Governmental health agencies at the state level are traditionally led by appointed state health officials (SHOs). While there have been SHOs leading our nation's state health agencies since their creation, little is known about the personal and professional characteristics or organizational factors that make those occupying these key positions successful. If these characteristics and factors could be identified, they could be shared with gubernatorial transition teams, state boards of health, or those who are selected to fill these positions to:
- Increase the likelihood of successful performance of the individuals selected and the health departments they lead;
- Prevent or mitigate career derailment; and
- Improve the process of selecting and preparing SHOs.
To fill this gap in public health leadership research, the Indiana University Richard M. Fairbanks School of Public Health, the Association of State and Territorial Health Officials, and the de Beaumont Foundation have partnered to enhance our understanding of some of these critical factors. Specifically, this study explores:
- Personal and leadership attributes of current and past SHOs;
- Selection processes through which SHOs are appointed;
- Preparation they receive for the job;
- Context in which they function(ed);
- Level of success achieved; and
- Approaches SHOs have taken to build effective leadership teams and compensate for their own gaps in knowledge and skills.
As studies of these specific questions for public health leaders have not been previously undertaken, we embarked on a series of conversations with state health agency leaders including past and present SHOs, deputy state directors, and state health agency staff to delineate our research hypotheses and deepen our understanding of key concepts.
What Does Success Look Like?
To study success, it must first be defined. At this stage of our research, 2 general groupings seem useful in describing “success”: (1) building an effective team and (2) organizational accomplishments.
Information received from experienced public health managers as well as newer public health professionals has emphasized the importance of developing a stronger team within the state health agency as one indicator of a successful SHO. Specific tactics to address this strategic goal might include:
- Formal development for existing team members;
- Formal leadership succession planning;
- Recruiting and retaining new talent to address skill gaps; and
- Enhancing team cohesion through team-building experiences.
Success might also be measured in terms of concrete accomplishments during the SHO's tenure, including:
- Policy change including laws, regulations, and departmental policies that support evidence-based public health interventions.
- Program development through a new or enhanced public health agency organizational focus.
- New or enhanced formal relationships with key partners, such as health care organizations, community organizations, other government agencies, and the private sector.
Although not explicitly identified in these preliminary conversations, another interesting question to be considered is whether a SHO should also be judged by national rankings and/or state health indicators. Our preliminary conversations suggest that organizational development and process are important, but how do these measures of “success” square with worsening health outcomes? How can any organizational leader be held accountable for outcomes that are, generally, outside of his or her control? However, these health outcomes may be the measures of “success” that are of most interest to governors, legislators, and advocates.
What Are the Critical Success Factors for SHOs?
When identified, critical success factors can be replicated. From our conversations and other research methods, we have identified 4 domain areas that may influence the likelihood of success for SHOs. These include individual factors, individual on-the-job behaviors, organizational structures and operations, and organizational culture.
We are identifying a range of individual personal attributes, skills and competencies, and professional experiences that may contribute to success. Desirable personal attributes may include trustworthiness, emotional intelligence, ability to listen well, integrity, and personal credibility.1 Desirable skills and competencies may include leadership skills, management skills, political awareness and aplomb, public health science knowledge, and policy development competency. Certain prior work experiences of the individual may be desirable, such as experience in leading a large complex organization, experience in government, experience working with the political apparatus, experience operating in the “public eye,” and experience in public health/population health.
Individual on-the-job behaviors
Once selected for the SHO position, it may be desirable for the SHO to demonstrate certain on-the-job behaviors including building and enhancing relationships; “managing up”; building trust inside and outside the health agency; communicating vision, strategies, and priorities; and having a systems perspective with the ability to “see the big picture.” Quick proactive leadership at the time of a local, state, or national crisis, such as an environmental crisis or a disease outbreak, early in the SHO's tenure can be central to future success. Using data and evidence to shape policy development may also serve as a desirable behavior.
Organizational structures and operations
A range of operational and structural considerations may contribute to (or limit) the success of the SHO.2 These include lines of supervisory authority, organizational placement, and internal communication, including ways to surface policy issues. Techniques and policies impacting relationships with the governor, key staff, cabinet members, other government agencies, boards, and oversight bodies may represent additional critical success factors. Other operational factors may include the complexity and scope of health agency programs, along with the authority to adjust agency structures, programs, and services and manage a senior executive management team. Factors related to length of tenure in the position and the impact of reduced tenure on SHO success will also be considered in our study.
Organizational culture may influence SHO success. Cultural factors may include internal policies on access to the SHO by senior management, by program managers, and by all employees. Cohesion of the SHO's executive team may be fostered by inclusive approaches to establishing or clarifying vision and goals, providing progress reports, and sharing feedback. Success may also be enhanced by the use of systems to promote the value of science and evidence-based decision making. Finally, success may be enhanced by the use of best practices to improve agency performance, develop staff, and promote creation of a “learning organization” with cultural sensitivity and a commitment to diversity and community engagement.
Conclusion and Next Steps
SHOs play a central role in protecting and improving the health of their state as well as enhancing the capacity of the agency that they direct. The 2014 Public Health Workforce Interests and Needs Survey3 identified several areas of needed growth for state health agencies. Ensuring that creativity was rewarded, that communications were inclusive, that staff morale was adequate are examples of areas in need of improvement. While individual supervisors can attempt to improve their relationships with staff and mediate issues within the organization, the SHO is the single most influential person within the health department. However, we know surprisingly little about those who are charged with the oversight and leadership of what Woltring and Novick4 called “the most essential element in our collective efforts in assuring the public's health.”
Furthermore, there is now a growing focus on the essential role of the health official as a “chief health strategist” whose aim is to improve the health of his or her state in partnership with local and state governments and private sector partners. Under this model, SHOs serve as a key health strategist for their communities, “capable of mobilizing community action to affect health determinants beyond the direct reach of their agencies.”5 In view of all these considerations, defining success will be complex and identifying critical success factors challenging, but we owe the workforce and the public the best leaders available and must complete this work for them.
In the future, we will be conducting surveys of current and former SHOs, performing in-depth interviews, and convening expert consensus processes to distill our findings and craft recommendations. As information becomes available, we commit to sharing the findings and recommendations through various professional avenues. Ultimately, we aim to enhance the success of SHOs and their impact on the public health system as a result of this groundbreaking research.
1. Jarris PE. Parting thoughts of a state health official. J Public Health Manag Pract. 2016;22(2):105–107.
2. Atchison CG, Beitsch LM, Benjamin GC, et al First Days: A guide for State and Territorial Health Officials. Arlington, VA: Association of State and Territorial Health Officials; 2009.
3. Sellars K, Leider JP, Harper E, et al The Public Health Workforce and Interests and Needs Survey: the first national survey of state health agency employees. J Public Health Manag Pract. 2015;21:S13–S27.
4. Woltring CS, Novick LF, Public health workforce: infrastructure's keystone. J Public Health Manag Pract. 2003;9:438–439.
5. DeSalvo KB, O'Carroll PW, Koo D, Auerbach JM, Monroe JA. Public Health 3.0: time for an upgrade. Am J Public Health. 2016;106:621–622.