Final Practicum Reflection Paper

by

Michael O’Driscoll

Gila County Arizona

1400 E. Ash St., Globe, AZ 85501

Supervisor: Don McDaniel, County Manager

MPH 599, Concordia University

Dr. Jen Janousek

August 2015

Abstract

Being the director of a local county health department is both a challenging and rewarding job at

the same time filled with successes and failures. Learning how to manage personnel, elected

officials, and community partners can be tricky, frustrating, and exhilarating all at once. In this

practicum I will chronicle my work activities in environmental health (EH), communicable

disease (CD), and public health emergency preparedness (PHEP) with insights into managing

these programs and directing staff to meet state law and grant deliverables. In addition, in each of

the three programs I discuss in this paper I will offer my personal observations and thoughts on

effective management in my health department.

Introduction

There is no formula or career track one has to take to become the director of a local

health department. Other health directors I have met across the U.S. come from all different

backgrounds, education, and experiences. In fact, there is a county health director in North

Carolina who never before worked in public health until recently but is a skilled financial

planner; and, his job is to understand the needs of his staff and community and find funding for

it. In my opinion, the skills needed in a health director are those that require a combination of

fiscal acuity, conflict resolution, program evaluation, team building, and a large amount of

common sense. Those skills become even more significant as funding for public health continues

to decline.

According to a 2013 national survey of local health departments by the National

Association of County and City Health Officials (NACCHO), since 2010 , the median number of

employees and full time employees (FTEs) has decreased significantly. This has led to

substantial changes in organizational structure and programmatic operations in many health

departments across the country, including the county where I work, Gila County Arizona. My

budget has been decreased 35% over the past four years causing workforce reduction, a change

in our strategic plan, and increased stress on my staff. Managing a health department through

economic challenging times and having to rebuild the entire infrastructure has provided me with

a unique perspective on managing a pubic health system in a rural community. This paper seeks

to offer guidance to aspiring health directors and advice for young leaders in managing public

health programs in a local county health department. In addition, the projects I worked on over

the course of my practicum are discussions that are occurring in many health departments across

the U.S. and I hope a brief glimpse into these will assist others as they pursue management

positions in public health.

To satisfy my requirement for the Master of Public Health program, I participated in a

worksite practicum using my current position as the foundation of my project and have

documented my thoughts and actions on how to properly manage and direct the following three

programs in times of shrinking resources and increased community needs: 1) environmental

health, 2) communicable disease, and 3) public health emergency preparedness.

Gila County

Located in the middle of Arizona, Gila County borders six counties and is home to 1% of

Arizonans (53,597 residents). Named for the Gila River, Gila County was created in 1881,

originally carved from portions of three other Counties, it spans across 4,752 square miles. Of

the total land mass in Gila County, 55% is federally owned, 40% is owned by the San Carlos,

Tonto and White Mountain Apache Nations, 1% is State owned, and only 4% is considered

privately owned and operated. Gila County's landscape runs from Saguaro desert vistas in the

south to Ponderosa Pine covered mountains in the north. The elevation ranges from 2,123 feet at

Roosevelt Dam to 7,153 feet at Mount Ord. This provides vast expanses of wilderness areas and

creates two distinct geographical areas each having its own distinct weather system and lifestyle.

(Hirano, 2010). In addition, the driving distance between the two biggest population centers is 80

miles and takes on average 1 hour 30 minutes travel time to get to one or the other.

Gila County residents have a significantly lower medium income as compared to the rest

of Arizona residents. They are also less likely to have college degrees and tend to be older. There

are distinct differences among the population within the county, the most notable between

Payson and Globe/Miami. Payson residents are almost twice as likely to be over 65 years of age

in comparison to Globe/Miami and more likely to have a high school diploma. (Hirano, 2010).

In essence, the population tends to be poor with a low household income is split between two

separate areas 80 miles apart from each other and resources for public health services have

declined 40% in Gila County since 2011.

As the director, my mission is to provide the best possible services to the residents while

trying to protect them from disease and injuries. With declining resources and increasing

community needs, I will discuss the challenges and decisions that I had to make to change the

EH, CD, and PHEP programs to meet the expectations of my elected officials, county manager,

and community stakeholders.

Discussion

Environmental Health

A typical environmental health department conducts food safety inspections, septic

system installations, investigates foodborne, waterborne, and vectorborne illnesses, and responds

to public health related property complaints. In 2014 my board of supervisors adopted the FDA

2013 food code making Gila the 2nd county in Arizona to adopt the latest food code. Over the

past 8 weeks of my practicum my team of two registered sanitarians and myself worked on two

large projects together: 1) reviewing and evaluating our current food program to begin paving the

way to adopt the FDA Voluntary National Retail Food Regulatory Program Standards, and 2)

rewriting our policies and procedures to align with the new 2013 food code.

The FDA Voluntary National Retail Food Regulatory Program consist of nine standards

which in its own way is similar to the national accreditation process for local health departments

or joint commission accreditation for hospitals (FDA, n.d.). Each standard is intended to enhance

or change a current food safety program in a local health department to be more uniform and

increase the effectiveness of the licensed sanitarians performing the food safety inspections. In

addition, the voluntary standards promote workforce development and specialized training to

increase the sanitarians skills on how to handle foodborne illness investigations and conflict

resolution.

In the first week of my practicum I attended the National Environmental Health

Association (NEHA) annual meeting in Orlando Florida where I was able to participate in

voluntary food standards presentations by John Marcello of the FDA. In addition, a key part of

attending these national association meetings is to network with other professionals across the

country who may be going through similar situations or have solutions to issues I am seeking

answers to. I was able to meet several environmental health directors who provided me with a

road map on how their departments incorporated the voluntary standards into their food

inspection process. Since the NEHA meeting I have scheduled meetings with my two EH staff

every week to begin reviewing each standard; and, once that is complete we will create a

strategic plan and begin implementing the changes into our food safety program.

Toward the end of this practicum my environmental health staff and I met for one day of

strategic planning and incorporated the FDA voluntary food standards into our national

accreditation deliverables and food inspection program and will begin to hold stakeholder

meetings in October 2016 to work with industry while we make the changes. In essence, we will

be moving to a risk-based food inspection with no scoring or grade given to the food

establishments and our inspectors will focus on the behavior of food preparers. Also, my staff

and I have begun weekly meetings to update all of our internal policies and procedures to make

sure they are aligned with the 2013 FDA food code. Once the policies and procedures are

updated we will then create a “EH Field Guide” as a reference for staff and managers to use in

their daily activities or in case of employee turnover.

EH Managing Observations

Managing EH, even a small program like mine can be tricky. The inspectors are asked to

go into a restaurant or on private property to identify health hazards and ask the owners to

correct those. Communication between the sanitarian, homeowner, and/or restaurant owner is

vital and can break down at any given moment. If the employee uses bad body language or poor

word choices, what can be a normal conversation about correcting a few things can turn into a

verbal fight and end badly. I meet once a week with my sanitarians and talk about

communication, body language, and being able to read a situation to avoid conflict. My staff is

probably tired of these meetings, but we have gone from receiving dozens of complaints each

month about our inspections to only two in the past year.

Even though in most health departments the environmental program is small, sanitarians

are a valuable asset to the community. They conduct communicable disease outbreaks

investigations and any other type of unusual situation such as, hazardous materials complaints,

environmental contamination issues, and neighbor complaints. Most of their time is spent in the

field communicating with the public so they can become the eyes and ears of a community.

I put a lot of trust into my employees and I see my role as the director of environmental

health more of a supporter for my team. As a group, we all agree to the overall goal of the

program and my job is to provide them with the support (training, supplies) to reach the

objectives. Also, EH staff spend most of their time in the field and as such, to be an effective

leader a manger should spend time in the field with the inspectors to build relationships and get a

better understanding of their responsibilities.

Communicable Disease

A communicable disease outbreak can occur in a community at any time and local health

departments are charged with investigating these outbreaks and preventing further spread of the

disease. Arizona has four counties that border Mexico and issues such as immigration, illegal

drug trade, insect borne diseases, and living conditions in Mexico pose significant public health

issue for the residents of Arizona. Currently, the state of Arizona is experiencing a higher

incidence of Dengue Fever and Chikengunya, mostly near the border of Mexico. Both diseases

are mosquito borne and endemic to Mexico until recently when infected mosquitos have been

discovered in many Arizona towns and villages.

During my practicum, the health directors from around the state met several times to

discuss the creation of a statewide surveillance system with limited resources. It was agreed that

all border counties would increase their mosquito surveillance program and the state health

department would provide the tests, traps, and laboratory supplies to the local departments to

help. Also, what I thought was a stroke of genius, an employee for the state health epidemiology

department came up with the idea of getting high schools involved in the surveillance program.

The idea is to provide all participating high school science classes in the border counties supplies

to start a mosquito surveillance program on the school grounds and the teachers would be able to

use that as an assignment and laboratory work for students. This program is currently being

implemented and the response from the high school science teachers has been overwhelmingly

positive.

Communicable Disease Management Observations

Communicable disease is much different than many direct service programs found in a

local health department. Most of the time spent by a communicable disease specialist or

epidemiologists is in front of a computer entering data into statewide databases or on the phone

tracking down potential contacts in a case. Therefore, the biggest challenge I have is to keep my

communicable disease specialist (CDS) challenged and engaged in her job. I do this by offering

to send my CDS to her choice of an annual conference each year and allow her the flexibility to

work in other public health programs to increase her knowledge so that someday she may be

prepared to become an effective manager. I firmly believe the number of employees who leave

for better opportunities can measure the success of an organization.

Public Health Emergency Preparedness (PHEP)

If it’s one program in public health that tends to be overlooked, public health emergency

preparedness (PHEP) would probably be that one. Yet, it is one of the most important programs

charged with preparing entire communities to respond to manmade and natural disasters. During

my practicum I was fortunate enough to receive additional CDC Ebola grant funding which I

used to hire a designer to create a new preparedness website for Gila County (readygila.com).

This website will allow my department to communicate with the residents before, during, and

after an emergency and provide them with valuable information. In addition, five months ago I

received Homeland Security funding to purchase a communitywide notification system

(http://www.everbridge.com/) which will provide additional methods to communicate to entire

communities during an emergency and we will provide links to this system on our new website

starting in November of this year.

PHEP Management Observations

Last year, due to budget reductions, I eliminated my emergency manager position and

combined PHEP and EM into one program; and, that has been far more successful than I

originally thought. I currently have four employees who make up our EM/PHEP program and I

have had to provide very little direction or oversight to because they have so much to learn about

in both programs that they seem to be busy every second of the day and appear to be my most

content group of employees. Both programs are funded 100% by federal grants and at the

employees request I moved more resources into travel and training to allow them to participate in

emergency preparedness exercises in other jurisdictions. I have been impressed with the

improvements my staff has made to our EM/PHEP program and many of the changes came from

participating in exercises along with organizations. Sometimes the best way to manage a group

of high producing employees is to stay out of their way.

Personal Assessment

My practicum was a very positive experience. I realize that as the director a local health

department I am in a different position than many other students who take part in Concordia

University MPH program, however, through this experience I have learned a great deal. It has

allowed me to re-evaluate some of my managing techniques and refocus my attention on our

environmental health, communicable disease, and public health preparedness programs, which

have been a lower priority due to other personnel and political issues. In addition, this practicum

has allowed me to increase my core competencies that are a set of skills for the public health

professional defined by the ten essential services of public health. According to the CDC’s

National Public Health Performance Standards (NPHPS), the ten essential public health

competencies include (CDC, n.d.):

1. Monitor health status to identify and solve community health problems.

2. Diagnose and investigate health problems and health hazards in the community.

3. Inform, educate, and empower people about health issues.

4. Mobilize community partnerships and action to identify and solve health

problems.

5. Develop policies and plans that support individual and community health efforts.

6. Enforce laws and regulations that protect health and ensure safety.

7. Link people to needed personal health services and assure the provision of health

care when otherwise unavailable.

8. Assure competent public and personal health care workforce.

9. Evaluate effectiveness, accessibility, and quality of personal and population-based

health services.

10. Research for new insights and innovative solutions to health problems.

I believe that a profession in public health is a continuing learning experience.

Understanding how the ten essential services fits into each program and creating a culture of

openness and learning among employees will produce a strong cohesive organization where core

competencies will be a by-product of that environment. During my practicum there are different

competencies I utilized for each program. When my team was reviewing and updating our food

protection policies and procedures we were gaining skills in core competency number 5, develop

policies and plans that support individual and community health efforts, and number 6, enforce

laws and regulations that protect health and ensure safety. Enforcement of public health

regulations is never a popular topic of discussion, especially with elected officials. However, in

environmental health enforcement is a key component of preventing foodborne illness,

vectorborne disease, and environmental contamination of communities. Understanding where the

governments powers of enforcement are derived from and creating a process within the court

system to bring a homeowner or food establishment owner in front of a judge for failure to

correct violations is necessary for all EH employees to learn to be successful.

Working with my communicable disease specialist and clinical staff during this

practicum I utilized numbers 1, 2, and 8 of the ten essential services to build mine and my staffs

core competencies to address the growing risk of Dengue Fever and Chikengunya in Arizona.

Part of a successful communicable disease program is to monitor the health status and trends of a

community. First, in Gila County we do this by utilizing data provided to us by the State of

Arizona Health Department and import that information into a GIS mapping system to monitor

health issues in our communities. Second, when there is a reported disease our communicable

disease staff is responsible for investigating the issue along with any health and safety problem

in the community. Lastly, to be of value in our community, I believe in providing the best

training available to my communicable disease staff so I am assured they we are all competent

and up to speed on all emerging infectious disease issues. Therefore, at the request of my

employees, they have created a workforce development plan that will provide them with the

training and skills to become better communicable disease specialists. I approved this plan

during my practicum and will provide the necessary financial resources needed for my staff to be

successful.

Public health emergency preparedness is a program that cuts across most of the ten

essential services and during my practicum we worked on several projects that specifically

utilized numbers 3 and 7. By creating a new preparedness website we provided a new format to

inform, educate, and empower people of Gila County to be aware of the hazards which exist in

their communities and steps they can take to become better prepared in case of emergencies. This

website links people to services and during a crisis will provide information to our residents

where to access health care and other services.

Conclusion and Recommendations

I am blessed in my personal life with a beautiful wife of 25 years and two intelligent

children who make their parents proud, mostly because they are giving, caring people.

Professionally, I am fortunate to have been offered the opportunity to be the director of a local

health department and asked to rebuild a broken system to refocus on the people of our

community to help improve their lives. Throughout Concordia’s MPH program I have had

instructors from all walks of life with different perspectives of what public health is, and for 8

weeks in each class I have learned from their experiences. This practicum is the culmination of

utilizing my experience and being taught new skills by my Concordia instructors to improve my

management skills and be better equipped to improve public health in Gila County.

During my practicum I worked on projects with my staff from environmental health,

communicable disease, and public health emergency preparedness. My environmental health

inspectors will be rewriting all of our policies and procedures for our food protection, vector

control, and property maintenance programs to align those with current state codes and county

ordinances. This will be important to the future protection of the residents in Gila County as my

team creates a legal system to prevent the spread of foodborne illnesses and vectorborne diseases

by enforcing public health standards and state statutes.

Meeting with my communicable disease staff to address the growing concern of Dengue

Fever and Chikengunya in Arizona made me realize why I love public health so much. My staff

created a simple plan of attending weekly phone conferences with the state health department for

updates and is in the process of creating a series of press releases which we will post on our new

preparedness website and Facebook page to inform the public and increase their awareness of

these mosquitoborne diseases. I was impressed by their teamwork and simple proactive solution

to this issue and have learned that sometimes the best way to manage people is to be quiet and let

things happen naturally.

Finally, last year when I had to eliminate my emergency manager due to budget cuts I

decided to combine PHEP and EM and was unsure how my staff would react to the complete

change in program deliverables. However, spending time with my PHEP/EM staff during this

practicum showed me I have very motivated and creative employees willing to tackle tough

issues and work on improving preparedness in our community. I approved their plan for a new

preparedness website and the result was awesome. We now have one of the most interactive

preparedness websites in the country.

I have worked with many different types of managers over my career, some good and

some bad and I have taken away lessons learned from both styles. As the director of a local

health department with 45 employees my advice for someone who wants to move into

management is to trust your employees that they will make the right decisions and provide them

with the resources to be successful. There will be employees who abuse that trust and even put

you in a position where you may question your own judgment, but don’t let a few employees

change who you are or how you treat others. Public health is constantly changing in how

programs are funded or administered, but helping others in need is still the most important part

of public health; and, that has not changed.

Appendix A

Practicum Materials Developed

ReadyGila Website (www.readygila.com)

New Food Inspection Form

AZ EH Statutes

AZ EH Statutes

Dengue/Chikengunaya

Practicum Evaluation by Supervisor page 1:

Practicum Evaluation by Supervisor page 2:

References

Center for Disease Control and Prevention. (n.d.). Ten Essential Services. Retrieved August 14,

2015 from http://www.cdc.gov/nphpsp/essentialServices.html

Everbridge. (n.d.). Everbridge. Retrieved August 10, 2015 from http://www.everbridge.com/

Gila County. (n.d.). ReadyGila. Retrieved August 10, 2015 from http://www.readygila.com

Hirano D. 2010. Health planning report for Gila County, Arizona. Tempe, Arizona.

National Association of County and Cities Organization. (2013). Retrieved July 22, 2015 from

http://nacchoprofilestudy.org/wp-content/uploads/2014/02/2013_National_Profile021014

.pdf

U.S. Food and Drug Adminstration. (n.d.). Voluntary National Retail Food Regulatory Program

Standards – November 2013. Retrieved July 27, 2015 from

http://www.fda.gov/Food/GuidanceRegulation/RetailFoodProtection/ProgramStandards/

ucm245409.htm