1. Turnock, Bernard J. MD, MPH

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When real estate professionals speak of the three most important considerations in their field, they invariably identify location, location, and location. If health administrators, especially those working in public health agencies, were to list the three most important considerations for their field in a similar manner, it would likely be the workers, the workers, and the workers. After all, the primary role of administrators is to manage the resources available to them in an effective and efficient fashion to achieve organizational goals and objectives. From that perspective, it is hard to argue that the people doing the work should not occupy the top three spots on a manager's list of assets.


But from a systems perspective, this asset actually represents three interrelated dimensions of work doing, the workers, the work, and the work organization.1 Way back in high school, we learned that work can be defined as moving a force over some distance (work = force x distance) and that there are tools, often called levers, that can facilitate work doing. Within organizations, many different management tools are available to facilitate work doing. Several such tools are highlighted in contributions to this special issue of the journal.2-5 These tools serve as levers that can be wielded by administrators to move massive objects, including nasty problems and huge bureaucracies. Levers are certainly not new to public health practice. Symbolically, as well as literally, John Snow gave us one when he dismantled the pump handle of the Broad Street Pump, ushering in a new age for public health practice. When strategically and systematically deployed, levers in the form of business process improvements, decision science techniques, and evaluation and performance management practices offer powerful tools to improve organizational performance and community health outcomes. Powerful as these tools are, there are several important considerations related to their use.


Right Tools in the Right Hands

One of the wisest adages circulating in the emergency medical services community for decades (long before the advent of emergency preparedness and response programs) was that "Evaluation is too important to be left to the evaluators." The basis for this wisdom is that those who are in a position to put new information to use should play major roles in designing and conducting evaluations. For example, when prehospital and emergency department personnel identify issues and participate in evaluations that answer questions important for their work, new policies and practices will be deployed more rapidly, thereby saving additional lives and limiting morbidity. The same can be said for planning and planners (ie, that planning is too important to be left to the planners) although the link with immediate outcomes is less compelling. In any event, evaluation (and for that matter planning) are essential problem-solving duties for health administrators that should never be fully relegated to others.


There is considerable evidence that evaluation as an organizational practice is not a major strength of public health agencies. Polyak and colleagues2 underscore this point in their report. This adds to a growing literature of similar findings in previous assessments measuring standards comparable with those for the operational definition of a functional local health department, the National Public Health Performance Standards Program, and evolving voluntary public health accreditation standards. Invariably, performance for evaluation lags behind performance for other important organizational practices. In another article in this issue, Bhandari and colleagues3 provide additional evidence that higher evaluation scores comport with higher overall local health department performance. Extending basic program evaluation practices into organizational performance management and improvement systems is now an area of emphasis in state and national public health agency accreditation initiatives. Hopefully, this will foster organizational cultures in which the right people are asking the important questions and channeling the answers back into the organization's operation.


Tools that help the right people examine important organizational practices are evident in two other reports in this edition. Landesman and colleagues4 describe an on-line electronic monitoring system that tracks the number of hours worked by physicians in residency programs to reduce medical errors and other patient safety concerns.4 Honore and colleagues5 find utility in the application of principles and practices of decision science to budgeting within public health agencies. New technologies and principles adapted from other fields can be powerful tools in the hands of good managers. Another useful tool is the skill to frame questions from a different perspective.


Maps and Territories

A case in point is the long-standing controversy as to the appropriate minimum population base for a local health department. Six decades ago, Emerson and Luginbuhl6 recommended that the minimum population base necessary for an effective local health department was a population of 50 000. Several studies since 1990, including the report by Bhandari and colleagues3 in this issue, consistently report that size does matter. Nonetheless, a substantial proportion of local health departments serving populations of less than 50 000 can indeed meet modern public health standards, although somewhat less efficiently in terms of per capita costs. This perspective shifts the debate from whether smaller local health departments can meet current standards to how scarce public health resources can be optimized in a public health system through shared services and regionalization. Proposals for sharing and consolidation are likely to fare better in the face of political and parochial objections when argued from the perspective of more efficient use of scarce resources within a public health network than when based on assertions that small agencies cannot meet basic standards.


Bhandari and colleagues3 also reviewed the relationship between public health performance and several other structural elements of local public health practice, including gender of the chief executive officer and governance. For these latter elements, they conclude that these characteristics indeed matter although in directions we would not expect for reasons we do not fully understand. The finding that the presence of a board of health is associated with lower levels of local public health performance should once again remind us that there is no such thing as an optimal structure for public health activities.7


In the end, we must not mistake powerful tools in the hands of managers for effective management itself. The map is not the territory is an often-cited principle of semantics that admonishes us to distinguish between phenomena that represent reality and the reality itself. This principle implies that there are limits to the usefulness of tools that simulate real-world problems and situations since the value of these tools can actually diminish as their apparent accuracy in depicting reality increases. In one of his books, Lewis Carroll's character, Mein Herr, described a fictional map that had been improved, enlarged, and perfected such that it had "the scale of a mile to a mile."8(p169) After describing the objections and practical difficulties with using such a map, Mein Herr notes that "We now use the country itself, as its own map, and I assure you it does nearly as well."8(p169) In the end, tools and maps may hold great promise, but their full benefits will come only when managers manage their tools instead of the other way around.




1. Kennedy VC, Moore FI. A systems approach to public health workforce development. J Public Health Manage Pract. 2001;7:17-22. [Context Link]


2. Polyak G, Madamala K, Vasireddy V, Landrum L, Bassler E, Stob N. Self-assessment of public health essential services among Illinois local health department administrators. J Public Health Manage Pract. 2010;16(2).93-97. [Context Link]


3. Bhandari MW, Scutchfield FD, Charnigo R, Riddell MC, Mays GP. New data, same story? Revisiting studies on the relationship of local public health systems characteristics to public health performance. J Public Health Manage Pract. 2010;16(2).110-117. [Context Link]


4. Landesman LY, Markowitz F, Conde N. Business process improvement: an electronic system to monitor compliance with medical resident work hours. J Public Health Manage Pract. 2010;16(2).104-109. [Context Link]


5. Honore P, Fos PJ, Smith T, Riley M, Kramarz K. Decision science: a scientific approach to enhance public health budgeting. J Public Health Manage Pract. 2010;16(2).98-103. [Context Link]


6. Emerson H, Luginbuhl M. Local Health Units for the Nation. New York, NY: Commonwealth Fund; 1945. [Context Link]


7. Starr P. Professionalization and public health: historical legacies, continuing dilemmas. J Public Health Manage Pract. 2009;15(6)(suppl):S26-S30. [Context Link]


8. Carroll L. Sylvie and Bruno Concluded. London, England: Macmillian; 1893. [Context Link]