There is growing interest in the factors that influence the tenure and early success of state and territorial health officials (STHOs)1 , 2 and the competencies new STHOs need to excel throughout their leadership journey.3 , 4 This is understandable, given the key role STHOs and their executive teams play in setting public health priorities and advancing programs, policies, and partnerships that promote health and ensure optimal health for all. While STHO tenure is similar to other appointed federal and state leaders and corporate “C-suite” executives (Matt Salo, National Association of Medicaid Directors, e-mail communication, 2018),5 , 6 its brevity (average 4.1 years and median of 2.9 years)2 illustrates the intensity of the job and potential for derailment and burnout in what are often very political and highly visible leadership positions. In addition, the brief tenure illustrates the need to ensure that new STHOs are quickly prepared to assume the mantle of leadership and accelerate efforts to improve health and well-being as soon as they are appointed to their positions.
The literature on executive transitions and a leader's first days is helpful to informing the essential elements of a new STHO's onboarding. An executive's first months on the job are important to setting the tone and pace of his or her leadership trajectory.7–10 Likewise, starting out “right”7 has significant impact on follower buy-in to a new STHO's priorities as well as an STHO's success managing up with governors and other leaders such as board of health chairs and state or territorial legislators. Swift onboarding is particularly important for state and territorial public health executives who are new to the work of government and lack familiarity with the processes, procedures, politics, and culture of large bureaucracies that employ hundreds of people and manage millions of public dollars. The research of Baker and colleagues11 on what STHOs “wish they had known” when they started in their positions includes both a better understanding of the political process (state and federal) and a better understanding of how state and territorial government functions. This research validates the need for quick onboarding and orientation of new leaders.
Management literature has focused on the first 90 days,8 , 9 100 days,10 and 6 months12 of a new executive's tenure; however, there is little empirical evidence for a specific time period that defines being “new.” Rather, most STHOs will have to go through an entire year on the job before becoming familiar with the ebb and flow of the agency's planning and budgeting processes, the appropriations, and policymaking cycles; experience response to seasonal disease outbreaks and natural disasters (eg, hurricanes, ice storms, floods, wildfires); review agency grant proposals, audits, and annual reports; and live through other “rites of passage” and annual milestones in the life of their agency.
Regardless, state and territorial health officers new to their roles often describe their first months as “drinking from a firehose.” The pressure in these first days arises from the need to comprehend the vast scope of their agency's work, establish authority and acclimate to the organizational culture, and quickly but accurately assess the agency's internal and external opportunities and challenges. It is the tension between needing to listen and learn before acting that makes the first few months so critical in the life of a new executive: too much listening and input, and the new leader may experience analysis paralysis; too little listening and input might lead to changes that may seem ill-advised, capricious, or impulsive to those in and outside of the organization. As such, it is STHOs' judgment call on when their “honeymoon” is over, but the 3- to 6-month period in which new leaders are gathering input while also forming their management team and assessing the organization's culture and strategy that commonly defines being new.
In November 2018, there were gubernatorial elections in 36 states and 3 territories.13 Each of these transitions involves the appointment of new cabinet secretaries, and when the STHO serves at the pleasure of the governor or a Secretary of Health and Human Services, the STHO typically transitions out along with other appointed leaders. This means that shortly following gubernatorial inaugurations in early 2019, more than half of the nation's state and territorial health leaders may change. Even in nonelection years, there is tremendous turnover in STHO leadership. In the 2-year period, August 2016 to July 2018, there were 29 STHO transitions.
As the national organization representing STHOs and their executive leadership teams, the Association of State and Territorial Health Officials (ASTHO) developed leadership competencies for STHOs.3 , 4 To inform ASTHO's leader development efforts and better understand what is important to preparing new STHOs for their roles, ASTHO reviewed the management literature on executive onboarding, practical guides specific to health officials in their first days and months on the job, and competency domains for newly appointed STHOs.3 , 7–11 , 14 , 15 The themes presented in this literature cluster into 4 “Essential Elements,” summarized in the Table. These include the following: (1) Be Prepared; (2) Think Strategically; (3) Lead Up, Down, and Across; and (4) Manage Yourself.
Be Prepared: Early Listening and Continuous Learning
This element includes becoming oriented to the job prior to its official start, planning for an STHO's first day, and continuous learning throughout the STHO's tenure. This element also involves the tactical work of preparing for and orienting one's self to the STHO position, laying a foundation for success with agency partners and leaders, and accelerating learning about the agency. Bradt et al10 aptly call these early days the “fuzzy front end,” characterized by leveraging the time between accepting the new position and the leader's arrival to learn about the organization, meet with stakeholders, and prepare for the job. Similarly, several authors suggest that this front-end work includes early listening and learning on topics such as the agency's budget and resource availability, obtaining information about the challenges unique to leading in public health, and understanding the legal powers and regulatory authority bestowed upon state or territorial health officers.12 , 14 , 15 Becoming expert in the governmental policymaking process, including how to navigate state and territorial legislatures and how to work with state legislators and their staff, is also an important part of being prepared. This is especially true since STHO appointments often take place at the start of a state's budget development cycle and may require legislative confirmation.
The “Be Prepared” phase also involves meeting with agency staff, colleagues, and STHO alumni prior to the STHO's official start date, reviewing briefing materials and reports, and reading summaries of the agency's projects, processes, and procedures. Once on the job, a key feature of this element is continuous listening and learning. Successful new leaders use their first months to meet with agency staff and partners to learn about their prior experiences and future expectations. These conversations help new STHOs avoid “predictable surprises,”9 inform their early strategy development, identify necessary culture changes, and demonstrate new leaders' interest in learning from staff and engaging partners.
Think Strategically: What's the External Game?
Management literature on transition7–10 and guides for new health officials12 , 14 , 15 focus on the need to quickly develop organizational strategy and create a vision and mission to motivate staff and coalesce organizational efforts around common goals and objectives. This includes developing a vision for the organization7 and “burning imperatives”8 to unify staff activity and galvanize the organization's efforts to align various functional areas. The “Think Strategically” element stresses the need to achieve “early wins”7–9: successes that demonstrate new leaders are capable of achieving results and can deliver outcomes soon after they start. While recent research suggests that early wins can actually derail new leaders,16 especially when they are accomplished too fast and/or without enough time on the job, many experienced STHOs and STHO alumni point to early wins as critical to establishing their credibility with superiors and subordinates and demonstrating a results-orientation.15
Another aspect of the “Think Strategically” element involves partnership development including coalition building and forming alliances to advance the work of the organization. For new STHOs, this means developing the external game plan: those things that externally position the agency strategically to successfully achieve results outside of the organization. The external game means participating in key public health and health care partnerships, meeting with governmental and nongovernment health leaders, and getting to know key industry executives including health care and hospital leaders. Thinking strategically also means discerning the agency's priorities and external goals and assessing how the agency's strategy may or may not align with the interests of other organizations.
Strategy setting in governmental public health agencies is difficult17: agency activities are often funded through specific legislative mandates and by restrictive categorical funding from federal grants and cooperative agreements that often create rigid, stove-piped programs focused on functional work versus crosscutting agency strategic outcomes. The “tyranny of the urgent” and significant public health crises often take center stage, putting health officials on the defensive rather than being able to plan proactively and tactically implement objectives.18 These constraints make strategic alignment with new or different priorities difficult and can stymie STHO efforts to redirect agency efforts or support cross-agency priorities. Primers for new health officials suggest that STHOs identify and understand “hot” issues as part of their strategic assessments14 , 15 and point new STHOs to important resources to review when setting strategy including the agency's workforce development plan, health improvement plan, community health assessments, grant reports, accreditation documentation and reports, prior strategic plans, program workplans, and other documents that inform or direct agency activities.
Contemporary public health practice requires establishing effective partnerships and collaborations with a number of sectors to address the social determinants of health and ensure optimal health for all. In addition to the 2 themes cited earlier, Baker and colleagues11 identified “better understanding of partnership development approaches” as a third theme. While new STHOs may justifiably prioritize getting to know their own agency's staff in their first days, they should also prioritize meeting key external leaders, including health plan and hospital CEOs, medical society leaders, business leaders, academic leaders, health journalists and reporters, leaders in the faith community, and other key partners across the state, since leaders in these organizations are crucial to obtaining early wins and lasting impact. Thinking strategically involves spanning the boundaries between organizations to obtain shared goals. Enrst, Chrobot-Mason, and the Center for Creative Leadership's19 “boundary spanning leadership” research demonstrates that successful organizations use similar overarching strategies and key practices to recognize, address, and leverage boundaries that exist between various organizations and stakeholders. These strategies are important guides for new leaders looking to build strategic partnerships and coalitions to improve health.
Leading Up, Down, and Across: What's the Inside Game?
Literature on executive transition emphasizes a new leader's ability to establish executive presence and adopt a leadership style that adapts to the organization commonly described as the “fit” between a leader's style and the organization's culture. To be successful, an STHO must not only “fit” but also effectively lead “up,” “down,” and “across.” Leading “up” refers to the relationship between the STHO and his or her superiors (eg, governor, cabinet secretary, board of health chair), leading “down” refers to the STHO's relationship with subordinates, and leading “across” refers to horizontal relationships with peer agency heads within government. Each of these directions requires different types of leader communication, emphasis, and strategy. A focus on any one direction at the exclusion of others may isolate the leaders, cutting them off from key situational intelligence and the information they need to effectively lead their agency and obtain results.
Leading up involves working with governors and their surrogates (chiefs of staff, policy directors, etc) to define success factors and priorities for the governor's administration. Clarifying and setting expectations between STHOs and governors or their surrogate is a key part of this element (“negotiating success,” “clarify expectations”).8 , 9 , 14 Leading down and establishing a management team of trusted advisors and effective managers are another component of this essential element and often require a great deal of time and attention for new STHOs. Leading “down” or developing working relationships with senior staff, especially the “senior deputy” (often the “number two” leader in the agency) and others on the STHO's management team, is also important to early success. Senior deputies have important institutional history, deep situational awareness, cultural acumen, and the overall knowledge of “how to get things done around here” to support new STHOs and enable their success. Paradoxically, new STHOs have to build trust with their team while objectively assessing individual team members' competencies to ensure they get “right people on the bus,”21 that is, hire subordinates who support STHOs' vision, can serve as guides for strategy implementation and cultural transformation, and support the organizational changes needed to enhance agency performance. Getting the “right people on the bus” is often complicated in government where civil service laws, collective bargaining agreements, and competition with the private sector for talent make selection of new team members complicated but not impossible. Senior staff fluent in the human resource rules and regulations of the agency are key partners in supporting STHOs looking to select new talent and develop the competencies of their existing staff.
Manage Yourself: Who Am I as a Leader?
Perhaps, the most essential element to new STHO transition is how the STHOs manage themselves as a leader. Research on leader efficacy has found that humility,21–22 a servant leadership mind-set,23 , 24 and a “transformational leadership”25 , 26 style are the most effective approaches new leaders can use to establish themselves in their roles and develop buy-in from subordinates. In addition, a leader's emotional intelligence has also been correlated with leader success and organizational performance.27–30 Tools such as a “360-assessment,”31 the DiSC Profile,32 or a StrengthsFinder33 assessment can help new leaders assess their leadership style, build self-awareness, and identify blind spots that might hinder the STHOs' success and their team's performance.
Developing self-awareness as a leader includes establishing trusted relationships with staff and peers in other state and territorial agencies to help work through difficult situations and identify opportunities for growth. Trust is an important factor in executive team effectiveness because it serves to underpin team performance and results.34 Seeking advice and counsel, developing self-awareness, and evaluating one's blind spots are important tactics for new leaders. Primers for new health officials suggest that networking, mentoring, and establishing relationships with peers nationally are other ways to develop STHOs' capacity to manage and effectively lead their organization. “Who am I?” as a leader is an important question for new STHOs both when they are new and throughout their leadership journey. Executive coaches, national leadership development experiences, and other external sounding boards and supports are helpful resources for STHOs to consider in discerning the answer to this question.
The first months of STHO tenure are crucial to setting the leadership cadence and management rhythm of their future administration. They are also essential to building a solid foundation for STHOs' legacy that lasts well beyond their tenure in state or territorial government. The 4 essential elements (Be Prepared; Think Strategically; Lead Up, Down, and Across; Manage Yourself) help guide action in the important first months and set STHOs on a success trajectory to implement health improvement strategies with significant impact.35 Continuous learning and self-assessment, as described in the “Be Prepared” and “Manage Yourself” elements, are as important on the last day of an STHO's appointment as they are on the first. Veteran health officials, STHO alumni, and public health thought leaders have described the ongoing challenges and opportunities of leadership well beyond their first few months that advance the “Think Strategically” and “Lead Up, Down, and Across” elements in subsequent phases of an STHO's tenure.17 , 35–40 As ASTHO looks toward onboarding and orienting more than half of the nation's health officials in early 2019, helping new STHOs start out right is of upmost importance both for the success of individual leaders and for our nation's health.
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