Improving LA County Health Services Performance

SPA 4 VIEWPOINT
IMPROVING THE PERFORMANCE OF
THE LOS ANGELES COUNTY
DEPARTMENT OF HEALTH SERVICES (DHS)
Los Angeles County Department of Health Services • Public Health
July 2001
Metropolitan Service Planning Area Health Office (SPA 4)
SPA 4 BEST PRACTICE COLLECTIONRELIABLE INFORMATION FOR EFFECTIVE COMMUNITY HEALTH PLANS, PROGRAMS AND POLICIES
M. RICARDO CALDERÓN, SERIES EDITOR

Improving DHS Performance: SPA 4 Viewpoint July 2001
METROPOLITAN SERVICE PLANNING AREA HEALTH OFFICE (SPA 4)
241 North Figueroa Street, Room 312
Los Angeles, California 90012
(213) 240-8049
The Best Practice Collection is a publication
of the Metropolitan Service Planning Area
(SPA 4). The opinions expressed herein are
those of the editor and writer(s) and do not
necessarily reflect the official position or
views of the Los Angeles County Department
of Health Services (LAC/DHS). Excerpts from
this document may be freely reproduced,
quoted or translated, in part or in full,
acknowledging SPA 4 as the source.
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
Fred Lead, Acting Director
Jonathan E. Fielding, MD, MPH, MBA.
Director of Public Health and County Health Officer
James Haughton, MD, MPH.
Medical Director, Public Health
BEST PRACTICE COLLECTION TEAM
M. Ricardo Calderón, Series Editor
Manuscript Author & SPA 4 Area Health Officer
Carina Lopez, MPH.
Project Manager, Information Dissemination Initiative
Visuwat Taweesup
Graphic Design
At a Glance
The SPA 4 Best Practice Collection fulfills the 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 utiliza-
tion of Angelinos and definable subpopulations”.1
It is a program
activity of the SPA 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 mak-
ers and funding agencies regarding health promotion and disease
prevention and control
To share information and lessons learned in SPA 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 4 Information Dissemination Initiative is an adaptation of the
Joint United Nations Program on HIV/AIDS (UNAIDS) Best Practice Col-
lection concept. Topics will normally include the following:
1. SPA 4 Viewpoint: An advocacy document aimed primarily at policy
and decision-makers that outlines challenges and problems and
proposes options and solutions.
2. SPA 4 Profile: A technical overview of a topic that provides informa-
tion and data needed by public, private and personal health care
providers for program development, implementation and evaluation.
3. SPA 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 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.
2

Improving DHS Performance: SPA 4 ViewPoint Improving DHS Performance: SPA 4 Viewpoint July 2001
The World Health Organiza-
tion (WHO) carried out an
analysis of the world’s health
systems and published its
findings in The World Health
Report 2000. According to
this report, the U.S. spends a
higher portion of its gross do-
mestic product than any other
country but ranks 37 out of
191 countries according to its
performance.2
The main mes-
sage from this report is that
“the health and well being of
people around the world de-
pend critically on the perfor-
mance of the health systems
that serve them.”2
The health and well being of
people who live in Los An-
geles County (LAC) depend
upon the performance of the
Department of Health Ser-
vices (DHS), the second larg-
est municipal health system
in the U.S. Improving DHS
performance will, therefore,
enhance the health of LAC
residents and the nation as a
whole.
This document provides
recommendations to find a
successful new direction for
the Department of Health
Services. It was prepared in
response to the request of
the former Director of Health
Services, Mr. Mark Finucane,
for input and feedback from
staff at his employee forums.
It was also developed in
response to his expectations
that“each executive manager
make a very personal com-
mitment to accomplishing
the tasks necessary to suc-
ceed over the next 5 years”
and the“need to unleash the
creativity that exists within the
Department.” 3
The“Improving DHS Perfor-
mance Viewpoint”is intended
to stimulate discussion and
reflection regarding health
system performance. It aims
to propel continued dialogue
and encourage the pioneering
of new combinations of inno-
vative concepts and approach-
es through a format of 10
Problem Statements, 28 Rec-
ommendations, and a Sum-
3
mary Table. It is hoped that the
DHS Executive Team will be
open to needed, challenging,
controversial, and/or futuristic
performance improvement
routes. This will enable DHS to
(a) achieve further extraordi-
nary improvements, (b) not to
fall short of its potential, and
(c) develop the best and fairest
health system possible for Los
Angeles County residents with
available resources.
TheU.S.spendsahigherportion
of its gross domestic product
than any other country but
ranks 37 out of 191 countries
according to its performance.2
The health and wellbeing
of people around the world
depend critically on the
performance of the health
systems that serve them.2
3
Introduction
“New opportunities rarely
fit the way an industry has
always approached the market,
define it, or organize to serve
it.”
-Peter Drucker

Discussion and Recommendations
Problem Statement I:
The protection, promotion, and
maintenance of the health of a
population are not a function of a
health department alone. The health
of LAC residents cannot be improved
with only medical and public health
interventions.
Recommendation #1: A Health
System Approach must be adopted.
In this system: (a) all public, private
for-profit, and non-profit organiza-
tions, institutions, and resources
devoted to producing health actions
are equally involved, and (b) all ef-
forts to improve health rely upon
multidisciplinary and multisectoral
interventions.
Recommendation #2: A compre-
hensive Strategic Plan for this health
system must be developed. This plan
should promote a unifying concep-
tual framework that: (a) outlines the
vision of the health system and DHS’
critical functions, strategic goals and
objectives, operational approaches,
and performance benchmarks; (b)
serves as the basis for the planning,
management, and evaluation of
programs and services implemented
by all stakeholders, and (c) is under-
stood, supported and continually
enhanced by the health workforce.
Recommendation #3: The DHS
must assume the technical and
managerial leadership for the
development and promotion of
recommendations #1 and #2 above,
since the ultimate responsibility for
the performance of LAC’s health
system lies with the government.
This leadership responsibility should
be focused on the principal activities
of policy dialogue and resource mo-
bilization, and be expressed through:
(a) optimal utilization of multi-
disciplinary staff, (b) partnerships
with other health departments, (c)
partnerships with community-based
organizations and the private for-
profit sector, (d) intra- and interde-
partmental collaboration with other
LAC departments and (e) effective
relationships with state and federal
agencies.
Problem Statement II:
Current DHS strategies focus
primarily on cost-cutting measures
to maintain its fiscal stability. Plans
based on economic considerations
unintentionally disregard the overall
goals and vital functions of the
health system.
Recommendation #4: Current
programming must be reinvigorated
with new goals for DHS. Managers
should keep staff focused on a few
key strategic goals (business objec-
tives). The following three overarch-
ing goals developed by WHO to
measure health system performance
of countries worldwide are recom-
mended:
Goal #1: Good Health
Goal #2: Responsiveness to the
expectations of the population
Goal #3: Fairness in Financial
Contribution
The WHO Rationale:“Better
health is unquestionably the
primary goal of a health system.
Health care can be catastrophically
costly and the need for it unpre-
dictable. Mechanisms for sharing
risk and providing financial protec-
tion are important. The second
goal of health systems is fairness
in financial contribution. The third
goal is to enhance the responsive-
ness of the system to the legiti-
mate expectations of the popula-
tion reflecting the importance
of respecting people’s dignity,
autonomy and the confidentiality
of information.”4
Recommendation #5: Current pro-
gramming must be aligned to new
vital (core) functions for DHS. Man-
agers must keep staff centered on a
few key vital functions. The follow-
ing four vital functions developed
by WHO to measure health system
performance of countries worldwide
are recommended:
Service Provision: delivering public,
personal and private health ser-
vices.
Resource Generation: creating
resources through investment and
training including investing in peo-
ple, buildings, and equipment and
generating the human and physical
resources that make service delivery
possible.
Financing: revenue collection, pool-
ing of resources, and strategic pur-
chasing of interventions/services.
Stewardship: oversight, acting as
the overall stewards of entrusted
resources, powers and expecta-
tions, setting and enforcing the
rules of the game and providing
strategic direction for all the differ-
ent actors involved.5
4
Theprotection,promotion,and
maintenance of the health of a
populationarenotafunctionof
ahealthdepartmentalone.The
health of Los Angeles County
residents cannot be improved
with only medical and public
health interventions.

Recommendation #6: The current
DHS organizational structure and
functions should be aligned with
the overall goals and vital functions
outlined in recommendations #1 and
#2, i.e.: (a) the specific strategies
and objectives of divisions, programs
and Service Planning Areas (SPA) of
DHS must be brought into alignment
to demonstrate how their work con-
nects to and impacts the overall DHS
goals and vital functions, and (b) the
proposed new vital functions must
be specifically assigned to existing
divisions and/or new structures cre-
ated for such purposes.
Problem Statement III: Cost
effective healthcare for the entire
population must replace current
health care delivery thinking.
Recommendation #7: Incorporate
WHO’s twofold objective of good
health into DHS thinking, values,
and guiding principles; that is,“the
best attainable average level of
health (goodness), and the smallest
feasible health differences among
individuals and groups (fairness).”6
Recommendation #8: Implement
the current worldwide trend to
reform health systems based on the
fundamental principle of delivery
of high quality essential care for
everyone. Lessons learned from pre-
vious reforms of health care systems
--founding of national health care
systems, extension of social insur-
ance schemes, promotion of primary
health care to achieving affordable
universal coverage-- are paving the
way to the current health sector
reform trend. Rather than all pos-
sible care for everyone or only the
simplest and most basic care for the
poor, the aim is to deliver high qual-
ity essential care to everyone defined
by criteria of effectiveness, cost and
social acceptability.7
Consequently, DHS should
re-examine what essential services
should be available to LAC residents
based on local priorities, burden of
disease and cost effectiveness.
Problem Statement IV:
Health care systems have tradition-
ally concentrated almost exclusively
on the presumed needs of indi-
viduals. Too little attention has been
given to people’s demand for health
care. In addition, health promotion
and disease prevention and control
are affected by individual, structural
(social), environmental and econom-
ic (super-structural) factors within
and beyond communities that must
be viewed comprehensively. Protect-
ing and improving the health of a
population is a shared responsibility
among residents, public institutions,
private for-profit and non-profit
organizations, key stakeholders,
opinion leaders and policymakers.
Recommendation # 9: A Commu-
nity Liaising Program is needed to
consolidate and lead an expanded
response aimed to strengthen, ex-
pand and diversify public, personal,
and private health programs and
services. Unlike previous liaising staff
or efforts in the past, the goals of
this program should be to:
Increase awareness of and gener-
ate more support for health
promotion and disease prevention
and control programs.
Identify and secure additional/po-
tential resources (human, material
and financial) aimed to integrate
public, personal and private health
programs and services through,
but not limited to, the following
strategies: (a) Community Net-
working. (b) Strategic Alliances
Partnering, (c) Community Mobili-
zation, (d) Private Sector Leverag-
ing, (e) Resource Development,
and (f) Policy Development and
Advocacy.8
Recommendation #10: The future
DHS direction must deliver services
that are demand-driven rather than
supply-oriented. New mechanisms
and strategies must be created to be
responsive to expressed community
needs including the Community Liais-
ing Program described in Recommen-
dation #9.
5
Rather than all possible care for
everyone or only the simplest
and most basic care for the poor,
the aim (of a health system) is
to deliver high quality essential
care to everyone defined by
criteria of effectiveness,cost and
social acceptability.7
At first people refuse to believe
that a strange thing can be
done, and then they begin
to hope it can be done, then
they see it can be done, then
it is done, and all the world
wonders why it was not done
centuries ago.”
-Frances Hodgson Burnett
5

Problem StatementV:
Performance measurement and
improvement is the key to DHS’long-
term competitive advantage, success,
effectiveness, stability and survival.
Managing for improved performance
requires an objective assessment of
three organizational building blocks.
These components are the worker,
the workplace and the work itself.9
Recommendation #11:
Institutionalize a DHS-wide perfor-
mance measurement and improve-
ment plan shifting the focus from
a process-oriented oversight to an
insight-oriented outcome (results
oriented).
This plan should include but not be
limited to the following:
Immediate attention to growth
and development of human re-
sources at every level.
Specific training in measurements
of attainment (what is achieved
with respect to established
goals) and performance (how
to compare attainments with
what the system should be able
to accomplish, i.e., the best that
could be achieved with the same
resources)10
keeping in mind that
measurement drives behavior and
behavior creates culture.
A commitment to create a self
aligning organization that keeps
all the vital elements of DHS
aligned and headed in the same
direction at the same time. In oth-
er words, a culture and systems
that keep everyone in DHS doing
the right things right, i.e., Service
Quality Index, Customer Service,
Process Quality Indicators, Leader-
ship Index, etc.11
(Please refer to
Problem Statement VIII).
Performance measures that are
linked to rewards and recogni-
tion including a system of applied
sanctions due to evidence of fail-
ure to meet expectations or lack
of productivity.
Recommendation #12: Implement
a sound quality assurance capability.
A commitment to quality reduces
expenditures. Research on the cost
of quality has repeatedly showed
that 20% to 30% of a typical orga-
nization’s expenses are the result of
redundancy of effort, rework, error,
inefficiency, recurrent problems, un-
trained personnel and cumbersome
systems.12
Recommendation #13: Conduct
thorough technical, management
and financial performance audits
prior to the contracting of services
including sound monitoring and
evaluation. Lessons learned from
work with the non-profit sector
have shown both excellent and
poor outcomes. In the absence of a
strong quality assurance mechanism
the risk for fraud, abuse, malprac-
tice, underperformance, inflated
workload figures or understated
costs increases. In addition, many
grants are awarded to organizations
without a track record because they
relied on staff with strong writing
skills or consulting writers.
Problem StatementVI: Despite
the best efforts to date to integrate
services, integration has not been
achieved effectively within (intra) DHS
and outside (inter) DHS (other LAC
Departments and Community Based
Organizations). Consequently, the
LAC health system is characterized
by fragmentation of services, com-
partmentalized programs, an excess
of implementing units, and lack of
decentralization. The word integration
has been used with a variety of mean-
ings and in different situations, i.e., a
new organizational structure merging
various disease control programs,
regular coordination through informa-
tion sharing among decision makers
of existing programs, adding tasks
to unqualified and already overbur-
dened staff, and sharing of resources,
such as transportation, among differ-
ent programs. The Harvard School of
Business used the term integration
to describe the state of collaboration
that exists between departments that
are required to achieve unity of effort
by the demands of the environment.13
However, integration is more than
coordination, collaboration or shar-
ing of resources.14
Recommendation #14: View inte-
gration as sharing of responsibilities
by programs,
SPA’s, CBO’s, departments and
people involved in implementing
health care at all levels.
Through such sharing of responsibil-
ity, broader access to health services
can be achieved in an environment
where stigmatization can be mini-
mized, earlier access to services is
facilitated, and easier continuation of
services is guaranteed.
6
Research on the cost of quality
has repeatedly showed that
20% to 30% of a typical
organization’s expenses are the
result of redundancy of effort,
rework, error, inefficiency,
recurrent problems, untrained
personnel, and cumbersome
systems.12

Recommendation #15: Incorporate
coverage and quality as the corner-
stones for an integrated approach.
The DHS should promote an integra-
tion concept that enhances cost-ef-
fectiveness through the provision of
appropriate and better services at an
early stage of disease development.
More providers would administer
these services to a greater number of
people closer to those in need. This
should be done in an environment
where educational, preventive and
clinical activities take place, refer-
rals are ensured, and patients feel at
ease.15
Recommendation #16: Develop a
decentralized operational structure
where Area Health Offices and/or
a Regional Structure are entrusted
with a larger number of technical,
management and financial deci-
sions based on guidelines, criteria
and procedures promoted by central
units. These central units should be
responsible for developing policies
and training materials, ensuring
technical guidance and initiating
relevant audits, evaluation and
research (please refer to Problem
Statement X).
Recommendation #17: Carry out an
organizational alignment assess-
ment to set the future DHS direction
(strategic planning), link processes
and systems (vertical and horizon-
tal alignment), and make constant
adjustments. The need for companies
to re-engineer is in many respects a
consequence of past failures to make
small manageable adjustments on an
on-going basis16
(please ref er to Problem Statement
VIII).
Problem StatementVII:
Previous DHS re-engineering, down-
sizing, rightsizing, cascading and
reduction-in-force efforts have created
a culture in which managers end up
pushing rather than leading staff, and
subordinates are characterized by low
morale, unbelief, fear, insecurity, and
lack of motivation.
Recommendation #18: Priority
training of DHS executive, senior and
middle managers and supervisors is
needed to develop a new leadership
competence and culture. Human
Resource Development (HRD) objec-
tives should include the acquisition of
knowledge and skill sets that enable
managers to: (a) connect their staff’s
behavior to the DHS mission, turning
intentions into actions, (b) shape DHS
strategy linking teams and processes
to the changing needs of customers,
and (c) create a culture in which all
elements work together seamlessly.
The following HRD programs are
recommended:
The Six Key Functions of Top
Management developed by the
American Management Associa-
tion (AMA):“leadership, managing
culture, developing people, change
management, organizing and de-
ploying resources and formulating
strategy.”17
The Four Core Categories of Public
Health Leadership Competency
Framework developed by the Na-
tional Public Health Leadership
Network:
“Transformational Competen-
cies: systems thinking including
analytical and critical thinking
processes, visioning of potential
futures, strategic and tactical
assessment, communication and
change dynamics.
Legislation and Political Com-
petencies: skills to facilitate
negotiate and collaborate in an
increasingly competitive and
contentious political environ-
ment.
Transorganizational Compe-
tencies: skills to be effective
beyond public health workers
(PHWs), organizational bound-
aries, i.e., single stakeholder
group, community unit, profes-
sion or discipline, organization
or government unit.
Team and Group Dynamics:
effective communication and
practice are accomplished by
PHWs through team building
and capability, i.e., team-ori-
ented structures and systems,
facilitation and mediation
roles.”18
A Culture Change Strategy
comprising of new and practical
management principles such as
those listed below and promoted
by the SPA 4 Area Health Office
during the last year.
Let’s [1] become problem
solvers, [2] go where we have
not been before, [3] become
tomorrow thinkers, [4] suc-
ceed as a team, [5] set SMART
goals, [6] acknowledge the
necessity for rest and relax-
ation, [7] become pre-active
and proactive planners, [8] take
the time to delegate, [9] guard
our priorities and our personal
and professional schedules,
[10] keep in mind that when
we want something we have
never had, we have got to
do something we have never
done, [11] permit the correc-
tion of mistakes, [12] avoid
unnecessary confrontations,
[13] educate our down-line,
7
7

[14] do not permit down-line
to show disrespect, [15] believe
in our product, vision, mis-
sion, goals and strategies, [16]
become a performance-based
and a learning SPA , [17] ex-
pect better performance, [18]
aim to increase our best and
reduce our worst managerial
qualities, [19] develop a pas-
sion for our vision, mission and
goals, [20] recognize that every
great achievement requires a
willingness to begin small, [21]
remember that what we hear
repeatedly, we will eventually
believe, [22] master the ap-
proaches of a successful work-
ing leader and manager, [23]
accept the responsibility for the
mistakes of our down-line, [24]
become follow-through people
and finish what we start, [25]
learn to think possibilities,
[26] do not allow what others
say about us to change our
focus, goals, course or personal
opinion about ourselves, and
[27] become a team of inspira-
tion.19,20,21,22,23
Problem StatementVIII:
The DHS cannot afford to maintain
the negative impacts of a misaligned
organization. The following issues
reflect a misaligned organization:
reactive versus proactive orientation,
repeated deployment of short-term
fixes, recurring/chronic issues and
problems, failure to identify and
correct the root cause and systemic
problems, reduced productivity and
employee satisfaction, increased
expenses and loss of revenue,
decreased customer satisfaction,
retention or loyalty, routine business
does not go finished, fixes that do
not produce intended effects, objec-
tives and goals are not achieved,
signals of various sorts go undetect-
ed, opportunities for improvement
are missed and performance and
growth are hampered.24
Recommendation#19:Move from
the old linear approach
to management to one of
simultaneity-alignment. Alignment
is the degree to which all elements
of an organization’s infrastructure
are tightly integrated and working
in concert to enhance performance
and growth.25
Alignment links the five key ele-
ments of an organization. This in-
cludes strategies and people (vertical
alignment), processes and customers
(horizontal alignment), and leader-
ship to keep all the vital elements
and staff headed in the same direc-
tion at the same time.
Recommendation#20:
Change the conventional thinking
of running DHS operations from as-
signing priority first to stakeholders
Board of Supervisors (BOS), second
to customers, and third to Employ-
ees to Employees first, customers
second, and stakeholders (BOS)
last. World-class businesses today
acknowledge the new thinking of
a well-run business; that is, well
trained employees deliver quality
products (programs or services) and
maintain customers’happy, thus
pleasing shareholders/stakeholders
(BOS) and increasing profitability
(constituency satisfaction and sup-
port).26
Recommendation #21: Develop
better programs to educate stake-
holders (community members,
gatekeepers, opinion leaders, policy
influencers, political leaders, and
key decision makers) about public
health, preventive medicine and
health care delivery. Stakeholders
wish to make correct decisions and
improve life for their constituents.
However, the absence of good deci-
sions is due to lack of, or incorrect
information, or the inability of the
stakeholder to interpret the informa-
tion.27
Recommendation #22: Enrich
DHS strategies with ideas that come
from employees at all levels of the
organization, thus avoiding prob-
lems like: (a) strategy that is owned
by the top but ignored by everyone
else, (b) good employees who fail to
focus on key goals, and (3) lack of
commitment and momentum in the
organization.28
Recommendation #23: Utilize the
people closest to the action to elicit
ideas for improvement, identify
pitfalls and get a reality check for
critical DHS issues in addition to,
as a complement of, or instead of
external consultants.
8
“Ifyoualwaysdowhatyoualways
did, you will always get what you
always got”
-Arthur R.Tenner Irving J.DeToro
World-class businesses today
acknowledge the new thinking
of well-run business;that
is,well-trained employees
deliver quality products
(health programs and services)
and maintain customers’
happy (patients and clients),
thus pleasing shareholders/
stakeholders (Board of
Supervisors) and increasing
profitability (constituency
satisfaction and support). 26

members, gatekeepers, opinion
leaders, policy influencers, and key
decision makers which can affect
the viability of the organization.”30
Recommendation#25:
Develop performance contracting
mechanisms that require. counter-
part contributions, cost-sharing quo-
tas and resource diversification plans
from the program, grant or part-
nership inception. This will ensure
continuity of activities and benefits
in the absence of DHS funding.
Problem Statement X:
The Cluster Network System in
Personal Health Services and the
Area Health Offices in Public Health
Services contribute to compart-
mentalized and disintegrated DHS
operations
and structure.
Optimal utilization of a single
regional managerial structure could
better increase efficiencies and re-
duce costs, reconfigure and reduce
specific services, integrate and align
public, personal and private health
services.
Recommendation #26: Create
strengthened and more cost effec-
tive Service Planning Area Health Of-
fices by merging the capabilities and
resources of the Cluster Network
and the Area Health Offices. There
is a need to reconcile DHS personal
and public health services at the
operational level focusing priority on
prevention and public health over
personal health and clinic services
due to the reasons described in
recommendation #28.
Recommendation #27: Utilize the
personal and private health care
delivery systems for prevention
measuring and assigning priority to
health outcomes, quality and cost
effectiveness rather than access,
quantity and cost. Access is only a
process measure that provides no
assurance of better heath in itself. A
focus on health outcomes has been
shown to address service utilization.
Prevention provides the best quality
of life, and the most cost-effective
approach should be the goal of any
health system.31
Recommendation #28: Rational-
ize and maximize the utilization
of resources from personal health
services. The following example
provides evidence of the persistent
challenges of health systems. The
health determinants of people and
their contribution to the reduc-
tion of mortality were documented
back in 1976. Almost 90% of this
mortality was attributed to lifestyles,
human biology and the environ-
ment. Expenditures for these areas
accounted for 10% of the budget.
Conversely, personal health services
absorbed 90% of the budget but
contributed only 11% to mortality
reduction.32
9
Problem Statement IX:
The DHS should incorporate sustain-
ability thinking into any strategic
plan, reengineering program, cost
reduction measure, public/private
partnership or capacity building ef-
forts. Increasing capacity at this level
not only represents the cumulative
effects of capacity building initiatives
at the individual organization levels,
but also attempts to change the
environment, structure and needs
that define how organizations and
initiatives are conceived and imple-
mented.
Recommendation #24: Improve
organizational sustainability by
incorporating Family Health Interna-
tional’s four complementary types of
sustainability into all DHS programs
and services -technical, manage-
ment, financial and political sustain-
ability. An organization without any
of these components will either
be ineffective (lacking technical or
managerial sustainability), unpro-
ductive (lacking financial sustain-
ability) or irrelevant (lacking political
sustainability).29
“Technical sustainability: the abil-
ity of an organization to provide
technically appropriate, state-of-
the-art, high quality services.
Management Sustainability: the
ability to plan and manage all
aspects of the operations.
Financial Sustainability: the ability
to generate sufficient working
capital to continue to produce
goods or provide services.
Political Sustainability: the abil-
ity to maintain the support and
involvement of the community
An organization without
sustainability strategies
will either be ineffective
(lacking technical or
managerial sustainability),
unproductive(lacking
financial sustainability) or
irrelevant(lacking political
sustainability).29
9

10
Summary Table
II. Plans based primarily on economic considerations
disregard (unintentionally) the overall goals and vital
functions of DHS.
I. The health of LAC residents cannot be improved with
medical and public health interventions alone.
Adopt a Health System Approach.
Develop a comprehensive DHS-wide Strategic Plan.
Assume technical and managerial leadership for Items I and II.
AdoptWHO’s three (3) new goals for health systems: Good Health,
Responsiveness to the Expectations of the Population, and Fairness in Financial
Contribution.
AdoptWHO’s four (4) new vital (core) functions for health systems: Service
Provision, Resource Generation, Financing, and Stewardship.
Align functions and structure of DHS according to Items IV andV.
IncorporateWHO’s twofold objective of good health –goodness fairness.
Reform the health system based on the fundamental principle of delivery of high
quality essential care for everyone.
Institutionalize a Community Liaising Program.
Develop and deliver services that are demand-driven.
Institutionalize a DHS-wide performance measurement and improvement plan.
Create a sound quality assurance capability.
Conduct thorough technical, management, and financial performance audits
prior to contracting out services, including effective monitoring and evaluation.
View integration as sharing of responsibilities.
Incorporate coverage and quality as cornerstones of an integrated approach.
Develop a decentralized operational structure.
Implement an organizational alignment strategy.
Create a new leadership competence and culture through training of staff in the
Six Key Functions ofTop Management,The Four Core Categories of the
Public Health Leadership Competency Framework, and a Culture Change
Strategy.
Move from the old linear approach to management to one of simultaneity.This
preferred approach is alignment.
Change conventional priority thinking to the new thinking of well-run businesses.
Develop better programs to educate stakeholders.
Enrich DHS strategies with ideas that come from employees at all levels.
Utilize the people closest to the action to elicit ideas for improvement, identify
pitfalls, and get a reality check on DHS operations.
Improve organizational sustainability by incorporating Family Health
International’s four complementary types of sustainability: technical,
management, financial, and political.
Develop performance-contracting mechanisms that require counterpart
contributions, cost-sharing quotas, and resource diversification plans.
Create strengthened and more cost-effective Service Planning Area Offices by
merging Cluster Network with Area Health Offices.
Utilize the personal and private health care delivery system for prevention.
Rationalize and maximize the utilization of resources from personal health
services.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
III. Cost effectiveness for all, rather than all possible care for the
whole population or the simplest and most basic care for the
poor, must replace current health care delivery thinking.
IV. Health care systems have traditionally concentrated almost
exclusively on the presumed needs of individuals. Too little
attention has been given to people’s demand for health care.
V. Performance measurement and improvement are the key to
DHS’long-term competitive advantage, success, effectiveness,
stability and survival.
VI. Integration of services has not been achieved effectively
both within (intra-DHS) and outside DHS (Inter-Departments
and Community-Based Organization) despite extensive efforts.
VII. Previous DHS reengineering, downsizing, rightsizing,
cascading and/or reduction-in-force efforts have created a
culture in which managers end up pushing rather than leading
staff, and subordinates are characterized by low morale,
unbelief, fear, insecurity, and/or lack of motivation.
VIII. The DHS cannot afford to maintain the negative effects of
a misaligned organization.
IX. The DHS should incorporate sustainability thinking into any
strategic plan, reengineering program, cost reduction measure,
public/private partnership or capacity building effort.
X. Optimal utilization of a single, regional management
structure could better increase efficiencies and reduce costs,
reconfigure and/or reduce specific services, and integrate/align
public, personal and private health services.
PROBLEM STATEMENTS RECOMMENDATIONS
“Rather than saying it cannot be done,let’s find a way to get it done”
—M. Ricardo Calderón

11
1. Department of Health Services/ Public
Health Goals, Los Angeles County, 2000
2. World Health Organization.
TheWorld Health Report 2000:
Health Systems: Improving
Performance (WHO, Geneva,
Switzerland, 2000).
3. Office of the Director of
HealthServices, Rathgar Retreat
Minutes (Los Angeles County
Department of Health Services,
August 22-23,2000).
4. World Health Organization.
The World Health Report 2000:
HealthSystems: Improving
Performance (WHO, Geneva,
Switzerland, 2000).
5. Idem.
6. Idem.
7. Idem.
8. SPA 4 Area Health Office.
Community Liaising Program:
A DHS Restructuring and
ReinvigorationInitiative (Los Angeles
County Department of Health
Services, 2000).
9. Gilbert, Tom, Behavioral Engineering
Model.
10. Family Health International. The
AIDS Control and Prevention
[AIDSCAP] Project Evaluation
Tools: Introduction to AIDSCAP
Evaluation (USAID/FHI, Arlington,
Virginia,1993).
11. Labovitz, George Rosansky,
Victor, The Power of Alignment
(Organizational Dynamics, Inc. USA
1997).
12. W. Leebow and C.J. Ersoz, The
Health Care Manager’s Guide to
Continuous Quality Improvement
(Chicago: American Hospital
Publishing, 1991), pp. 3-4.
Victor. The Power of Alignment
1997).
14. Dallabeta, Gina et al. Control of
Sexually Transmitted Diseases:
A Handbook for the Design and
Management of Programs (USAID/
Family Health International,
Arlington, VA, 1995), pp. 43-56.
15. Idem.
1997).
17. American Management Association.
The Management Course for
Presidents (AMA, Hilton Head
Island, South Carolina, 1998).
18. Wright, Kate et al. Competency
Development in Public Health
Leadership (American Journal of
Public Health, August 2000) Vol. 90,
No. 8, pp 1202-1207.
19. Schuller, Robert H., 365 Positive
Thoughts (Crystal Cathedral
Ministries, Garden Grove, CA,
1998).
20. Maxwell, John C., Leadership 101
(Honor Books, Tulsa, OK 1994).
21. Murdock, Mike, The Double
Diamond Principle (The Wisdom
Center, Denton, TX, 1995).
22. American Management Association.
The Management Course for
Presidents. AMA, Coronado Island,
San Diego, CA, 2000).
23. Gilbert, Tom, Behavioral Engineering
Model.
24. EnTarga, Approaches to Planning
(EnTarga Business Planning).
25. Lawrence, Paul and Jay Lorshc,
Organization and Environment
(Homewood, Ill.: Richard D.
Irwin,1969), pp. 11.
(Organizational Dynamics, Inc., USA
1997).
27. Idem.
28. Idem.
29. Calderón, M. Ricardo. HIV/AIDS
Prevention and Control SYNOPSIS
Series: Capacity Building (Family
Health International, Arlington, VA,
1997), pp. 5-12.
30. Idem.
31. Foege, William H., The Scope of
Public Health: Challenges to Public
Health Leadership (Oxford University
Press, 1997), vol. 1, pp. 402-417.
32. Dever, G.E.A.: An Epidemiological
Model for Health Analysis (Soc. Ind.
Res. 1976), Vol. 2.
11
References

Metropolitan Service Planning area (SPA 4)
241 North Figueroa Street, Room 312
Los Angeles, California 90012
Tel: (213) 240-8049
Fax: (213) 202-6096
www.lapublichealth.org
© 2001 SPA 4

Improving LA County Health Services Performance

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