PH WINS is a hybrid survey that asks about public health employee engagement, training needs, and demographics. It is especially valuable in that (1) it allows a health department to compare 2014 responses with 2017 responses, (2) it is conducted and analyzed by partners who are at the cutting edge of public health improvement and advocacy, and (3) each participating department's results are reported back to the department with anchoring comparisons to similar health departments. It is also noteworthy that the vast majority of the articles in this supplemental issue have contributions by people who are not academic researchers, but rather people who work either in or for health departments. Lately, we've been paying a lot of attention to ensuring our public health messages are being delivered the right way, by the right messenger. Hearing we need to do better with engaging and training our public health workforce is easier to embrace from our peers than from academia.
The San Antonio Metropolitan Health District (Metro Health) is the public health provider for the nearly 2 million people who live in San Antonio/Bexar County. Over the last decade, Metro Health divested the majority of its clinical services to the local hospital authority; saw the retirement of its tenured and beloved director, Dr Francisco Guerra; hired a new director who left in short order; had an interim director for 18 months; and hired me as their permanent director in March of 2017.
Given the tumultuous changes described previously, assessing and improving employee engagement and morale was an essential first step for me as the new director. Our team started by sending out a quick, 10-minute survey that focused on Gallups' 12 questions to assess employee engagement. We incentivized participation by throwing a celebratory luncheon when we reached a 90% response rate. We then gave the survey results to a volunteer group of nonsupervisory employees to prioritize the top 3 employee engagement issues and develop actions to address those 3 priorities: (1) Involve employees in solving problems; (2) Recognize exemplary employee performance; (3) Provide greater access to professional development and training. PH WINS was the first opportunity we had to assess whether our work around these issues was making a difference.
When I compared the average score for each PH WINS question from 2014 to 2017, I saw improvement everywhere. Literally every single question in 2017 had a better score than in 2014. This was important and timely feedback that our changes were indeed making a difference. Next, I looked at how our average scores compared to other big city health departments. I found that while we had improved significantly since 2014, there were many areas where we fell below the performance of other big cities. Knowing this helped us fine tune some of the actions we're taking and gave us opportunities to check in with other similar health departments to see how they're addressing these issues as well.
Finally, given that 1 of our top 3 priorities was a focus on professional development and training, we took an in-depth look at the results of the training needs identified by our public health staff. Our outcomes were very interesting. The results were reported by “nonsupervisory staff,” “supervisors and managers,” and “executives.” The training goals identified by different staff levels varied, with 2 exceptions. All staff levels identified greater knowledge around “funding mechanisms” and “agency business plans” as important areas for professional development. There was greater concordance between the supervisors and executives than the nonsupervisory staff and either group. The other interesting finding was that the highest percentage of staff identifying a training need as high importance/low skill was only 56%, meaning slightly more than half the staff felt this 1 item was important and they needed help with it. For most of the top 5 items, the majority either identified it as a high-skill area for them or a low-importance area. All this to say: if readers are looking for the 1 area where the public health workforce needs additional training, at least in San Antonio, this survey provides no definitive answer.
One concern I have about this training needs assessment is that it lacks a 360-degree dimension. Knowing what individual staff identified as a training need is important, but as valuable to me as the director of a large health department with limited training resources is an assessment from each group on what training needs they perceive are needed for the other 2 groups. So, for example, what training do nonsupervisory employees think their supervisors and executives need? As somebody who is a regular utilizer of 360-degree performance evaluations, it never ceases to amaze me how frequently an employee's self-assessment is markedly different from their other raters. This often manifests as an employee underestimating their abilities and being surprised when the final report indicates their raters believe they are quite strong in areas they identified as needing improvement. If we are to use the results from this survey to determine a national public health workforce training agenda, as some have suggested, we need a more nuanced understanding of not just what individuals believe they need, but also what their supervisors, peers, and others believe is needed.
Finally, here in San Antonio, only the executives in our health department identified the need to “incorporate health equity and social justice principles into planning across the agency.” You could interpret this 1 of 2 ways: (1) health equity and social justice are so embedded in our culture that it has become the norm and not something people even need to think about any more or (2) we have a basic lack of understanding that equity and social justice are 2 pillars upon which the public's health is built and therefore we “don't know what we don't know.” Unfortunately, I believe it is the latter. The concept of emerging training needs being beyond our conscious understanding of those needs is an important caution to consider as we interpret the results of this survey.
I understand the time-limit concerns around this survey. If we added everything everybody thought was important, the survey could take hours to complete and participation would plummet. Perhaps a solution would be to create a PH WINS toolkit for health departments to dive more deeply into their specific results. This kind of toolkit could include tips and tools for getting a full 360-degree understanding of the agency's top training needs as well as suggestions on research methods to identify emerging training needs. This toolkit could also include help for communicating the results and working with staff to create follow-up actions; too often, survey results are not shared with participants.
Overall, the PH WINS survey provides critical information to public health practitioners and leaders on public health workforce demographics, engagement, and self-identified training needs. Because the recommendations for improvement provided within this special issue of the Journal of Public Health Management and Practice were made mostly by people working in and on behalf of the public health workforce, these recommendations are more palatable than the traditional academic-led research studies about what public health practitioners need to do their jobs better. The recommendations would, however, benefit from further refinement by incorporating a 360-degree assessment of training needs and keeping in mind that there may be an unacceptable delay in emerging training needs being identified by the public health workforce.