State health officials (SHOs), the leaders of state governmental public health agencies, play a central role in their states. Recent work has significantly enhanced our knowledge of the attributes and characteristics of successful SHOs,1 including insights gained into the factors that contribute to the premature slowing of career advancement or “derailment.”2 In this column, we focus on the prevention of “derailment” by the intervention of those with a unique position to detect “early warning signs”—senior health department deputies3 and other senior leaders. Although we focus here on the unique situation of SHOs, many of the approaches we describe apply in other settings.
Early warning signs of SHO derailment are sometimes visible to the public through news media coverage, legislative hearings, and public meetings. These forums may afford opportunities for the public to observe the warning signs of potential derailment, for example, the existence of a public health crisis where the SHO is not perceived to have credibility; the emergence of a disease outbreak where the health agency is perceived to not be doing enough to protect the public health; or the SHO caught up in a contentious and highly charged political issue related to the health of the public. But before these public indicators of derailment are visible, there are usually underlying signs of trouble that are first recognized by senior staff who work closely with the SHO.
The Dynamics of Derailment
The majority of SHO derailment comes not from a failure of public health technical expertise but from an error in leadership or management.2,3 This could be due to a lack of alignment between the governor's leadership priorities and those of the SHO or an equally catastrophic management issue associated with personnel or financial management. The senior leadership team within the SHO's own agency is often in the best position to recognize the first signs of leadership and management failure.3 They are also in the best position to act to mitigate the SHO's shortcomings in leadership and management by supporting the SHO and acting to prevent derailment. Collectively, their ability to recognize the early signs of derailment and effectively intervene to support the SHO with their own techniques and management skills can spell the difference between an SHO's success and failure.
Derailment Early Warning Signs
Derailment early warning signs related to the governor's office
Experienced senior staff are often sensitive to signs that indicate a troubled relationship between the governor's office and the SHO. The signs can be subtle or more dramatic.
- Signs that a governor's office is not in alignment with the SHO:
Signs that an SHO is not in alignment with the governor's office:
- Lack of a protocol for alerting the governor to an emerging public health crisis.
- A statement on a highly visible issue from the governor or the governor's public information officer is inconsistent with statements from the SHO.
- An apparent lack of support in the governor's office for public health issues (eg, public health is not a legislative priority or lacks funds in the governor's proposed budget).
- The governor's office places senior staff in the public health agency (eg, a liaison, a chief of staff, a policy advisor) who are loyal to the governor rather than being loyal to the SHO. As a result of this common practice, effective working relationships between the governor's office and the SHO could be jeopardized.
- The SHO is unclear about the governor's support for and understanding of public health issues and priorities and does not achieve agreement on strategic direction.
- The SHO does not have a clear understanding with the governor about the response to a public health emergency, thereby setting the stage for conflict during an emergency.
- The SHO was too optimistic regarding the challenges of implementing a governor's public health priority leading to a widening gap between expectations and actual progress.
- The SHO has not been able to gain the support of other state agencies for implementing public health initiatives.
Derailment early warning signs related to agency operations
Newly appointed SHOs often arrive on the job with high expectations. Depending upon the experience they bring to the job, they may underestimate the complexities of the political process, cross-sectional partnership development, and the business processes of state government.4 This can lead to internal agency tension, frustration, and dysfunction that first become apparent to agency staff. Thus, identification of internal “early warning signs” is as important as those related to the governor's office:
- The SHO arrives on the job with predetermined plan and proceeds to micromanage it without engaging senior management.
- By underestimating the complexity of government business systems, unrealistic time frames are agreed to by the SHO.
- Long-standing partnerships are strained or broken by changes in policy and agency direction that come across as insensitive and disrespectful to agency partners.
- The SHO goes directly to program staff and bypasses senior agency leadership on issues and questions related to agency operations.
- Critical information about agency direction is not shared by the SHO in effective ways resulting in a failure to get the entire management team on board.
- The SHO is distracted by the issue of the day and fails to keep an eye on the long view.
- The agency appears to the staff to be in constant crisis mode (eg, budget crises, bad media coverage, enmity with partners, key staff resignations).
- The SHO loses credibility and trust among agency staff; voluntary turnover of staff increases; and the SHO begins to disengage.
Our research related to SHO success points to the central role of agency senior deputies in identifying these “early warning signs” and orchestrating an intervention to prevent SHO derailment.3 Others in the agency senior leadership team (eg, senior legal staff and chief information officer) may also contribute to the process of derailment prevention. Key tactics include clarifying the governor's expectations, avoiding letting internal issues getting so out of control that it is impossible to recover, and helping the SHO avoid micromanagement. The senior deputy can employ certain management techniques and methods to help the SHO avoid derailment. The techniques and methods that prove most useful to senior managers depend on the variables unique to each SHO and the public health agency they manage.
Ensuring that the governor's expectations are known and that there is a strong working relationship with the governor's office
One would like to think that a governor could and would explain expectations clearly to the SHO at the outset and during the course of the governor's administration. But having a clear understanding of the governor's priorities and how to relate to the governor's office early in the SHO's tenure does not always happen. A senior deputy can assist in identifying the expectations of the governor's office by helping the SHO frame expectations in terms of agency operational requirements. The senior deputy can support the SHO by encouraging the identification of a point of contact within the governor's office to work with the senior deputy to help monitor and refine expectations. The deputy can also put reporting systems in place to manage progress and report back on a regular basis.
Often, even the smallest interactions with the governor are not direct but are mediated through the governor's staff. To make matters even more challenging, the governor's staff person and the governor may not be in accord on certain issues. In certain circumstances, direct contact with the governor can be needed to clarify sensitive issues. An experienced senior deputy may assist the SHO in navigating these tricky waters.
Addressing internal issues related to the derailment dynamic
A strong senior management team, led by the senior deputy, can intervene to prevent derailment before it is too late using several potentially useful techniques:
- Influence scheduling of the SHO. Commitments scheduled for the SHO should be aligned with strategic objectives, designed to showcase the SHO's strengths, demonstrate political awareness, be essential to achieve leadership and management objectives, and minimize the opportunities for setbacks. The senior deputy can establish a weekly calendar review meeting with the SHO, the SHO's calendar scheduler, and key leadership team members. Doing this with discipline enables delegation of commitments to senior managers if needed and can provide an opportunity for the senior management team to hear the leadership rationale they need to function effectively in implementing policy.
- Increase the communication between members of the senior management team. The goal of good communication between the SHO and the senior staff is to keep managers current with the SHO's leadership decisions, enabling them to use accurate rationale to reflect those decisions, avoiding inaccurate speculation, and surfacing inconsistencies in management that require corrective action. Well-established techniques to enhance communication include regular meetings, reports, electronic media, and even regularly planned informal contact between team members (eg, planned coffee breaks).
- Establish an understanding with the SHO and the scheduler that a senior manager participates with the SHO in all meetings related to agency operations. This tactic ensures that the most current program information is available in the discussion. It also assists in building accountability into any action items that result from the meeting.
- Have the SHO self-identify his or her strengths and weaknesses. Attempt to work candidly with the SHO to identify management areas that are not the strong suit of the SHO, or not the best use of the SHO's time and then implement ways to address these areas.
- Identify the member of the senior leadership team who works well with particularly challenging stakeholders and allow that team member to represent the SHO. If the relationship between the SHO and a key individual or group is not going well, involving a senior staff member who has a good relationship with that stakeholder may help.
- Do not insulate the SHO from problems and challenges, even if the SHO does not like bad news. The senior deputy and the management team should work closely enough with the SHO to know when to surface bad news and always be able to offer some solutions or strategies for getting to a solution.
- The senior deputy should enable the SHO to confidentially express management frustrations and help frame potential solutions to troubling problems and situations. The senior deputy can play the “trusted advisor” role or encourage the SHO to find a mentor to provide a safe candid way to discuss problems (eg, personnel issues, management team challenges) and potential solutions.
Avoid letting the SHO get so engaged micromanaging that the skills and experience of the senior leadership team are not fully utilized
The “boss knows best” concept can be a dangerous trap leading to derailment. State health official input is critical up front and periodically as high-profile programs and activities are carried out. To assure the SHO that these programs are being effectively managed requires coordinated planning, an agreed-upon action plan, frequent feedback, and measurable progress. Clarifying expectations up front and building in accountability can go a long way toward ensuring that the best possible performance is achieved. This approach can take the form of an actual written operating agreement that defines roles of senior agency leaders and managers.5 The SHO can be asked “If this initiative is successful, what will actually happen?” By asking this question, senior staff can assist the SHO in making expectations concrete and actionable. The senior deputy can assure the SHO that micromanagement of a situation is not needed, because progress is being made according to a mutually agreed-upon timeline with opportunity for course corrections.
A final word
The senior deputy and management team supporting the SHO should assess what they can control and what they cannot control and focus on those things within their control. In challenging circumstances, they should not see themselves as victims.5 There are several management techniques the team can consider implementing, depending upon their assessment of the organizational environment. We have offered some strategies to consider as a starting point for helping the SHO avoid derailment, support SHO's success, enhance agency performance, and contribute to the health of the public.
1. Halverson PK, Yeager VA, Menachemi N, et al State health official career advancement and sustainability evaluation—description of the methods used in the SHO-CASE study. J Public Health Manag Pract. 2020;26(1):5–8.
2. Baker EL, Boedigheimer SF, Moffatt S, Altman D, Castrucci BC, Halverson PK. Preventing leader derailment—a strategic imperative for public health agencies. J Public Health Manag Pract. 2018;24(4):400–403.
3. Boedigheimer SF, Yeager V, Chapple-McGruder T, Moffatt S, Halverson PK, for the SHO-CASE Steering Committee. Public health senior deputy's perceptions of state health officials' success factors: professional characteristics, personal attributes, and signs of derailment. J Public Health Manag Pract. 2020;26(1):16–22.
4. Baker EL, Castrucci BC, Moffatt S, et al What health officials wish they had known and how they learned best. J Public Health Manag Pract. 2018;24(1):85–86.
5. Chambers HE. My Way or the Highway—The Micromanagement Survival Guide. San Francisco, CA: Berrett-Koehler Publishers, Inc; 2004.