Action Step 1.4: Conduct two internal tabletop drills to evaluate effectiveness of the SPAs.

Results: A tabletop was held in December, 2003 and designed to test our Public Health response to a SARS emergency. The second tabletop is referenced in Action Step 1.3 above for the mass clinic training ICS teams. A third tabletop was held on May 20, 2004 with Public Health leadership to exercise a plague scenario.

Action Step 1.5: Design SPA ICS and train staff.

Results: We added this Action Step to create a SPA-specific ICS struc-ture and adopt it for use by the SPA staffs. This was completed and approved by the Medical Director for Public Health on September 22, 2004. The schematic for SPA ICS is attached (see page 18). Staff train-ing for implementation will begin in October 2004 and is expected to take four months.

OBJECTIVE 2:

Public safety sector providers and local governments will include LA County Public Health as a collab-orative partner in planning for and responding to all disaster events and drills by December 2004.

Action Step 2.1: Public Health SPA-based staff and subject matter experts from BT and disease control programs will develop an “all haz-ards” Public Health Disaster Pre-paredness and Response plan and exercise it in at least two internal tabletops.

Results: A draft of the Public Health “All Hazards Plan” was completed in July 2004. On August 3, in con-junction with the TEW, a tabletop exercise was held to test Public Health ICS. On September 21, 2004, TEW and Public Health con-ducted an 8-hour tabletop exercis-ing a Radiological Dispersal Device requiring Public Health to respond.

Action Step 2.2: Public Health SPA-based staff and subject matter experts from BT and disease control programs will finalize the Public Health Disaster Preparedness and Response Plan based on scenarios developed by Public Safety sector for implementation in the Novem-ber 2004 countywide disaster drill.

Action Step 2.3: Conduct system-wide after action reports that include input from SPA-based staff and program staff, as well as com-munity partners, and revise the plan accordingly.

Results: Action Steps 2.2 and 2.3 are scheduled to coincide with the County-wide and State-wide drills held annually in November and De-cember of the year. Our participa-tion in these exercises will include, for the first time, the response of Public Health within the ICS.

OBJECTIVE 3:

Create internal capacity within Los Angeles County Public Health to design “All Hazard Exercises”.

Action Step 3.1: Create a Multidis-ciplinary Management Team from L.A. County Public Health and send to the University of North Car-olina (UNC) Management Academy with the goal of creating a disaster business plan and a comprehensive internal management plan.

Results: A five-member Multi-disciplinary Management Team was created comprising a health educator/planning director from the central Bioterrorism program and four representatives from the SPAs (2 medical directors and 2 public health nurses). The UNC Management Academy provided an excellent opportunity to develop this middle management level team in order to strengthen and expand the penetration of our leadership teams’ efforts.

Action Step 3.2: Obtain funding for management academy team.

Results: Funding was allocated from our Bioterrorism Preparedness Program.

Action Step 3.3: The Multidis-ciplinary Management Team will develop business plan and col-laborate with the NPHLI Leadership Team in regular meetings at least bi-monthly.

Results: The Multidisciplinary Management Team has begun to develop a business plan as a

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“Knowing is not enough; we must apply. Willing is not enough; we must do.” Johann Wolfgang von Goethe



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part of their participation in the UNC Academy. The plan focuses on implementing and maintain-ing the practice of the ICS system throughout the SPAs and district clinics, including the development of a community partner disaster communication network. The team benefited greatly from the lessons learned through the management academy. Team members have de-veloped a better understanding of their strengths and weaknesses as managers as they work to develop into a cohesive team. Our leader-ship team is guiding the growth and development of this manage-ment team.

Action Step 3.4: Integrate scenari-os and response structure as action templates for the L.A. County Public Health Disaster Preparedness and Response Plan.

Results: As the Multidisciplinary Management Team project de-velops, scenarios and response structures are included in the plan for maintaining the practice of the ICS response system in the SPA’s. One challenge that has arisen is the use of the business plan model for carrying out planning for this work. This management team has struggled with the requirement to make their plan an actual busi-ness plan with revenue generation aspects. Revenue generation from activities funded by a Bioterrorism Federal Grant is not allowed. This has taxed the creative powers of the team members and caused them to stretch their thinking in non-traditional and adaptive ways.

OBJECTIVE 4:

Utilize existing community networks to establish additional community-based points of communication regarding prevention, preparedness and response activities by August 30, 2005.

Action Step 4.1: Community mo-bilization and engagement to develop public/private partnership and strategic alliances.

Action Step 4.2: Development of a comprehensive information dissemi-nation plan in collaboration with community partners.

Action Step 4.3: Design com-munication materials and formats, including web-based materials that are culturally and linguistically ap-propriate.

Action Step 4.4: Test point of com-munication and their effectiveness in conjunction with at least two drills or tabletop exercises.

Results: Action steps 4.1, 4.2, 4.3 and 4.4 are being developed as part of the Multidisciplinary Management Team’s project. Each Area Health Office is compiling a list of contact information for local community opinion leaders and key stakeholders for inclusion within a specialized compartment of the electronic Health Alert Network Sys-tem for distributing disaster related information. Our bioterrorism train-ing division and health education staff are designing communication materials and formats, including culturally and linguistically appropri-ate web-based materials. Nearly two hundred and eighty middle and upper level managers are being trained in communication skills for high stress situations, particularly re-lated to communication with com-munity members during disasters. Dr. Vincent Covello is conducting 7 training sessions as a direct result of our Leadership Team exposure to him during the May NPHLI Retreat at UNC.

Action Step 4.5: Community partners involved in “after-action report” for all drills and exercises and review plan and materials ac-cordingly within 60 days of the drill or tabletop.

Results: The implementation of the community leader’s communication network will roll out as the plan of the Multidisciplinary Management Team is implemented during the upcoming year

“Leadership and learning are indispensable to each other.”

“Sure it's a big job; but I don't know anyone who can do it better than I can.”

“Change is the law of life. And those who look only to the past or present are certain to miss the future.”

“The human mind is our fundamental resource.”

John F. Kennedy


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IV. IMPACT OF THE PROJECT Impacts on Team

In the year since our PHLI Launch, the four of us have truly become a team. We had had the benefit of working together as colleagues in Public Health over the previous four years. While we had similar responsibilities, our assignments kept us occupied in our respec-tive Service Planning Areas with occasional interactions at meet-ings. When participation in PHLI was proposed, and enthusiastically endorsed, we had little idea what the year would hold. Looking back over what seems a remarkably short time, our experiences in attend-ing the Program Launch together, reading our books and discussing them, preparing our initial proposal and mid-term report brought us in much closer contact as we had to make the time to sit together and work through the group process. Each of us had taken some pride in our independent ability to produce quality work. Combining our talents and efforts required learning a different kind of interdependence where the group was depending on us as individuals to complete our project responsibilities and yet we had to learn to relinquish and rely on the group if one member had to miss a key project effort. With our time at UNC in May, the interde-pendence process deepened even further. We worked together into the nights on our project and on our skit. We saw each other work under conditions of stress, cold and fatigue, and at weak moments. Working like this created a level of reliance on the team and within the

team that generally does not exist in most professional experience. As a direct impact of this project, our four members would feel capable of undertaking major public health change projects together or individually by creating comparable teams in our own areas.

Impacts on Organization

• Bioterrorism Preparedness and Response Program

In the immediate term, the im-pact of this project on our Public Health department has been to move it away from a traditional public health role in disasters which emphasizes the recovery phases. With the pre-eminent role of Public Health in a bioterrorist emergency, Public Health leaders and staff must learn to act as first responders

where the traditional first respond-ers in police and fire will be depen-dent on us to identify the organism/agent, prescribe vaccination or prophylaxis, and establish clinics to distribute the drugs or vaccines, all in very tight time frames. To do this, Public Health has to be able to communicate effectively with law and fire partners whose lingua fran-ca is Incident Command Systems. In addition, Presidential Homeland Security Directive 5 requires that all emergency responders adopt the National Incident Management System (NIMS) to coordinate efforts in a disaster. Los Angeles County Public Health has begun to make major strides toward this transition. Through the Action Steps in this project, Public Health leaders and staff now have a NIMS-Compliant All Hazards Plan and ICS Training and Exercises to test its effective-ness.

• Service Planning Areas

The Service Planning Areas (SPAs) have three layers of change to achieve full integration of both SPA and community into the ICS system. At the first layer, the SPA manag-ers and their staff have completed Incident Command training. This training was essential, not only in the event of any immediate disaster events, but also for the long term integration of this structural ap-proach in Public Health. Managers and staff are able to “crosswalk” the Incident Command roles within the disaster event framework.

Impact of the Project

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“You must be the change you wish to see in the world”.

“A man is but the product of his thoughts what he thinks, he becomes”.

“Live as if you were to die tomorrow. Learn as if you were to live forever”.

“Action expresses priorities.” Mohandas Gandhi


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Impact of the Project

This, then, opens the door to the second layer of transition, which involves articulating the structure as integral to SPA-based operations, rather than seeing the ICS roles as separate from their regular roles in Public Health. This layer of under-standing is beginning to take hold across the SPAs and we anticipate that this will continue to grow across all levels with management and staff. The third layer of integra-tion of ICS will be to translate ICS beyond departmental structures into our community linkages to create the inter-sectoral network necessary to see the project to a successful outcome.

• Impacts on PartnershipsThe major partnerships neces-sary for the success of this project were with neighboring city health departments in Pasadena and Long Beach, the Terrorism Early Warning Group, the UCLA Center for Public Health and Disasters, and the LA Emergency Medical Services (EMS) Agency. Our EMS organization has long operated in ICS structure and patiently taught us in Public Health how the system works and how to work within the

system. The roles of UCLA and the TEW have been described above. UCLA gave us the ICS tools and the TEW allowed us to practice them. Long Beach and Pasadena have worked with us in creating our di-saster response plans. The partner-ships between and among all of us have been strengthened during the development of this project.

• Impacts on Policies

Public Health did not have a formal chain of command policy for the responsibilities of the Director of Public Health and Health Officer at the beginning of this project. These policies had to be written as a critical starting point for the development of a Public Health ICS structure. For a seemingly simple task, it has taken over six months but was finalized for the ICS train-ings. Similarly, Public Health has had a policy spelling out Public Health employees’ responsibilities in a disaster. It became apparent that in case of a disaster requir-ing Public Health to bring up mass clinics, we would need many more staff than the 3,700 which ex-isted in Public Health. Hence, we proposed extending the policy to all of Health Services (some 24,000) so that the expectations were clear that all of us under County Code become Disaster Services Workers in emergencies and must sign the policy annually to re-commit to this responsibility. Working this policy through the County hospitals’ unions was an experience. Finally, Public Health adopted the policy for the Incident Command System on approval of the Health Officer in May of this year. These policies will

govern Los Angeles Public Health department’s response to disasters for years to come.

• Impacts on Communities and Community Health

The community impact of our project is scheduled for Year 2. The first year has been spent bringing our systems into place and train-ing our staff. In the second year, we will be identifying the natural community networks in each of our SPAs, getting their contact informa-tion into data bases and engaging their leadership in our efforts to take preparedness planning out to the communities. There have been media campaigns with radio and billboard information out to the residents of the County, in English and Spanish, on Public Health’s role in preparedness for Bioterrorism. There has also been a series of press releases and media interviews so the community has received some information. However, the need to get down to specific community levels and across multiple ethnicities and languages remains to be done in the upcoming year.

V. FINAL LOGIC MODEL (see Page 12)

CONCEPTS AND SKILLS IMPLEMENTED

Action LearningTechnical and Adaptive ChallengesVision and Sense of UrgencyMobilize, coordinate and direct broadcollaborative actionsCoach, mentor and empower othersRisk and High Stress Communication


Outcomes Approach Logic Model

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Our individual and collective leadership ability was strength-ened, expanded and put into practice, particularly the follow-ing leadership competencies and skills:

• Deeply understanding a real public health problem, chal-lenge or opportunity, taking wise actions, and reflecting on what we learn

• Understanding and differ-entiating technical problems from adaptive challenges and applying solutions ac-cordingly

• Creating and implement-ing a vision with a sense of urgenand through a broad coalition

• Mobilizing, coordinating and directing broad collaborative actions within the complex public health system

• Coaching, mentoring and empowering others in order to develop leaders and self-directed work teams at all levels of the public health system

• Learning the value and the techniques of high risk, high stress communications.

2. What did you/your team learn about yourself/itself as leader(s)?

Our team learned that leader-ship must and can be learned and, therefore, we must be committed to lifelong growth, development and learning. We learned that an effective leader is not someone who is necessari-ly loved or admired but someone whose followers do the right things. We have recognized that without followers there can be no leaders; hence, the real definition of a leader is someone who has followers. Since each of our team members holds a position of high visibility, we learned that it is critical to model the way, walk the walk, talk the talk, set the examples and, above all, demonstrate results and become doers instead of preachers. We also came to the realization during our interac-tion amongst ourselves as well as with our supervisors, peers, subordinates and partners that leadership is not a rank, or a privilege, or a title. Leadership is a responsibility.

Lessons Learned about Leadership

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VI. LESSONS LEARNED ABOUT LEADERSHIP

1. What leadership skills did your your team exercise and develop in the project? Did you use any specific concepts or skills taught in PHLI, and if so, how?

Our team exercised and de-veloped many leadership skills throughout the duration of our project. Leadership knowledge, skills and abilities were acquired through a variety of approaches as follows:

• November 2003 PHLI Pro-gram Launch

• PHLI Long Distance Learning Program

• PHLI Reference Materials and Reading Assignments

• May 2004 PHLI Residential Retreat Week

• Self and Team Reflection and Study

• Action Learning Project, and

• Peer Education among PHLI Program Participants and Teams

“Leadership training, support and development must be a high priority.”

The Future of the Public’sHealth in the 21st Century, Institute of Medicine, 2002.


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Lessons Learned about Leadership

4. What difference will these lessons learned about leader-ship make to how you/your team members plan to lead in the or-ganization –and “community”—in the future?

Our team believes that the lessons learned from the PHLI Program have strengthened and enhanced our leadership knowl-edge, skills and abilities to make a difference at individual, team and community level. These competencies will enable us to effectively:

• Apply knowledge and skills to current work problems

• Practice being collaborative leaders

• Make progress on public health challenges and problems

• Strengthen our team on an ongoing basis

• Deepen our understanding of specific public health issues

• Strengthen reflective practices

• Learn the value of group reflection

• Consistently build leadership skills and develop expertise over time

ing, team development and leadership, empowerment and delegation, evidence-based practice, core functions of pub-lic health (assessment, policy development, assurance), ten essential public health services, priority setting, values clarifica-tion, community assets and resources, leading and manag-ing change, culture change, in-novation and change, coaching and mentoring, sharing power, strategic planning, action plans, results objectives, alliances and partnerships, learning organi-zations, collaborative leaders, integrity and honesty, flexibility and high expectations, time management, problem-framing or clarification, problem-solving or resolution, leader-based leadership, relationship-based leadership, follower-based leadership, community engage-ment, stakeholders, and con-tinuous reflection and learning.

3. What lessons did you learn about what a “good” leader needs to do in your context?

The PHLI leadership develop-ment process taught us the importance of (1) thinking differ-ently, (2) questioning and asking different questions, and (3) speaking a different language. In addition to systems thinking and big picture perspectives, action learning taught to ask different questions such as: what needs to be done instead of what do we want, what can and should we do to make a difference, how can we become direction setters and change agents within and outside our organization, what are our insti-tution’s mission and goals, how can we align values with strate-gies, resources and people, and what constitutes performance and results in our institution.

We also learned the value and the benefits as well as the need for diversity in people in order to design and implement more effective programs, plans and policies. And we also learned that leaders speak a different language. A language comprising, but not limited to, the following concepts, vocabulary and terminology:

• Shared vision, systems think-ing, adaptive challenges, risk and high stress communication, transformational leadership, action learning, inter-sectoral collaboration, coalition build-

INDIVIDUAL & TEAM CONCEPTS LEARNED

Leadership must and can be learned Lifelong growth and development A leader is someone who has followers Followers do the right things Model the way, set the examples Demonstrate results Leadership is a responsibility


Lessons Learned about Leadership and References

We feel better prepared to shape responses to the full range of 21st Century public health challenges and threats, be they a result of natural disas-ters, bioterrorism acts or newly emerging or re-emerging disease outbreaks. We feel better equipped to face and overcome the expected resistance of any change effort and, thus, to win the support of staff, supervisors, peers, partners, customers and stakeholders. We also feel ener-gized, motivated and inspired to create and transform our organi-zation and communities by:

• Creating a shared vision

• Establishing a sense of urgency

• Forming a powerful guiding coalition

• Empowering others to act on the vision

• Planning and creating short-term wins

• Consolidating improvements and producing still more change, and Institutionalizing new approaches

On the human side, we are each struck by the comfort level this year has created in our ability to rely on each other. This is now demonstrated in activity levels that we can carry into other assignments we work on jointly. Also, we note a commitment to create “next generation” teams and find challenging assign-

ments for them where they can experience “connecting the dots:” working across traditional service areas and disciplines and seeing how the big picture af-fects the way the smaller pieces come together.

Over the course of this year we have become a better team than when we previously worked together as Area Health Officers, and we thought we were un-usually collaborative then! This tells us that a great deal of work remains to be done if our Health Department is to continue to reap the benefits from their investment in our National Public Health Leadership Institute experience. We believe that our specific project will be of great benefit and a down payment on the benefits that will accrue in the years to come.

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What a Good Leader Needs to do in Los Angeles County

Think differently Question and ask different questions Use systems thinking Value diversity Speak a different (leadership) language

REFERENCES

1. National Public Health Leadership Institute. University of Carolina, Chapel Hill (UNC) Website, 2005.

2. Umble, Karl et al. The National Public Health Leadership Institute: Evaluation of a Team-Based Approach to Developing Collaborative Public Health Leaders. American Journal of Public Health. 95(4): pp. 641-644, April 2005.

3. National Public Health Leadership Institute. The Martha Katz PHLI Team Leadership Project Award. University of Carolina, Chapel Hill (UNC). 2003/2005.



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DHS Incident Command System Chart

Appendix


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SPA Incident Command System Chart

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Appendix


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Table 1: Goals, Objectives and Action Steps

Appendix


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Table 1: Goals, Objectives and Action Steps

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Appendix


National Public Health Leadership Institute: Martha Katz Award

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Appendix


San Gabriel Valley Service Planning Area (SPA 3)Metropolitan Service Planning Area (SPA 4) 241 North Figueroa Street, Room 312Los Angeles, California 90012Tel: (213) 240-8049Fax: (213) 202-6096

www.lapublichealth.org© 2004 SPA 3 & 4

Documents

Building a Better a Public Health Response System in Los Angeles County