11/06/2002
i",
(C
e
New Hanover County Health Department
Revenue and Expenditure Summary
September 2002
Cumulative: 24.99% Month 3 of 12
-Ii,
.
.
ReveDua
Type 01
Revenue
Budgellld
Amount
Current Year
Revenue Balance
Elrned R""'"lnln9
%
PrIor Y..r
Bud98l8d Rlvln.. 8I18n..
Amount Elm'" R8fIl8lnln
%
249,238
623%
23.91%
19.64%
IDIVIOI
20.35%
32.43%
17.47%
F8d1St818
ACF_
MldIc8ld
Mldlc8ldMIX
EHF_
HeaIIh F_
0th8r
1,723,208
533,1)44
1,035,386
143,954 $
138.743 $
179,573 $
1,579,254
394,301
855,813
$
$
$
80.613
127.473
187.943
$ 1,213,437
$ 405,571
$ 773.991
-
~
EXpeDditures
e
Type 01 Budg818d
ItuI8 Amount
Exp8ncI8d
Amount
B8l8nce
Remaining
%
Iludg8I8d
Amount
Prtor V881 FY 02
Exp8ncI8d Il8I8nc8
Amount R8fIl81n1ng
%
CUIY8nl Y881 FY 03
-- ~
Summary ..L
Budgeted Actual %
FY 02.03 FY 02.03
expenditures:
Salaries & Fringe $ 8.969.404 $1,878,780
Operating Expenaes $ 1,919,004 $ 405,523
Capital OuUay $ 181,964 $ 1,548
Total expenditures $11,070,372 $2,285,849 20.65%
;
Revenue: $ 5,196,885 $ 893,799 17.19% \
Net County $$ $ 5,873,487 $1,392,050 24.70%
e
Revenue Ind Expenditure Snmmary
Fiscal Yelr 03
As of September 30, 2002 9
,
"Il
.
.
.e
e
e
Oats (80
111612002. _.
1012120ci2.
9/412002
BnI2002
71312002
6/512002
51112002::". ""
41312OO2"Fi....c.'..
3I6l2OO2
21612002..' "
1/212002 .
12/512001
111712001
9/512001
, ,,"'.:., .
8/112001
". '.
7/1112001
I' .
NEW.HANOVER COUNTY HEALTH DEPARTMENT..
BOARD OF HEALTH (BOH) APPROVED
GRANT APPLICATION STATUS FY 02.03
.. Griliil.;:.:.:,:..... "".,.:." ,
Ma~~of Dlrn"c;ha~r Community GrantB. .
PRJeC1':STOP ($50;0Cl0) . . .
~ K1c18BuckleUpProgram-Norlh cCarolina
Siitei<ldi> '.. . . .
Developing Geographic Information Systema
(GIS) Capacity In Local Health Department In
Eaa18m North Carolina-Duke University
Nichola School of the Environment end Earth
Sclence8 (NSEESl
Totala
Pendlna Receivecf . DeiII8d :
.. .
$50,000:/ .'
. 5,000 . ," drJ() . ....
Reaueal8d
'.' $50,000
,
$5,000
$18,000
$18,000 .
.".~
'.C"" H', .. .
.;. '.' c.'
...... ",., ".,.' :,...,....,.'
$60 000
$11,800
$350
$10,000
.,"
$16,500
$16618
$30 000 $30 000
... .
$11,800
$350
$10,000
,. ..'
$16 500
$3000 $13318
$500
.:..:c.... ."
. .
No activItY to ",DOrt SeDtember,2002
No actlvltl(,toreDOrt for Auguat 2002
No ac:tIvItY,toNpOrt for'July 2002;
Prenatal Health Education and
InformatlonIReferral Services- March 01 Dimes
Communltv Grant Program $49,975 $49,975
.....~ili!~for.MIIY..'."'.::..' . ,.'. . . ,. "'''': '....
,1IiO"~'1!!NpOrt:fOi'AprII'2002;:'L;::;'l. T.. _~. .'.'"T. ".. ,.,.. ':',:C"
'. ~.8c:tIiiIlr1D"~:torIl8n:b2OO2;":':': '", ' . ...... ., , ..
tjo ac:tIvItYtoNpOrtfor.l'ebii.a,y2oo2. . i. ..' . .
HollCtl1illJjO .NPdri'toiJilnlla.y2002," cc.....
Diabetes Education, Management and
Prevention - CFMF
t'.""'i.','",.'':--,:-.:.".,
Youth Tobacco Prevention ProJect- Robert
Woods Johnson Youth Center
Teena Against Tobacco Uae (TATU)-Heallh
AclIon CouncIl of NC
~~rollnla_~~DH~S" .'i' ',..
Family Asseaament Coordination- March
of DlmB8
Folic Acid Prolact- March of DilnB8
Safe KIda Coalition- State Farm"Good
Nelahbor" . $500
..~.:"..;,:...':'" ....: '.'2"'i. ....i,:.::,: ,.:....
TB Elimination and P",ventlon - CDC,
NCDHHD, DPH. TB Control pmaram
Teen Aida Prevention (TAP\- CFMF
:':,...,'":,",'",.:,,,::.., ",..:' .
Diabetes Today - Diabetes Prevention & Control
Unit, NCDHHS
Lose Weight Wilmington - Cape Fear Memorial
Foundation
.' " '.'
$10.000
$45,500
.:.f:
$ 9,200
$25,000
"i.."':;')c:,'"
$800
$20 500
...."...".i'.
$10.000
$10,000
$75,000 $75,000
$:479,243 . $104,975" $117.850., "$158,118
27.66%
Pendina GranlB 3 20%
Funded Total Reaueat 6 40%
PartlaiiV Funded 4 27%
Denied Total Reaueat 2 13%
Number of GranlB ApDlied For 15 100%
As of 1012312002
. NOTE: NotIfIc8lion received since IasIlllport.
31.08%
41.17%
10
e
e
e
..
\-\ E"c9 Ii-~
NEW HANOVER COUNTY BOARD OF {uJU'\MIE";1. ..5
REQUEST FOR BOARD ACTION
Meeting Date: 11/1!t.02
Department: Health Presenter: Elisabeth Constandy, Health Educator
Contact: Elisabeth Constandy, 343-6658
SUBJECT: ' (tIP f fa r -to r -rn tee j uM ')
Grant Application for $10o,oooFm ~e North Carolina Health and Wellness Trust
Fund Commission Teen Tobacco Use Prevention and Cessation Program
BRIEF SUMMARY:
We are requesting Board of Health approval to apply for a $100,000 grant from the North Carolina
Health and Wellness Trust Fund Commission (NCHWTFC) for a Teen Tobacco Use Prevention and
Cessation Program to contract with New Hanover County Schools, UNCW, and other Community youth
organizations to provide more intensive youth tobacco prevention programs.
The grant Is for $100,000 per year for each of 3 years. The Health Department will contract with NHC
Schools to hire a Tobacco Use Prevention Education to be housed within the school system to provide
direct contact, service, and consultation to students and faculty.
Attached Is a more detailed summary and a budget page.
RECOMMENDED MOTION AND REQUESTED ACTIONS:
Approve grant application and associated budget amendment if awarded.
FUNDING SOURCE:
ATTACHMENTS:
8 pages-an Executive summary and budget page, and a 6 page request for proposal.
11
I'
"
.
e
e
North Carolina Health and Wellness Trust Fund Commission Teen Tobacco
Use Prevention and Cessation Program
Community/School Prevention Programs Initiative
Executive SummarY
The New Hanover County Health Department will be applying to the NC HWTFC
to fund ongoing youth tobacco prevention initiative in New Hanover County.
NHCHD has hosted the New HanoverlBrunswick Project ASSIST Coalition since
its inception a decade ago, and has proven to provide consistent quality
leadership in this role for both counties. For the purposes of this grant
application, NHCHD will be applying for funding for NHC only; Brunswick will be
submitting a separate application. This decision was based on funding
guidelines, not due to lack of cooperation or agreement.
NHCHD is requesting the full grant amount of $100,000 per year for 3 years, to
contract with NHC Schools, UNCW, and other community youth organizations, to
provide more intensive youth tobacco prevention programs within the framewor1t
of the organizations listed. NHCHD will contract with NHC Schools to hire a
Tobacco Use Prevention Educator to be housed within the school system, to
provide direct contact, service, and consultation to students and faculty.
There has long been a demonstrated need for a more comprehensive presence
in the school system regarding tobacco use. Many programs, such as
Alternatives to Suspension, Tobacco Awareness Month, Teens Against Tobacco
Use, and the Not On Tobacco cessation curriculum would have been much more
successful had there been a point of contact within the schools to coordinate the
events and initiatives. There are many avenues that have not been explored due
to the lack of time and resources, that this position and initiative could more
effectively address, most notably the Tobacco Free Schools Initiative, for which
NHC has received much publicity, and the establishment of Tobacco Free
student organizations and programs.
In addition to the 1 FTE within NHC Schools, NHCHD will contract with UNCW
Crossroads Co-Op Substance Abuse Prevention Program's peer educators to
help facilitate campaigns such as Social Norms and student focus groups, and to
provide technical assistance on trainings for the Alternatives to Suspension and
Teens Against Tobacco Use curricula. Coastal Horizons Center is available to
contract for ~n services, both for youth that desire cessation ~Od for
faculty and staff of NHC Schools.
Additional partners have been identified for this grant, including the Community
and the Brigade Boys and Girls Clubs. Project ASSIST Coalition activities will be
supported by the HWTFC grant funds to expand prevention services to these
12-
agencies, such as awareness campaigns, media advocacy, and underage youth
access to tobacco activities. Locally, New Hanover County has benefited from
the Question Why Youth Tobacco Center, house at Wilmington health Access for
Teens. That program is available for additional technical assistance, skills and
capacity building exercises, and presentation purposes.
Please refer to the Draft Budget below'
1 FTE Tobacco Prevention Coordinator
New Hanover County Schools
(Salary and Fringe)
UNCW Crossroads Cc>-Op
Technical Assistance and Training
$50,000.00
$2500.00
Social Norms Campaign
(Including data collection, printing, travel,
and distribution of results)
Coastal Horizons Center
Cessation Classes, group quote
($500 per group; per year adult
5 per year youth)
Program Costs:
$7500.00
$5000.00
Tobacco Awareness Month for NHC Schools
(incentives, advertisement, supplies)
$15,000.00
Start-Up Stipend for School Based Clubs
($1500 per school, estimated 3 per year, to
purchase supplies and educational materials,
develop logos, ete)
$4500.00
Coalition Advertising and Media Costs
(radio spot development, studio and production costs
for youth developed media, air time) $10,000.00
Training and Travel Costs
$5500.00
TOTAL
$100,000.00
.,
e
e
e
13
.
e
e
.;
North Carolina Health and Wellness Trust Fund
Commission Teen Tobacco Use Prevention and
Cessation Program
CommunitylSchool Prevention Programs
Initiative
Request For Proposals
P!1rpose
The Health and WellDess Trust Fund Commission ("Commission") mmounces the availability of
grant fnnding dming calendar yeaIll2003-200S to expand and ....banee the stateWide effort to
prevent and reduce teen tobacco use. Funds will be provided to local commllllity.agencies,
schools, state agencies,local government or other political subdivisions of the state and nonprofit
organizatiODS for inilialives that seek to:
. Prevent youth initialion of tobacco use,
. RUminate you1h exposure to environmental ("seconrlhantl") tobacco amokl:,
. Provide tR'Dtm""~ options for llleDS who want to quit. and
. RUminate health disparities among minority youth atttibu~le to tobacco use.
These goals me linked to a document entitled: VISion 2010: Comprehensive Plan tD Prevent and
Reduce tM Health Effects ojTobt:u:co Use. published by NC Tobacco Prevention and Control
Branch, NC Depaxtment of Health and Human Services. This document is available on the web
at www.communitvhealtb.dIlbs.state.nc.us.This plan ~lished ~ty and schOol-based
initiatives as a comtIStone of an effective effort to prevent and reduce the negative heaIIh efIilcts
of tobacco use,.wiIh an P.I1Ip1wriA on evi~based policy intmventions. ..
Background
Tobacco use is the nnm...... 0IIIl preventable cause of premature death aod disease in NoIth
Carolina and the nation (U.s. Department of Health and Human SerW:es, 2000). Tobacco use
conlribubls 10 II101i than 14,500 deaths annually among adulllI in the North Carolina (NC
Department of Health and Human Services, 2001). While cigarette smoking among adulllI
cl...dinP.dbd.ween 1965 and 1990, tobaa:ouse by you1h increased in the 199Os, andonlym:ently
experienced a slight ,w,lin... (NC Department of Health and Human Services and NC Department
of Public Instruction, NC Youth Risk Behavioral Survey (NC YRBS) and NC Youth Tobacco
Survey (NC Yl'S. 2001). Mme startling, the Centers for Disease CoDlrol and Prevention (CDC)
has clearly docwnented that among adults who have ever smokJld daily, over 9QIjf, of fitst-
tobacco use occum prior to age 20. The average age of initiation far tobacco use is 13.
.
14
~
The NC Yl'S. contInrtM in the fall of 1999. shows that 38.3% of high school students and 18.4%
of J1Iitldl.. school stndents cmrently use a tobacco product (cigarettes. spit tobacco. cigaIs or
pipes). Tobacco use increases by grade level: 10.6% of 6Ih gradem compared to 45.2% of 12m .
gradm report to be .......<all tobacco users. Su8Ce{'tibility to smoking also increases with age:
33% of mitld1.. school stodents and 44.7% ofhigh school stodents were detemlined by survey
response to be mOIe susceptible to initiation of tobacco USe.
General Guidelines
Grant appH""ntR are encouraged to consider adapting existing program models. where feasible,
and to considerinl:Olpnnotillg strategies from the Centers for Disease Control and'PreventiDn
(CDC) Best Prw:licesfor Comprehensive Tobacco Control Progr(llm, which can be found at
htto:llwww.cdc.l!ov/tobaccoJbestorac.htm. Applicants should also consider addressing the
Healthy People 2010 risk reduction objectives with regatdto tobacco use
(httno/lwww.health.l!OvlhealthvoeonleJdefault.html.Alistofrelated websites is provided below
as a Iesource for reviewing pertinent infonnation.
Natinnlll'
. www.tobaoco~1ndA.om
. www.cdc.l!OV/tobaoco
. www.tobacco.nen.edu
. Www.tobaa:o.wholnt
. www.cdc.l!Ov/tobaccoslZJ..Dalre.htm
. WWW.eoLl!OVliaalellJ .
. www.nd nib.2OV
. www.ama':issn.omIsmolrelessstates
. www.lun,,"u omItobacco
. www.Dhs.b........eduJssholrwi/rwi.htm
. httn:llwww.cancer.OII!
e
North Cuolina:
. WWW.8tIAJ.uuDC.1Y\I.It
. www.extlcltobaa:o.com
. www.N.mIrmmitvheaIth.dhhs.state.nc.us (Includes the Tobacco Prevention and Conlrol
B...........)
. www.ncbealtbvschools.onr:
. www ~dion.onr:
. www.ncDIeVentic.UllUltuers.om
The Program
. W1w MGJ' Appl]
Under the NC General StalUtes, an organization is eligible to receive a grant from the
Cnmmiui.on ifit fits into any of the following categories:
- A state agency,
e
15
.
e
e
.;:.
_ A local goV"'"'1TlP.I1t or otbe:r political subdivision of the state OI a combination of such
eutities (lI1C'lJvlH Iocal education agency andIOI public charta: schools), and
. A nonprofit OIgll"i7Arinn which bas as a si~an1 pw:pose promoting the public's health,
limiting you1h aa:ess In Inbacco products, orreducing the beaIIh consequences of tobacco
use (includes any nonprofit mganization intel:eSted in preventing and reducing teen Inbacco .
use).
0theI entities interested in reducing use of tobacco products may apply in partnership with an
eligible OIgl'm7mon which is functioning as the lead applicant fOI the gnmt. This lead.applicant
heals responsibility fur fisCal and overall management
An Oveniew oJthe Schools/Community Teen Tobtu;co Use Prevention and Cessation
lniliotive
The CommUDitylScbools Prevention Programs Initiative will consider grants from applicants fur
the fonowing pu1pCllICS:
. InItiate new eon..nnnlqrJscbool partnerships and eoUaboratiODs. J1 is anticipated that
gnmts will be awanled to applicants that are stmctured as follows:
o Lead Auolicanl Onnmization: Typically, a public health mganization OI
local education agency OI public chaIteI school, 1his en1itybeamthe
responsibility fur overall program and fiscal management.
Anolication PartneIshin: This is a foImal agreementamcmg oommnni(y-
based OIgaDizations, including the lead applicant, to implement the
proposed program. These OIganizatiOns !lIe listed as co-applicants, and
could include public beaIIh OIgl'nhatioiis,local education agencies, public
charta: schools, youth mganizations, voluntaIy agencies, non-profits, faith
communities, and substance abuse programs, IlIIlOIlg otheIs.
Collabor!!tinl! OmanizatiouslIndivid1i.lo~ The Commission enCOUIllgCS the
broadest possible coalition-building ~ong divemeorganiZations,
dedicated ~ achieving the goals of thiS Initiative. Collaborating entities
may include, but are not limited to, cxunmnnhyOIgllDizations and
individuals such as heallh care providers, concemed vob>nt"""'l, and
parents who m:e committed participants in the proposed progIlIIIL These
P!IItiri... m:e not listed as co-applicants.
. BuRd on Pdding efforts, Funds will also be available to OIganizations cum:ntly
conducting IDbaa:o use prevention activities, fur emh""""meut of those activities. It is
anticipallld that most of these enhancement gnmts will be awarded to applicants that are
structured as desc:rlbed above. Applicants that cmrentlyoperateindependent1ym:e
strongly eDCOIIIIIgCClln seek community partneIS as well as co11aboIating mganizations
and individuals.
. SClmlllateJonowClon In teen smoking prevention. The CommilUlion will also consider
applicatilmo from eligible mganizalions proposing innovative new approaches to prevent
and recInce teen tobacco use.
o
o
How Fruuls Om. Uud
Each Community/Scbools Prevention Program GIant recipient must use the funds to cauy out
activities that support the following goals. The stIategies listed below each goal/objective m:e
16
I-
;.
en"'PJll'l provided as gmdmW to pt applican1S. Applications should be based on locally
id-rified needs.
GoAL 1: P1tEVENT YOUIB INn'IATlON OF TOBACCO USE
OBJBCTIVES:
1. Increase the proportion of young people In middle school and bigb school tIlat have
never smoked. -
2. Increase the proportion of school districts tbat are 100% fob_free for aU
students. staff and visitorsoD aU school property at aU times (the model 1009&
tobacco-free school policy prohibilS tobacco use fur stl/dents, staff and visitom on aU
school ptOperty at aU times in their local education agency).
Strategies:
1. &q.u...... )'01Ilh In function as advocates for Inbacco use prevention programs and
pnll1'..... .
2. Promote etIective tobacco use prevention policies in schools and cxunnnnrin...,
3. Empower)'01llh'andadultro1e models In advocate fur 1009& tobacco-free school",
4. Generate pro-healIh media coverage, both to stimulate and poblicize youth-led
iutta .oa4ions,
S. Raise a_ of the dangers associated with tobacco advemlring that is taJgeted
towaIds youth,
6. Assure a .......1"eblmsi.ve approach to Inbacco use prevention in schools
(www.commnnltvheallh.dhhs.stam.nc.us). and
7. Pro~ote and ouwu4law enforcement efforts In reduce youth access to Inbacco products.
GOAL 2: SlGNIIl'JC&NTI.YREDUCE Y011l'll EXPOSURE TO ENVIRONMENTAL ("sECONDHAND")
SMOD
OBJBCl'lVES:
1. Increase the proportion of school districts tbat are 100" fob_free for aU
students, sCaff and visitors on aU school property at aU times.
2. Increase smoJr.e.free poUdes In both indoor and outdoor areas ftequentedby youtb,
such as: nstanrants, bowling alleys, maDs, movie theaters, homes, Parks.
am__t areas, and baR fields.
Strpt'lgl-'
1. Provide ecin<'Arinn on the heallh hazards of secondhand smohl, especially exposure of
children and adolescenlS in their homes, including asthma-related health rlsb,
2. Develop smote free policies for bolh indoor and outdoor areas freql1eJlted by youth,
.
e
e
17
.
I, .:;.
.
3. Earn pro-bea1th media coverage. includiug editorials. for youth programs 1hat reduce
secondhand smnb'~ and
4. Raise public a.._..dICSII in undenerved racial. ethnic, age and income groups 1hat are
more adveaely ~ by secondhand smoke.
GoAL 3: PRoVIDETREATMENT omoNS FOR YOUTBWBO WANT TO QUIT
OB,JECTIVllS:
. 1. Decrease the number of middle school and high school students who smoke
dgarettes.
2. Decrease the number of middle school and high school students who use smokelas
tohacco (spit tebacco) or any other form of tobacco.
3. Decrease the proportion of pregnant teens who smoke.
Strat~
1.
2.
e 3.
4.
S.
6.
7.
Promom and provide access to effective cessation and tre...",....t options.
Promote a cuItma1ly and linguistically IIP1"up.ciate NC Quit line and on-line quitting
Program (to be utllblished by the Commission).
Coordinate and promote the Not-on-Tobacco (N-O- 1') teen cessation program in schools
and community sPJri"8ll (program to be provided by separate Commi&sionfunding).
Empower youth as peer counse1OIS for cessation,
Bun pro-health media Coverage and editorials promoting cessa1:inu,
Provide tJ'Rinlllg and tedmica1 assistance for medical/dental offices to prioritize effective
cessation and f7-1m""t opIi.ons, and
Support voluntary initiatives from private and public insmeIlI to expand coverage for
smokiDg~~_t~"'"
GoAL 4: REDuCEllEALm DlSPARn1IlS AMONG MINORITY (AFRICAN AMERICAN,
BlSPANlc/LA.TINOS AND NA11VE AMERICAN) Y011l'll A'ITRIBUl'~ TO TOBACCO USE
OBJECTIVBS
L Decrease the proportion of minority middle school and high school students who
smoke da;-cUIs.
2. Decrease the proportion of minority middle school and high school stndents who_
smokeless tobacco (spit tobacco) or any other form of tobacco.
3. Decrease the proportion of minority pregnant teens who smoke.
e
18
.;
"
Strategl-~
1. IDcrease divemity of youth JesvI""'. community groups SDd mgl"'i7Ations ICJlI"V"tillg .
nn<lP.nP.rved populations adively involved at the local level in prevention of teen tobacco
UBe,
2. IDcrease the number of schools with large minority populations that adopt a.l~
tobscco-fxee school policy (the model 100% tobscco-1i:ee school policy prohibits tobacco
use fur slndents. staff snd visitOIS on all school p.toperty at s1l times in their loca1
...m.-.tion ageacy).
3. Th1in diverse youth as peer COunselOIS.
4. Develop cn1tnno11y "P}IlOpIiate youth leadership models such as U.lIMA. a youth-led and
adult l>UPpOrted Africsn American model tobacco use prevention program to reach youth.
'Ibe UJIMA program was developed through the African Americsn Action Tesm of the
Tobacco Prevention SDd Control Bmnch. (more information on UJIMA is provided at
www.lltemmDC.com)
5. Empbasize the iDfluence of adult role models on the initiation of tobacco use among
ethnic """,,,,,lnities,
6. Promom 8Dd provide culturally appropriate cessation programs. 8Dd
7. Promote tobsa:o use prevention efforts through pro-heallh media coverage aimed at
specifu: dispaIate populaIions.
Grant Terms
The. Commission will awatd gnmts to. new local programs or to enh"""" existing local pIUlSl........
The awards will mngefrom $2S.000- $100.000 annually, Project funding will beCOlIlIl1llDSlJl -
with the size SDd scope of the proposed activities, Subject to awilabllity of funds; and further ,.,
subject to BDDoal satlsfadery program evaluation and contlnoatlonpIans, the awards wDI
be for three adendar JIllIl'B, 2OlI3 - 2005.
GranJs will be disbmsed as follows: up to 3 months startup funding III the begiftnillg af.the.,
fl11..tillg cycle, folJowedby a monthly advance, bP.gjftniflg with monlh4.. 1bese-monthly
advances will be triggered by submission of monthly reports rl..t,.;lillg expenditures incumld in
the previous IIIOIIlh.
'Ibe Cnmmi,.,.;on e~ to receive more fnftrlillg requests 1I;Ian csn be awarded. Thcuawc,
submission of a gnat application does not guarantee receipt of sn awam. Additionally. grants
that are fimded may not be fimded at. their requested amount. 'Ibe grant size may vmy by
c:iIcumatances. JIll!lCl SDd pl"llllllA model. 'Ibe Commission reserves the rigbt to conduct pre-
awam iDImviews oron-sil8 ass~--".
As a condition of receiving a program grant awam. the Commill.'lion requires that each gmntIle
pBIlici:patll in a ldIIto-1evel outNlmf'Jlstwiy as wen as a monthly program acti.vity tTlIrlritlg system..
Applicsnls..shool4tiudjpdw 4-5 liours/month of staff time fur the progJam activity r.,or1ri1lg
system aad 1-8 homsimol11h of staff time for thestate-level 0IJU'n...... study.
The Tobai:co Prevention snd Control Bmnch (TPCB) will provide tmini1lg and ter.hni""l
assistance in the proper use.of the computer-based activity tracking system sndin submittillg-1he
information for centtsl data processing. As part of the state-level outcomes study, evsluators (to
be selected by the Commission) may require specific reports or information, mske periodic site
e
19
.
.~
,;
e
e
e
STRATEGIC PLANNING PRIORITIES
October 2002 Update
I. Access to health care
(Issues #7,11 & 5)
-+ Success by 6: is a United Way initiative, funded by the Bank of America. This year is a
planning year and Karen Kirk at UW who is organizing community efforts to look at gaps in
services for birth to 6. She is working closely with Smart Starts and the school systems in NHC,
Pender, and Brunswick counties, looking primarily at early literacy The group meets monthly
-+ Family Resource Centers: Yesterday staff from several family resource centers reported on
their work. There is a new family resource center at Greenfield village, many children are
receiving tutoring after school.
-+ 5.5 new school nurse positions approved by BOH and BCC
-+ The Child Health Division has a Workfirst client working in the Child Care Nursing Program
part time, on loan from DSS.
-+
II. Preventive services & lifestyle-related risks
(Issues #12 & 15)
-+ Car Seat Check: There will be a free child passenger safety seat check at the new Monkey
Junction WalMart this Saturday, 9/28, from 9-12.
-+ Adult Tetanus Vaccines: are being deferred again for routine boosters, pending receipt of
additional vaccine. University students are being given documentation to stay in school.
-+ Rabies Update: We received a report from the State of NC regarding a vaccinated cat that
tested positive for rabies virus. Immunosuppression may have played a role in the eat's failure
to respond to the vaccine. Analysis of the virus demonstrated that the virus type was one
associated with bats. A thirteen year old boy in Franklin County, Tennessee, died on August 31,
2002, from rabies. The virus was not suspected as a causative agent for approximately five
days into onset of symptoms, because no exposure incidence was reported. The family was
unaware that bats might be rabid and can transmit rabies virus to humans. Please convey to
everyone you have contact with that bats are the major vector of rabies virus human fatality
cases in the USA. The public must be made aware of the risks involved with handling bats
-+ Tetanus Vaccine: The Tetanus vaccine was received and we have resumed giving the
vaccine.
-+ Flu Vaccine: The tentative date for the start of flu vaccine is October 14.
-+ Safety Seat Check: The Health Promotion Team participated in a Child Passenger Safety
Seat Check this past Saturday, Sept 28, at the new Super WalMart at Monkey Junction. In total,
96 seats were checked, and many recalled seats were identified. WECT will be sponsoring this
as a yearly event due to the wonderful turnout.
-+ To reinforce our need for an Injury Prevention Educator' According to the 200Hraffic Crash
Facts just released by NC Dept of Transportation, New Hanover County still has the dubious
honor of holding the Number 1 spots for Total Crash Rate and Non Fatal Injury Crash Rate, the
number 3 spot for Crash Injuries per 1000 People, and the number 4 spot for Crashes per 1000
registered vehicles. The good news is that we continue to have very low numbers of severe,
fatal, or alcohol related crashes.
-+ WIC Caseload: The New Hanover County WIC Program had 2989 participants during
August 2002. This is the largest number we have had since before 1998. We are at 104% of
our paid caseload of 2854. Most WIC programs in the state are serving between 97-102% of
their caseload. with only two serving 105%. We are doing better than most others in the state.
Congratulations WIC Staff!
-+ Influenza Vaccine: More influenza vaccine has arrived, but still on Iv about 1/3 of our order.
1
,
I'
i'
'Y'"
Public will be asked to defer vaccines for all except highest risk categories until November
NHCHD employees who fit high risk categories (chronic illness) may receive the vaccine,
starting October14 Others are asked to postpone until November
-+ On Saturday, September 21, 2002, frorn 10 AM to 3 PM, the New Hanover County Dental
Staff participated in "St. Andrew's Health Fair" which was held at the St. Andrew's On-The-
Sound Episcopal Church near Wrightsville Beach. "St. Andrew's Health Fair" is an annual
health promotion event held for the benefit of all area residents. The Dental Staff presented a
display entitled "Dental Consumerism" along with information on various topics such as
brushing, flossing, and the prevention of periodontal disease. In addition, Dr David McDaniel
conducted Oral Health Assessments for many of the participants.
-+ October 1 was the start of a new way of billing CSC services and therefore a new way of
providing services as well. Many program changes were necessary to accommodate the new
Medicaid codes. Health Check clinic was suspended for the quarter and some other
assignments were shifted from CSC staff to assist with transition.
-+ Information from the state lab revealed a previously vaccinated cat exhibited signs of rabies
virus infection. The viral serotype detected was from a strain associated with bats.
-+ The New Hanover County WIC Program had 2989 participants during Aug. This is the
largest number we have had since before 1998. We are at 104% of our paid caseload of 2854
Most WIC programs in the state are serving between 97-102% of their caseload, with only two
serving 105%. We are doing better than most others in the state.
-+ Flu Vaccine: Response to flu vaccine has been slower than usual. More news releases sent
to remind public. County employees (other than health dept. staff) may get shots through
Immunization clinic now or off-site two dates in November
-+ Inner City Rabies Clinic: The annual Inner City Rabies Clinic will be held Saturday,
November 9, 2002, from 1-3pm at the Hemingway Center (formerly Five Points Community
Center) at 8th and McRae.
-+
III. Communication, education & marketing (promotion>
(Issue #1 & 4 in part)
-+ WIC Outreach: The state WIC office has developed Spanish language radio outreach
messages which will run 9/25 through 11/02 in Charlotte and surrounding counties, the Triad
area, the Triangle, and mid-south eastern NC. Four different PSA's will cover breastfeeding,
folic acid, lead, and WIC.
-+ AIDS Walk: is Sunday, 9-29-02 at 9am at upper level parking deck. TAP will participate.
Bake sale to raise funds for walkers on Thursday morning (9-26) outside NHCHD Auditorium.
-+ Dog Jog: We participated in the annual Dog Jog this past Saturday at Greenfield Park.
-+ NCALHD Meeting: Was held in New Bern on September 24. Items discussed was the
recently passed State Budget, West Nile Virus, Smallpox Vaccination Clinic Guide, The State
Smallpox plan, the endorsement of the Alpha Numeric food establishment grading/scoring card,
food and lodging fee increases, performance standards for health promotion, and the "Give Kids
A Smile Day" planned for February 21 , 2003.
-+ Coastal AHEC will have their annual info booth set up at our staff meeting on October 3rd,
outside the auditorium.
-+ The child health staff continues to assist families with four year old children with applications
for the More at Four preschool program. Janet McCumbee is on the advisory committee.
-+ Administration and Child Health staff is working on how to resolve issues around
incorrect/incomplete birth certificates. Our registrar is being asked to do many affidavits to make
changes after parents leave the hospital. Discussion has begun with the hospital about working
out the problems.
-+ Janet and the NAVIGATOR program is involved in a community group seeking additional
grant money for more support services in NHC. The collaboration includes Smart Start, Success
by Six (United Way), the Junior League, DSS, Cape Fear Memorial Foundation, the Carousel
Center, and a Child and Family Center in Durham. A local donor would like to see services
replicated here, from the Durham model.
e
e
e
2
.
.,.~'
e
-
-+ PSAs for flu vaccine distributed,
-+ ACS participated in the annual Dog Jog at Greenfield Park with an informational display and
hand-outs for participants.
-+ Intense media coverage brought attention to ACS, when three dogs were shot in the Myrtle
Grove area this past month. The dogs were charging people and had killed two domestic
animals prior to being shot by Sheriff Deputies.
-+ Influenza Season: Flu shots began Monday, 10-14. There was news coverage promoting
the annual kick-off,
-+ NCALHD Meeting: Dave Rice attended the NC Association of Local Health Directors
meeting on October 17 Items discussed were: DHHS Organizational Chart, Community-based
Organizat,ions/Local Health Departments survey, new HIV testing, immunization registry, DMA
monthly bulletin, and an update on a statewide automated information and data management
system for local health departments.
-+ Veterinarian Conference: ACS will hold its second annual Public Health Conference this
Thursday, October 24,2002, from 7-9pm. The meeting is primarily for area veterinarians and
their staff. We have 23 participants signed up so far
-+ Circumcision: Medicaid coverage for circumcision is being questioned, once again,
Correspondence with DMA refers to the Medicaid Bulletin with documentation of possible
changes to be made known in November, 2002.
-+
IV. Facility utilization & Information technology
(Issues #6 & 4 in Dart)
-+ Bar Coding Project: After three years of planning, the Medical Records barcoding system is
finally being implemented. In addition to improving our records management, this system will
also position the NHCHD very favorably for HIPAA compliance, and places us progressively
ahead of many other organizations in the state. We're fortunate to be proactive rather than
reactive to the increased security measures HIPAA will require, However, change sometimes
produces some necessary pain. The conversion team, Medical Records staff and IT have been
working days, nights and weekends to resolve final issues. During the coming weeks, staff in
Communicable Disease, Community Health, WIC, Women's Health, Child Health and IT will be
very involved in the transition to the new system. In order for a successful implementation to
occur, this project must be a top priority in the affected divisions. This week, a software
engineer and other technical support staff will be working in the building, Staff may be asked to
interrupt other work to allow changes to be made to hardware or software, or to answer
questions. Please excuse the interruptions... your patience and cooperation will get us all
through this change for the better!
-+ Chameleon: Animal Control Services upgraded to the Chameleon 32 bit software version
this past weekend. The initial process went smoothly, but we will probably run into a few
computer "glitches" before the changeover is completed.
-+ NHCHD Website: The NHCHD Website had 652 visits in September Our top six (6) web
pages were: Animal Control Services (198), Environmental Health (132), Department
Information (132), Community Health (98), Communicable Disease (84), and Board of Health
(84).
-+ Barcoding Project: Thank you to Staff in CDD, Community Health, WIC, Women's Health, IT
and Child Health for patience while we're working through the barcoding system implementation
issues. Much progress has been made with the technical components over the past 24 hours,
and the remaining trouble spots are being addressed as they are discovered. Once we've fully
transitioned to the new charts and tracking system, the benefits will be significant!
-+ Geographic Information System (GIS): Environmental Health Division received from Duke
University an $18,000 grant for increasing our capacity to utilize GIS, Equipment purchases will
include mapping quality GPS units. Dianne Harvell, Cathy Timpy and David Jenkins will attend
the grant related project workshop and training session Sunday, October 13 through Tuesday,
October 15.
e
3
.
~..
-+ Geographic Information System (GIS): Environmental Health Division received from Duke
University an $18,000 grant for increasing our capacity to utilize GIS. Equipment purchases will
include mapping quality GPS units. Cathy Timpy and David Jenkins are attending the grant-
related project workshop and training session this week.
-+ Auditorium Operable Partitions: Missing partitions should be installed in the next couple
weeks and the handle on the folding door to the kitchen area will be repaired at that time. Stay
tuned and we will let you know when these can be used.
-+
V.
e
Water quality, storm water management & drainage; & Air
ualit Issues #3 & 8
-+ NHCBH Environmental Health Committee: Met on October 3 to consider development of
water conservation measures to be implemented during drought weather conditions. The
regional hydrologist with NCDENR Division Of Water Quality discussed groundwater resources,
and remedies that can be initiated when the static water levels in wells decreases. The BOH EH
Committee decided not to pursue regulation of water use during drought weather conditions as
the limitations are quite different from those systems that rely upon surface supplies as sources
of drinking water
-+ Vulnerability Assessment: Dianne Harvell met with Mike Richardson and other City Of
Wilmington officials last week to begin a vulnerability assessment of the water system. This will
be conducted and completed over the next two-three months.
-+ Requests For Services Peaks: Staff has documented an unprecedented level of requests for
mosquito control services during recent weeks. For a record eight consecutive work day period,
we averaged more than sixty calls daily relative to mosquito control services. Late summer
rains and progression of the West Nile virus outbreak across the country raised well founded
concerns among the public.
-+
VI.
e
Emerging health risks
Issue #13
-+ Bioterrorism Update: State training for PHRST on October 6. Public Health Grand Rounds
on Bioterrorism on September 27 BTL Team met with PHRST on September 24 to discuss
potassium iodide distribution and smallpox vaccination plans.
-+ Lead Samples: The NHCHD Laboratory has submitted 25 lead samples of students from
Forrest Hill Elementary to the State Lab.
-+ Bioterrorism Update: State training for PHRST on October 6. CDC released the Smallpox
Vaccination Clinic Guide.NHC Community Coalition met this morning at NHHN. BTL Team and
PHRST are working on the plan to distribute potassium iodide to the 10 mile EPZ of the
Brunswick Plant. BTL Team and PHRST continue work on the NHCHD Emergency Response
Plan.
-+ Lead Samples: As of Monday, September 30, 2002, 33 lead samples from students at
Forest Hills have been referred to the State Lab. 17 reports have returned and all were well
within normal range.
-+ Bioterrorism Update: State training for PHRST was held on October 6. Some of the
information from Sunday's meeting: Overview of State Bioterrorism Activities was given by Dr
Jim Kirkpatrick; PHRST projected activities was discussed by a panel; PHRST
Communications Equipment Draft Plan was discussed; National Pharmaceutical Stockpile Plan
and PHRST responsibilities was presented; An overview of the Vaccination Plan for NC was
presented; and The Health Alert Network was presented by Bill Richardson. New website on
bioterrorism resources: http://www.nchan.org/BT.htm.
-+ Potassium Iodide (KI) Distribution: NHCHD will work with NHC Emergency Management,
Brunswick County Health Department and Brunswick County Emergency Management to
coordinate the pre-event distribution of KI in the 10 mile EPZ (Emergency Planning Zone). New
Hanover Count will develo a com rehensive Ian from re-event throu h emer enc event
e
4
.
,
.,
e
e
e
and plans to distribute KI in January or February 2003.
-+ Screened 34 students for lead poisoning after they were exposed to lead based paint at
Forest Hills Elementary School.
-+ West Nile Virus surveillance increased. Physicians notified of availability of state lab to test
humans.
-+ NHC residents were alerted to the dangers of building bat houses on their property to
capture mosquitoes. The threat of potential rabies exposure far outweighs the possible
exposure to West Nile Virus.
-+ Bioterrorism Update: Important dates in October' 10/17 - Smallpox vaccination pre-event
planning videoconference, 10/30 - Smallpox vaccination inoculation training. BTL Team met
and determined NHCHD attendance.
-+ West Nile Virus: New Hanover County received a report from the State Lab on October 11
that a blue jay tested positive for WNV Attached is the NHCHD news release.
-+ The first case of Influenza in NC was reported 10/15. The lab results show the patient, a
Wake County resident, tested positive for influenza Type A.
-+ Bioterrorism Update: NHCHD Emergency Response Plan being revised. Smallpox
Vaccination work group established and meetings set for October 25 and October 29.
-+ West Nile Virus: As of October 21, NC has had two cases of WNV U.S. has had 3,231
cases and 176 deaths from WNV
-+
VII. Population growth & diversity
(Issue #2)
-+ ESL Classes: The Management Team agreed to participate with Coastal AHEC's English
as a Second Language (ESL) classes. We will provide space for the classes at the health
department and will recruit our Spanish speaking customers to participate. The classes will
utilize health topics such as nutrition and exercise as well as the availability of health care as an
interesting means for learning the English language. Environmental Health Division will make
restaurateurs and their employees aware of the ESL classes.
-+ Interpreter Status: When it was thought that our interpreter with Amigo might resign, Amigo
decided to tender a 30-day notice unless hourly rates were increased. We once again
requested, through the NHC Management Team, that we be allowed to hire a county employee
in place of the contract interpreter The NHC Management Team approved an increase in hourly
rates or the reclassification of an existing position. NHCHD elected to renew the contract with
Amigo at a higher rate. The good news is that Jessie is staying!
-+ At the regular HOLA educational meeting on Oct. 2, a representative from Social Security
Administration spoke on the benefits available for Hispanics. The local SS office has 13 bilingual
staff now.
-+ Interpreters: The Social Security Administration on 16th Street has 13 bilingual staff to
assist clients.
-+
VIII. Discontinued services picked up by Health Department
(Issue #9)
-+
IX. Staff Development & continuing education
(Issue # 14)
-+ Mass Decontamination Exercise: with Wilmington Fire Dept. last week. Fire dept well
prepared with equipment and staff trained to handle incident requiring mass decon.
-+ TEEN DEPRESSION/SUICIDE. THE SILENT EPIDEMIC: will be presented by Fred Davis,
founder of PARENTS AGAINST TEEN SUICIDE, INC, on Wednesday, October 16, 2002 (7 - 9
pm) at St James Episcopal Church, Perry Hall. The church is located at 3rd and Market Streets.
Enter from the hall from Dock Street. Mr. Davis lost his dauQhter to suicide. There will be a
5
panel discussion moderated by Stuart Egerton and consisting of local counseling professionals.
Coffee and desert will be served following the presentations. Everyone is invited.
+ Important dates in October' 10/17 - Smallpox vaccination pre-event planning
videoconference, 10/30 - Smallpox vaccination innoculation training. BTL Team met and
determined NHCHD attendance. For October 17, BTL Team, PHRST Team, Ellen Harrison,
Kristi Barnes, Janet McCumbee, and Betty Jo McCorkle. For October 30, Beth Jones, Betty
Creech, Janet McCumbee, Betty Jo McCorkle, and six additional PHNs (to be determined).
+ Family Planning: Women's Health Care Staff attended a video conference on
contraception.
+ EpiTeam: Thanks to EPI Team for excellent attendance and input at quarterly meeting 10-
14. EPI Team is a multi- divisional team prepared to respond and provide leadership to assist
with large. outbreaks or events with public health implications.
+
X. Evaluation of services
(Issue #16)
+ HIPAA Videoconference: October 21, 2002: Working on getting Coastal AHEC as a site,
the room is available and UNC Office of Continuing Education (OCE) may be able to open this
site. Gathering information on how many people would be able to sign up for the site if we were
to open it. HIPAA Information, Flow, Assessment: IFA HIPAA subcommittee met to review the
spread sheet prepared from the Division IFA assessments. Will set up meeting made up of a
representative from division who participated in the IFA assessment last year to provide
explanation and request revision and feedback related to some non compliance issues. HIPAA
Entities Subcommittee: A spread sheet listing of possible Business Associates has been
developed as requested by the HIPAA Committee. The list shows categories local, state, and
federal. This is being reviewed and will be given to the full HIPAA Committee at our next
meeting on October 14, 2002.
+ MCC and CSC Changes: Today marks the first day of the new changes in the delivery of
MCC and CSC services as a direct result of changes in the Medicaid reimbursement system.
Staff will be working different schedules to include evening and possibly weekends as they
provide home visiting and use their cars as portable work stations. Thanks goes to Staff for their
commitment to seeking new and creative ways to continue to provide these valuable and Iife-
changing services. You will, no doubt, notice different faces in the building at different times.
Please give them a pat on the back and show your support and understanding for them while
they adjust to new schedules and work requirements.
+ Organizational Analysis Update: Bill Herzog and Dr Chuck Grubb will meet with key
stakeholders and the Health Director on October 8-9. The NCIPH Team will convene an expert
panel later this week to discuss possible recommendations. A draft of the report will be
presented at the Strategic Planning Retreat on October 26. A final report should be delivered to
NHCHD by December 10. An abridged version of the report will be distributed to all NHCHD
Staff in December and the complete report will be available for review.
+ Ordinance changes were discussed at the ACS Advisory Committee meeting. Possible
changes will be reviewed with the county attorney in the near future.
+ HIPAA Agency/County/Entitiy Designation: Holt Moore. County Attorney, is preparing
documentation designating New Hanover County as the legal covered entity for Health
Insurance Portability and Accountability Act (HIPAA). Under the County's designation, the
Health Department is designated as a covered/hybrid entity which allows us to determine if we
want to "carve out" certain non-covered components which will mean those components would
not be subject to HIPAA.
+ HIPAA Committee met on October 14,2002. The revised HIPAA Security Rules are to be
out sometime this fall (hopefully in November).
+ Birth Certificates: Health Dept. deputy registrars have had an increase in requests for
affidavits to add items to the birth certificate or change incorrect entries. We have also received
comolaints from parents about how they were rushed at the hospital and therefore did not make
.
\
e
e
e
6
.
'j
e
e
e
certain the birth certificate was correcl. A letter has been sent to the Birthplace Director to
address these and other issues regarding the need for accurate birth certificates being produced
at birth.
-+ Social Marketing: Belly Jo McCorkle participated in a videoconference on 10/18/02:
Integrating Social Marketing for Successful Family Planning Services. Local participants shared
experiences and positive results. Counties who had participated in the Health Metrics pilot
projects reported a decrease in no-show rates from 65% to 14% and as low as 7% in one
county. Improvements were also noted in waiting times, patient satisfaction and improved
services.
-+ Maternity Care Coordination: We are continuing to evaluate the transition in the Maternity
Care Coordination program as a result of funding changes. Staff are working diligently to
document time and to streamline processes. We are also monitoring the comparison of
reimbursement rates. Reports will be sent to Dr Joy Reed, Head, Local Technical Assistance
and Training Branch and to regional consultants.
~ WIC Vendors: are monitored to assure the stores are following WIC regulations. Beginning
July 1, 2002, all WIC approved foods in each store must either be individually prices or have a
shelf price posted. Sanction points are assigned for any deficiency found during the monitoring
visil. These sanction points remain on the record for one year. If a store accumulates 15 or
more sanction points within a 12 month time period, the store loses WIC authorization for no
less than 90 days and then must reapply to the state WIC office to be reinstated. The first New
Hanover County WIC vendor monitored for this fiscal year received 12 1/2 points on one visil.
The store will continued to be monitored every two weeks until the store passes the monitoring
visit or accrues additional points to lose WIC authorization, whichever comes firsl.
-+
7
'. .,
e
e
e
NEW HANOVER COUNTY
BOARD OF HEALTH
2029 SOUTH 17TH STREET
WILMINGTON, NC 28401-4946
TELEPHONE (910) 343-6500, FAX (910) 341-4146
E...,......._._.
Gel. N. Huoter, RN, FNP, Cbairman
W. Edwiu Link, Jr., RPb, Vlce-CbainolD
Henry V. Estep, RHU
Man-in E. Freemao, Sr.
Commissioner Robert G. Greer
Wilson O'Kelly Jewell, DDS
Auue Braswell Rowe
Philip P. Smith, Sr., MD
Melody C. Speck, DVM
Willialm T. Steuer, PElPlS
Edward Weaver, Jr., on
David E. Riot, MPB, MA
Hetdth_,
Lynda F. Smith. MPA
Asslsttmt Hetdth _,
October 9, 2002
Carmen Hooker Odom, Secretary
North Carolina Department of Health and Human Services
2001 Mail Service Center
Adams Building, 101 Blair Drive
Raleigh, NC 27699-2001
Dear Secretary Hooker Odom:
I am writing on behalf of the New Hanover County Health Board of Health to express
our strong concerns related to the new Medicaid rates for revised Y and W codes that
became effective October 1, 2002. Our Board passed the rate changes as a formality
on October 2, but with serious reservations given the unit constraints and reduced fees
for reimbursement and for staff delivering services.
In Child Service Coordination and Maternity Care Coordination services, the new rates
were presented as "cost neutral" by State staff. A comparison of the current caseloads
and practices with the new, time-based reimbursement (15 minute units) determined by
our staff documents a lack of neutrality
Maternity Care Coordination (MCC)
A comparison of revenue for MCC initial contacts, subsequent contacts and home visits
from FY 01-02 is as follows:
Old Reimbursement Rate = $335,500 (actual revenue from FY 01-02)
New Reimbursement Rate = $174,600 (estimated revenue with new billing units, using
FY 01-02 contacts and applying new rate; utilizing 6 units for an initial contact, 2 units
for a subsequent contact and 6 units for a home visit).
Child Service Coordination (CSC)
A comparison of revenue from monthly contacts by phone, in clinics, and on home visits
for CSC from FY 01-02 is as follows:
"Your Health - Our Priority"
A' ..
Secretary Hooker Odom _
October 9, 2002 _
Page 2
Old Reimbursement Rate = $ 347,388 (actual revenue from FY 01-02)
New Reimbursement Rate = $182,480 (estimated revenue with new billing units, using
FY 01-02 contacts and applying new rate; utilizing 6 units for initial contact, 4 units for
face to face tracking visits, and 2 units for subsequent contacts).
Our staff has been working diligently to find new ways to deliver the services and to re-
organize under the new system. The short time frame (September 5 memo;
implementation October 1), along with the dramatic changes, have presented what
could be seen as unfair restrictions for organizing and implementing a completely new
way of doing business and providing public health services.
As you are aware, introduction of case management services (especially MCC) was
originally proposed by NCDHHS through the RFP (grant) process for one-time start-up
funding with the promise of being 100% self-supporting through Medicaid
reimbursement. We bought into this system in good faith and demonstrated that the
program could, in fact, be carried out while being self-sufficient. Both MCC and CSC
data have demonstrated the effectiveness of the programs and the resulting life-
changing results in relation to improved pregnancy outcomes, reduction of infant
mortality and early intervention with high-risk mothers, babies and families.
Communicable Disease
STD Treatment and TB Control Treatment are now combined into one code, although
they were previously reimbursed at $80.00 for STD Treatment and $89.00 for TB
Control Treatment. Now the maximum is 4 units daily (or $19.50 x 4 = $78.00) or a total
of $78.00. There are also more constraints regarding what disciplines can provide the
service, as well as, required training/courses. These factors will make it extremely
challenging for our agency, and others who provide this service for reimbursement.
e
Our concern is the dramatic and far-reaching changes are being implemented without
taking into consideration adequate overhead costs and time requirements for
completely revamping the entire delivery system. The State memorandum announcing
the changes states that the new system will be monitored .very closely to assure that
local health departments are not losing significant funds though this transition." Our
question is, "Will changes be made if it is determined that the system is not working?" If
changes are indicated, how long will it take to make the changes? Our fiscal year is
well underway with revenue/expenditures established based on the old system of
reimbursement. We have made a commitment to the New Hanover County
Commissioners to be 100% self-supporting of the case management programs. W~ do
not have the luxury of a grace period while we try out the changes. If we are not able to
demonstrate immediate success with the new billing rates, or the reimbursement rfites
e
e
e
e
of-
Secretary Hooker Odom
October 9, 2002
Page 3
are not adjusted and paid this fiscal year, we will be required to eliminate MCC and
CSC staff positions and services.
The staff of the New Hanover County Health Department has joined forces to do our
very best to apply the new system and adapt to the changes. October 1, 2002 was a
new beginning in the delivery of MCC and CSC services. We will be diligent in
documenting the time spent implementing and delivering billable and non-billable
services under the new system. We felt an obligation, however, to let you know our
concerns with the changes and the implications for our agency and the people of our
community
Sincerely,
k }l.~
Gela N. Hunter, RN, FNP
Chairman
New Hanover County Board of Health
Cc: Dr Leah Devlin, State Health Director
~
.....'-,,-..'-'.,
/...,. SfA1l ~..,.,
,''';,;-'',.'~ :!til,~
jtJI/12 1 '1.~~
,~ ~ltfj" ~ ~.
~'(. '.('iBj
(\l'. " If!
. .....".,... '"
.~~-:>.,..
North Carolina Department of Health and Human Services
2001 Mail Service Center. Raleigh, North Carolina 27699.2001
Tel 919-733-4534 . Fax 919-715-4645
Michael F. Easley, Governor
Carmen Hooker Odom, Secretary
October 29, 2002
Ms. Gela N. Hunter, RN, FNP
Chairperson
New Hanover County Board of Health
2029 South 17110 Street
Wilmington, NC 28401-4946
Re: Unbundling of Service Codes: MCC (Maternity Care Coordinator), CSC, Child
Service Coordinator), TB (Nurse Provided Tuberculosis Treatment), and (SID
(Sexually Transmitted Disease Nursing) Visits
Dear Ms. Hunter:
e
Thank you for your thoughtful letter of October 18, 2002, concerning the potential impact
of unbundling the aforementioned services.
As you are aware, a number offactors (not the least of which being the HIPAA mandate)
required that we unbundle these service codes. It is our desire that the transition to time-based
billing will, in aggregate, provide a budget neutral method of reimbursement. Further, we seek to
offer clarity and support whenever possible in order to facilitate a smooth process of change.
Dr. Leah Devlin, State Medical Director, and Ms. Nina Yeager, Director of the Division
of Medical Assistance, continue to follow this issue in order to ensure that the Administrative,
Local and Community Support Section work closely with all parties as we proceed with the
transition process. Please know that I share their desire to have all of DHHS work with local
health departments in a manner that fosters improved health and wellness. as well as an
environment of cooperation and support.
I will stay updated on this issue and I invite you to please notify me in the future of areas
of concern and success. Meanwhile, I would encourage you to contact Mr. Dennis Harrington,
Chief of the Administrative, Local, and Community Support Section, should you have specific
questions or require additional information.
Again, thank you for your time and consideration.
Sincerely,
~
e
n Hooker Odorn
cc:
Nina Yeager
Leah Devlin
Dennis Harrington
*
Location: 101 Blair Drive. Adams Building. Dorothea Dix Hospital Campus. Raleigh, N.c. 27603
An Equal Opportunity / Affirmative Action Employer
II
'i
tit
e
e
g.._.~
~~. ::Iif
~ : ~
.....~~
North Carolina Department of Health and Human Services
Division of Public Health . Office of the State Health Director
1915 Mail Service Center. Raleigh, North Carolina 27699-1915
TeI919-733-7081 . Fax 919.715-3144
Michael F Easley, Governor
Carmen Hooker Odorn, Secretary
Leah Devlin, DDS, MPH
Acting Stale Health Director
Director, Divi'iion of Public Health
October 29, 2002
Dear Health Directors:
Thank you for your partidpltion in the discussion on October 17th of the draft Smallpox Plan for North
Carolina. Your questions and suggestions were invaluable to us.
In response to your suggestions, the Office of Public Health Preparedness and Response ()>HP&R) has
developed the enclosed swvey instnunent that asks for the basic, essential questions that must be 3I1S\\6'ed
to develop the North Carolina Plan. While many of you have probably already begun more detailed
planning for your county, ~ these que;tions will suffice for the purposes of developing the
Statewide Plan. We hope that this instrument is helpful to you in simplifying the process. It should also be
helpful in providing a consistent format that can be rolled up to a regional and statewide level.
Please call on your Public Health Regional Response Teams ()>HRST) or the PHP&R as needed for
assistance in completing the swvey. Please return these completed forms to Dr. Jim Kirkpatrick
iim,kirkoatrick@ncmail.net no later than November 15, 2002. Given the holidays, this will give us a little over a
v.OO<: to mee the federal December 1st deadline for the N C Smallpox Plan.
To help you in completing the swvey, also attached are additional materials that were developed by the
Region 6 PHRST Additional information resources will be found on the N C Health Alert N etv.IJrk
~ite, www.nchan.org.
Thank you for your gocxI ideas and for your assistance in preparing the NC Smallpox Plan.
Sincerely,
Leah M. Devlin, DDS, MPH
State Health Director
~
EveryWhere. EveryDay. EveryBody.
Location: 13305/. Mary's S/re., o Raleigh, N.C. 27605
~
.,
..
_Understand the three scenarios of smallpox vaccination planning:
_. Pre-event vaccination: vaccination of a yet unspecified number of emergency response and
public health personnel before any cases of smallpox are known
. Ring vaccination: identification and vaccination of immediate contacts of a smallpox case and, in
tum, of their contacts
. Mass vaccination: vaccination of the general public after a smallpox epidemic is identified
Smallpox Vaccination Plannina Checklist
Understand the three stages of smallpox pre-event vaccination planning:
. Stage I: vaccination of public health personnel (Communicable Disease staff, Environmental
Health staff, community health nurses, regional surveillance teams, smallpox vaccinators, et
at); selectea hospital medical and ancillary staff; clinical laboratory staff; and other staff at
facilities where smallpox is likely to be treated
. Stage II: vaccination of EMS, HazMat, police, fire and other first responders; staff at medical
treatment facilities such as doctors' offices
. Stage III: vaccination of the general public (will probably not occur until 2004 in the absence of
known cases)
e
Secure a site for pre-event administration of smallpox vaccine which is:
. Accessible
. Of adequate size
. Secure
. Equipped with electricity for refrigerating vaccine, sanitary facilities, and sinks for hand-
washing
. Preferably expandable to be a site for ring vaccination (The local Health Department is the
most likely default location for pre-event and possibly ring vaccine administration)
Other:
. Identify altemate or additional vaccine administration sites-do not use hospitals
. Generate a list of first-line staff who would be Stage I vaccinees (listed above); communicate with
your local or regional hospital(s) to determine which of their staff would be Stage I vaccinees
. Identify by name staff who will train to be vaccinators (2-5 staff for pre-event, ring, and train-the-
trainer)
. Inventory and acquire assets and equipment according to the CDC's recommendations for
vaccine administration (LHD's will be responsible for supplying 2 x 2 gauze pads, air permeable
dressings, zip-lock bags for used gauze dressings, sharps containers, medical waste bags, etc.
The State will supply vaccine, diluent, transfer needles for mixing diluent with vaccine, bifurcated
needles, and forms.)
. Generate a plan to obtain additional staff needed for vaccine administration
. Develop a plan (logistics, operations, etc.) for giving pre-event vaccine to Stage I recipients (and
realize that soon LHD's will be asked to develop a plan for ring and mass vaccination as well)
e
. Educate yourself and your staff about the administration, follow-up, and side effects of the vaccine
. Understand why the vaccine may have to be administered as a clinical trial in Stage 1 and II and
the implications of such a trial
.
SMALLPOX PLANNING SURVEY
,
e
.
PLEASE SUPPL Y THE FOLLOWING:
1-Location of pre-event vaccination center:
a. Name and telephone number of the POC during normal work hours:
Name:
Phone:
b. 24n telephone number of the contact point:
2-Numbers of candidates for pre-event vaccination
a. Stage I:
b. Stage II:
3-Names of vaccinators trained on Oct 30:
e
4-Numbers and locations of mass vaccination centers
a. Location/address:
b. Name and number of Point of Contact
Name:
Phone:
5-Numbers of personnel available to operate mass vaccination centers, before asking for additional
manpower from state EOC:
6-Preferred location for reception of smallpox vaccine from the National Pharmaceutical
Stockpile
a. Name and telephone number of Point of Contact during normal work hours.
Name:
b. Telephone number of the 24n contact point:
e
.
, '
"
..
.
e
I!X3
AI!Jnoas
8 . ~ "U~Ud
uO!l~:llloJ 5WlOd E-<
o '" 0 ~
ON q)...
~ rA'~ ~ ~
=... <(.... .:;
0" "
.~ " 3 l;l .~ ~
~ .~
~t;i~> 88
.... CI.4 = N
~o.a o "
.....0." o >
> I > ~ i:o:: ..
..-:[,I.,
,,'"
.. "
CI).,
." '"
~~ I ."
Ul 8 ~ Ul
as 0 .; as
l!! 8 ~ o " e
<( i:o:: '" i:o::",::a c:(
~Ji! " .<( ~
't:l 023 '0
CD o.'E '.::l c t B CD
e go ~.~ B ~ c:
c: 0
0 CI)CI) .... ~ c:.... E
<= UelS MOl:! O!U!lO g~.a g t::
'E <<100 CI:S as
as >.....>> Q.
Q. ~
~ 0
0 Ol) ~~ '"
" " E
Ul 'a > o ~
E ".. Ol)~CI) 0
~&]'E .5 ~"a 0
0 II:
0 ~ v .~
II: CI).. CI) ~ .~ 13 Ul
0l.s"'0l gj
Ul " 8 " " ,,[,I.,~ u
Ul .. 0 "2 CI) ..
as Ol.s~
u ~~~~ .~ e ti:
138'0
~J>O: ~
~~i~ ~8i'E
08 CI)
[,I.,i:o::"'" [,I.,i:o::"'''
'0 "0 ." "0
~ " 0 ',l:! uelS MOl:! O!UIIO ~ 5 ~ .~
.g ~ ~
Q. OQ Q) a.. U) bO'n ~ t;
.E }It'l 'Iib c: - .-
.a " "''' '5 ~~ ~
.. 'C 0 ~ i:o:: 'C 0 ~ i:o::
tI:l Q:lU",,1t'l Q:lU",,1t'l
"
..
=
..
-
u
e 8-
-
1 (mopOllP01l '1lp3J3Jll" "lh) IlaJV lh""3lp1l~
tI:l
.... AI!Jnoas
t
~ aoueJlU3
..
~
.
Position Number per S-h Number per 16- Experience
Shift hDav
Fonns Distribution+ 9 18 Nonmedical volunteers
Triaae far III or Contact 2 4 Nurse ar EMT
Run Orientation Videa 8 16 Nanmedical (five
running roams and
three flaating between
rooms to assist)
Referral Personnel 16 32 Nonmedical volunteers
Medical Screeners 7 14 Medical training
reauired nurse or MD
Physician- Evaluators 2 4 Physicians to evaluate
ill or more difficult
medical history
screenina
Vaccinators/Witness 16 (vaccinator, 32 Cross-trained to
witness, surge a~emate vaccination,
personnel) fill out vaccine card,
and sian as wijness
Vaccine 2 4 Pharmacist, phannacy
Preparation/Supply to tech, or nurse
VS experienced wijh
vaccine or medication
reconstijution
Exit Review 2 4 Medical or public
health personnel for
final
auestions/instructions
Medical RecordslData 10 20 Nonmedical, data
Entry entry for infonnation
. collected on vaccinees
Clinic Manager 2 4 Existing Vaccine
Proarams Personnel
Supplv Manaaer 2 4 Nonmedical
Clinic Flow/QA 8 16 Nonmedical volunteers
ReviewerlForms Helpers to assist with forms
completion, collection,
and clinic flow
Security 20 40 Non-public health
resource
Traffic Flow 2 4 Nonmedical, assist
wijh loading and
unloading buses at site
if offsite parking
utilized
Translator (not At least one per major Unknown Language fluency with
counted in total clinic language per shift training
staffina estimatesl
Flaat Staff 3 6 Nonmedical volunteers
Contact Evaluation 4 8 Public health
EMT 1 1 Medical
IT Support 1 2 Nonmedical
Total Personnel 117 234
~
j
e
e
e
I
I :.,
--
I
I
I
I
I
I
I
"
I
I
I
I
I
I
'e
I
I
SCHOOL o(PUBLIC HEALTH
The UNIVERSITY of NORTH CAROLINA at CHAPEL HILL
. The N-QRJ:H CAROLINA
InstItute _Tor 1-YubllC Health
New Hanover County Health Department
Organizational Analysis
Volume 1: Report
October 2002
UNGt
SCHOOL OF PUBLIC HEALTH
I.,
~
I
I
I
I
I
I
I
"
I
I
I
I
I
I
Ie
I
I
New Hanover County Health Department
Organizational Analysis
Volume 1
Report
October 2002
by
H. Pennington Whiteside, Jr., MSPH
Deputy Director, NCIPH
Charles T Grubb, PhD
Consultant
William T Herzog, MSPH
Consultant
Janet G. Alexander, MSPH
Research Associate, NCIPH
Sheila S. Pfaender, MS
Research Associate, NCIPH
The North Carolina Institute for Public Health
School of Public Health
The University of North Carolina at Chapel Hill
I
Ie
I
I
I
I
I
I
I
"
I
I
I
I
I
I
Ie
I
I
New Hanover County Health Department Organizational Analysis
Table of Contents
Acknowledgements . . . . . . . . . . . . .. .... . . . . . . . . . . . . 3
Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. ........ 4
Framework for the Analysis .. .. .. .. .. .. . ... ............... .. 6
Context for the Analysis ..................................... 9
Results and Recommendations. . . . . . . . . . . . . . . . . . . . . . . . .. . 11
Introduction ............. . . . .. ..... .... 11
Recommendation 1: Administration.............. .. . ... 13
Recommendation 2: Administration...................... 15
Recommendation 3: Unity.. ..... ..... ..... . . . . . . . . 18
Recommendation 4: Management ......... . . . . . . . . . 21
Recommendation 5: Planning. ........... .......... 28
Recommendation 6: Services.... ........... .......... 36
Recommendation 7: Finance .. . . . . . . . .. ..... . . . . . . .. 40
Recommendation 8: Information Systems ................ 44
Recommendation 9: Training and Education.. ........... 47
Recommendation 10: Human Resources. .. ......... 51
Recommendation 11: Facilities.. .......... . ......... 55
The North Carolina Institute for Public Health 2
I
'e
I
I
I
I
I
I
I
t'
I
I
I
I
I
I
'e
I
I
New Hanover County Health Department Organizational Analysis
Acknowledgements
The staff and consultants of the North Carolina Institute for Public Health wish to extend
our sincere appreciation to the staff of the New Hanover County Health Department for
their invaluable cooperation, frankness and patience during the course of this long study.
We also would like to acknowledge the assistance of officials from New Hanover County
government, present and past members of the New Hanover County Board of Health,
and executives from community organizations and agencies whose insightful key
informant interview comments enhanced the study greatly. Finally, we wish to thank the
state and local health department and Board of Health officials whose review of the
document resulted in substantial improvements and clarity.
H. Pennington Whiteside, Jr
Charles T. Grubb
William T.lierzog
Janet G. Alexander
Sheila S. Pfaender
The North Carolina Institute for Public Health
3
I
'e
I
I
I
I
I
I
I
"
I
I
I
I
I
I
'e
I
I
New Hanover County Health Department Organizational Analysis
Executive Summary
Staff and consultants of the North Carolina Institute for Public Health (NCIPH), School of
Public Health at the University of North Carolina at Chapel Hill conducted a
comprehensive organizational analysis of New Hanover County Health Department
(NHCHD) during the period July 11 to October 26, 2002. This analysis included detailed
program reviews of each division of the department, focus group discussions among
employee groups that cut across divisional lines, interviews with individual staff, an on-
line staff survey and personal interviews with selected officials from county government,
present and former Board of Health members, and executives from other organizations
in the community. These activities provided evidence of a health department with
exemplary strengths, but also a definite need for change. The authors provide eleven
recommendations to improve the services and organizational climate of the NHCHD.
Health Department Strengths
History, Values and Culture
The NHCHD has a particularly strong sense of history and community. This is one of
the outstanding strengths of the Department and one in which the agency and the
community can take considerable pride. The Department has a lengthy and highly
regarded record of contributing to the realization of public health goals not simply in the
county, but in the state and nation as well.
Customer satisfaction, community service, and tradition itself are all strong values within
the Department. As a result, the NHCHD enjoys wide and significant support in the
community among those who are aware of its contributions. The culture and values of
the Department are extraordinarily important to many leaders, staff and Board of Health
members, and represent a focus for unity, pride, and organizational advancement.
Staff and Programs
The services the NHCHD offers to the community are comprehensive, up-to-date, and
reflect the best and most current priorities of the essential services expected of local
health departments. The staff is well-qualified, and loyal to the Department and its
goals. Staff enthusiasm, dedication to core values of community and service to its
citizens, and commitment to make the Health Department the best it can be are common
characteristics throughout the organization. The staff believes very strongly in what they
do and why they do it.
Strategic Direction
In 2000 the NHCHD conducted a comprehensive strategic planning process that
identified ten strategic priorities that have provided a framework and overall direction for
the department ever since.
This effort and the degree of guidance the strategic plan has provided in program
development and review has served the department well and places it among the very
The North Carolina Institute for Public Health
4
I
'e
I
I
I
I
I
I
I
t'
I
I
I
I
I
I
'e
I
I
New Hanover County Health Department Organizational Analysis
few health departments in the state with a clear view of its strategic priorities. The
NHCHD leadership and line staff demonstrate a high degree of understanding and
consensus regarding the Department's priorities and their importance in serving the
community
Recommendations for Improvement
Despite the obvious attributes of the NHCHD and its favorable rank among local public
health organizations within the state and the country, there remain notable opportunities
for improvement. Among the most significant issues are the overall administrative
structure of the Department, a need for improved integration within the divisional
structure, the proportion of supervisory positions to line staff, the need for improvement
in scheduling and management of meetings at all levels, and the diffusion of budgetary
and financial management responsibilities. These all represent concerns that can be
managed within the limits of existing resources and policies. There are, of course, a
number ot other issues facing the Department that relate directly to the budgetary
situation, especially the loss of key positions, the inability to recognize excellent
performance with meaningful salary consideration, and the crucial inadequacy of
working space in some areas of the Department. The following eleven
recommendations address many of these concerns.
1 Reduce the number of administrative levels between the health director and the
line staff.
2. Strengthen the central administrative staff of the Health Director's Office.
3. Promote an internal and external image of the NHCHD as a single organizational
unit.
4. Adopt a team-oriented management style.
5. Improve strategic and management planning systems.
6. Provide for greater unity, flexibility, and coordination of nursing and related
personal health service programs.
7. Consolidate finance, budgeting, and billing systems.
8. Strengthen information systems management and resources.
9. Centralize and strengthen health education, staff training, and communications
capabilities.
10. Conduct a comprehensive review of personnel (human resources) policies and
procedures and develop a written handbook of same that is interpreted and
applied consistently throughout the organization.
11. Review current space allocation and use and explore alternatives for
improvement given existing funding and resources.
The North Carolina Institute for Public Health
5
I
'e
I
I
I
I
I
I
I
t'
I
I
I
I
I
I
'e
I
I
New Hanover County Health Department Organizational Analysis
Framework for the Analysis
The overall goal of this effort has been to enhance the effectiveness and working
environment of New Hanover County Health Department (NHCHD). This specific focus
calls for an organizational analysis, an approach that differs significantly from several
related approaches: an academic research project, an organizational assessment or
audit, and organizational performance measurement. This difference in focus is
important in understanding the design, strengths, and limits of this initiative and in seeing
how the other efforts might be complementary at some point in the future.
An academic research project typically focuses on contributing to the general
knowledge base about organizations, such as how they are composed, why they behave
the way they do, types and styles of leadership and their effectiveness, and the impact of
structure and design on operations. Academic research projects seek to avoid or at
least limit the impact of the study on the organization being studied. The NHCHD
organizational analysis uses aspects of an academic research project, particularly in
choosing the basic elements and sub-topics to constitute the essential framework of the
analysis. While the present analysis has been as structured and rigorous as many
academically oriented organizational studies, a primary goal has been to have
meaningful impact on the organization, not to avoid such impact.
Organizational assessments or audits resemble a typical financial audit in that both
seek to verify that standard accepted services and organizational safeguards are
provided for, and to guide the leadership and staff in planning for and delivering these
services. The former APEx/PH (Assessment Protocol for Excellence in Public Health)
and current MAPP (Mobilizing for Action through Planning and Partnership) assessment
programs are good examples of that approach. Working from a comprehensive
checklist, the reviewers systematically document services and important organizational
characteristics, systems and procedures. Such an approach can assure the presence of
essential characteristics and services and provide an excellent overview of the
organization that can be compared with other organizations of the same type. The
NHCHD organizational analysis differs from the typical organizational assessment or
audit in its in-depth examination of organizational characteristics through detailed
program reviews, and interviews with staff and program leadership. It focuses not only
on determining the presence or absence of specific characteristics or services, but also
on how the organization functions and what might be options for improvement.
Organizational performance measurement is extremely important to governmental
and not-for-profit organizations where in the absence of well-defined and accepted
measure of organizational effectiveness it is difficult to establish credibility and prove a
relative level of success. This has far-reaching impact on organizational financing and
resources and upon organizational direction, leadership, and morale. When program
goals and achievement levels are difficult to quantify and publiC scrutiny is particularly
tight, there is a tendency for "leadership" to be defined in terms of "rule enforcement,"
"accountability," and "compliance" with established policies and procedures. In such
organizations complaints of lack of flexibility and micromanagement are common. The
Centers for Disease Control and Prevention (CDC) is developing a Local Public Health
System Performance Assessment Instrument as part of the National Public Health
Performance Standards Program (NPHPSP) to address the issue of measuring
achievement within public health agencies. When available for general use, this
The North Carolina Institute for Public Health
6
I
'e
I
I
I
I
I
I
I
tI
I
I
I
I
I
I
Ie
I
I
New Hanover County Health Department Organizational Analysis
instrument will improve the ability to assess local health department performance and
effectiveness, but will provide little guidance for improving organizational structure,
operations, and internal management.
Each of the approaches described above has a specific purpose and its own set of
strengths and weaknesses. The typical academic research approach focuses on
contributing to basic knowledge about organizations, but by design has limited impact
upon organizational policy or operations. Organizational assessment can be invaluable
in comparing organizations against a pre-established set of characteristics, but has
limited value in diagnosing organizational issues and outlining alternatives for
organizational improvement. Performance measurement systems can, potentially, raise
the level of understanding of strengths and shortfalls in organizational achievement, but
also have limited value in diagnosing organizational issues and outlining alternatives for
improvement.
The NHCHD Organization Analysis incorporates many of the features of the other
approaches, but does so with the specific focus of trying to improve organizational
effectiveness and the organizational working climate. It is based on a conceptual
framework that includes eight primary elements and a total of sixty-one specific sub-
topics, all of which are described in Appendix A.3. The primary elements are:
1 Organizational Mission/GoalslValues
2. TaskslTechnology/Workload
3. Structure/Communication/Coordination
4. Management
5. Human Resources
6. Finances/Facilities/Equipment
7. Inter-organizational Collaboration
8. Marketing and Related Functions
The framework of elements and sub-topics was integrated into each of the six specific
activities utilized to study the organization: Detailed Program Reviews, Individual Staff
Interviews, Key Informant Interviews with present and former Board of Health
members and selected community officials, a Staff Survey, Focus Group
Discussions, and an Expert Review Panel. Each of these is described briefly here.
The specific instruments used are described in greater detail and cross-referenced to the
framework of Elements and Sub-topics in the Appendices.
Staff and consultants of the North Carolina Institute for Public Health (NCIPH) conducted
the detailed Program Reviews, Individual Staff Interviews and Key Informant
Interviews. This process focused on the specific divisions and programs of the NHCHD
and included detailed review of written documents and records, interviews with work
group units, informal group discussions, interviews of individual staff at management,
supervisory, and line levels, and interviews with Board of Health members, county
officials and other key informants outside of the organization itself. Additional reviews
focusing on specific functions such as financial management, information systems, and
human resources management were conducted at a later stage of the study. Details of
the Program Review, Individual Staff Interview and Key Informant Interview processes
appear in Appendix B.
The North Carolina Institute for Public Health
7
I
'e
I
I
I
I
I
I
I
tI
I
I
I
I
I
I
'e
I
I
New Hanover County Health Department Organizational Analysis
The Staff Survey was adapted from a "Quik-Scan" Questionnaire developed by one of
the consultant team and tested and validated in previous consultations with health care
clinics, health departments, and health research organizations. It was made available to
staff on-line to increase convenience and to improve analytical capabilities. The survey
contained a series of 50 statements about various aspects of the NHCHD, with
responses to be selected from a five-part Likert scale. A number of tables summarizing
survey results appear throughout this report. The numbers shown in the tables
represent response as a percentage of the whole. Details of the Staff Survey are
presented in Appendix C.
An experienced team from the NCIPH conducted six Focus Group Discussions. The
focus groups were deliberately structured to cross the existing divisional lines of the
Health Department in order to improve the interdisciplinary nature of the study and to
encourage responses that focused on the organization as a whole. Five categories of
staff were invited to these groups: "professionals" such as laboratorians and
environmental health specialists, nurses (two groups), clerical staff, supervisors, and off-
site workers. Information gathered from the focus group discussions has been
incorporated in the substantive analyses and recommendations. The Focus Group
process is described more fully in Appendix D.
An Expert Panel of public health professionals met to review a draft of the
organizational analysis report on October 10, 2002, and their comments and
suggestions on the study methodology, findings and recommendations led to major
revision to the report. The members of this panel included representatives from the
North Carolina Departments of Health and Human Services and Environment and
Natural Resources, local health directors, and a Chatham County Board of Health
member. Expertise represented among the panel members included state and local
health services, laboratory, environmental health, and nursing. Panel members are listed
in Appendix E.
In an opinion-seeking study such as this, it is crucial that all individual and group
interviews, surveys and focus group proceedings be completely confidential in nature.
To ensure that the study design properly protected privacy and confidentiality, the team
sought review and approval of its methodologies from the Institutional Review Board
(IRB) of the UNC School of Public Health. The IRB helped the team design the privacy
assurances and confidentiality agreements that were explained to all project participants.
In compliance with IRB guidelines, the team did not and will not attribute any comment
or response to any specific individual, and asked all participants to honor this constraint.
Additional detail on the IRB-approved privacy guidelines appears in the Appendices.
The North Carolina Institute for Public Health
8
I
Ie
I
I
I
I
I
I
I
t'
I
I
I
I
I
I
Ie
I
I
New Hanover County Health Department Organizational Analysis
Context for the Analysis
If experience has taught us anything it is that we in public health can never be sure what
we will face tomorrow. Recent years have moved the most bedrock of public health
services and responsibilities onto shifting sands of political preferences, budgetary
vagaries, and actual and perceived threats to our citizens. These are serious times, and
they demand a serious response from serious people committed to the realization of a
common purpose.
Someone once compared the task of leadership in a modern complex organization to
trying to manage a canoe in "permanent white water," or, as many New Hanover County
natives might more appreciate, trying to manage an ocean kayak moving laterally in
crashing surf with heavy riptides. If this is true of a complex business organization it is
even more true of a local public health department. The fields of health care and public
health are highly specialized and categorized, and the professional barriers between
specialties are often so rigid that the field itself has been accused of suffering from
"hardening of the categories." Communication across disciplinary lines is notoriously
difficult and awkward, a factor complicated even more by privacy laws and legal liability.
Very little is secure or predictable about funding or the rules and procedures regarding
financial management, billing, and program coverage for even a period as short as six
months.
The only thing that most local health organizations can count on is that whatever rules
and pOlicies govern their programs one day (assuming there is an intelligible source of
information on these) will likely change next month, or the next. National or state policy
decisions related to financial support for specific diseases, conditions, or procedures in
public programs (and even private insurance programs) may indirectly shift a significant
group of clients away from health department clinics to other organizations one year,
and back again (with other clients) the next year. Environmental programs are equally
affected by unpredictable shifts in the local economy, political climate, rules and
regulations, acceptable standards, and public demand. This picture is further blurred by
the lack of a "bottom line" to demonstrate achievement, pUblic unawareness of local
public health's contribution to the community, and severe budget cuts which track across
related local, state, and federal programs. In the face of these challenges, the continued
dedication, positive "can-do" attitude, and organizational loyalty shown by health
department leadership and staff are impressive indeed.
Providing useful suggestions for changes that will improve the effectiveness and
organizational climate of the NHCHD is equally challenging. It would be easy to
recommend increases in staffing, salaries, and resources as potential solutions to the
issues that have been identified during the course of the organizational analysis. None
of those, however, is going to be forthcoming in any significant degree in the foreseeable
future. Furthermore, it is not likely that increasing resources will fundamentally address
and resolve most of the issues identified in this study.
In the judgment of the study team, the resource issues that the Health Department faces
(other than space) are largely issues of appropriate staff assignment and deployment,
optimal use of current staff and resources, role definition and clarification,
communication, teamwork and collaboration, and Department-level priority setting. As
challenging as the public health environment is today, much of the daily challenge and
The North Carolina Institute for Public Health
9
I
'e
I
I
I
I
I
I
I
t'
I
I
I
I
I
I
'e
I
I
New Hanover County Health Department OrganIzational AnalysIs
stress faced by NHCHD employees appears to be inflicted internally rather than by
forces in the environment.
Throughout this report the authors have endeavored to have the employees of the
Health Department "speak for themselves" by including quotes from the survey, focus
groups, and individual and group meetings. In each instance, the quotes are merely
illustrative, and sometimes poignant, representatives of common and widespread
perceptions and feelings of the staff. We have intentionally omitted expressions that
identified any specific individuals in the Health Department or which, in our view,
represented a distinct, perhaps, individual view. In each instance, the authors are in at
least general agreement with the views and observations expressed.
The North Carolina Institute for Public Health
10
I
'e
I
I
I
I
I
I
I
"
I
I
I
I
I
I
'e
I
I
New Hanover County Health Department Organizational Analysis
Results and Recommendations
Introduction
This rigorous and complex study has paralleled the commitment of the NHCHD itself to
(1) to enhance the services provided to the citizens of New Hanover County, and (2) to
make the Health Department a rewarding place to work for its employees. The overall
goal of the project was to find areas for improving the effectiveness and efficiency of the
Department and for enhancing its overall working environment. If the resulting analysis
and recommendations appear critical, they must be interpreted in this light.
The NHCHD is an excellent organization that has every right to be proud of its services
and traditions. It is has an outstanding reputation at the state level and among the other
local health departments in North Carolina. Many leaders in New Hanover County
government, agencies and organizations rate it at the top for services, responsiveness,
and staff Qooperation with citizens and officials. The very fact that the organization's
leadership had the dedication and courage to request a study of this kind demonstrates
the essential quality and values of the Department. Still, it was the purpose of this study
to find areas for improvement, and that purpose was accomplished.
Before entering into a detailed discussion of recommendations, it is important to review
several of the outstanding strengths of the organization.
Health Department Strengths
History, Values and Culture
The NHCHD has a particularly strong sense of history and community. This is one of the
outstanding strengths of the department and one in which the agency and the
community can take considerable pride. The Department has a lengthy and highly
regarded record of contributing to the realization of public health goals not simply in the
county, but in the state and nation as well.
The NHCHD enjoys wide and significant support in the community among those who are
aware of its contributions. However, the majority of citizens are not generally aware of
the services provided by the Health Department beyond issues that tend to gain media
attention - vicious dogs, mosquito spraying, and restaurant ratings. Customer
satisfaction, community service, and tradition itself are all strong values within the
department.
Strongly Disagree Agree Strongly Don't
Disagree Agree Know
This Is an organization In which customer values
and satisfaction are of top Importance. 0.8 16.5 56.2 20.7 5.8
There Is a strong sense of values and tradition in
his organization. 2.4 13.0 66.7 13.0 4.9
The North Carolina Institute for Public Health
11
I
--
I
I
I
I
I
I
I
tt
I
I
I
I
I
I
'e
I
I
New Hanover County Health Department Organizational Analysis
Staff
The responses to three questions on the survey provide a critical foundation for the most
notable strength of the New Hanover County Health Department - the staff.
Nearly 97% of the respondents strongly agreed or agreed with the statement, "The
activities and services of the NHCHD are important and valuable to the community we
serve." Approximately 86% strongly agreed or agreed with the statements, "I think that
the people I work with most closely have a very high commitment to make this
organization work and to be the best of its kind," and "The work that I do here is
interesting and motivates me to try to continually do a better job."
Strongly Disagree Agrae Strongly Don't
Dlsagrae Agrae Know
The activities and services of the NHCHD are
Important and valuable to the community we 2.5 0.8 31.2 65.6 0.0
serve.
I think thaHhe people I work with most closely
have a very high commitment to make this 2.4 8.9 47.2 39.0 2.4
or"anlzatlon work and to be the best of its kind.
The work that I do here Is Interesting and
motivates me to try to continually do a better 2.5 9.9 54.6 31.4 1.7
ob.
Staff commitment to what they see as the purpose and value of the Health Department
and their contribution to it are notably high. The staff believes very strongly in what they
do and why they do it. The Health Department should take advantage of that
commitment by encouraging and engaging every staff member in a constant and
continuous effort to enhance Department programming and operations. It should also
develop procedures, management systems, and a culture that recognize the
commitment, responsibility, and reliability of the staff. We believe that the Board and
Health Department Leadership should do everything they can to recognize and leverage
the very high commitment and belief of the staff in the purpose and value of the Health
Department to the community.
Strategic Direction
The Department went through a comprehensive strategic planning process during the
summer and fall of the year 2000, resulting in a list of ten strategic planning priorities that
have provided a framework and overall direction for the Department's activities ever
since. Quarterly updates which cut across Division lines are reported to Department
leadership and the Board of Health and are available for review by staff at all levels, This
strategic planning effort involved gathering extensive data on Health Department
program activities and priorities. Department leadership and Board members conducted
personal and telephone interviews with a number of community stakeholders, and staff
reviewed a broad range of health statistics and relevant community data. All these
elements were used in deciding upon the top priority issues.
This effort and the degree of guidance it has provided in program development and
review has served the department well and places it among the very few departments in
The North Carolina Institute for Public Health
12
I
--
I
I
I
I
I
I
I
tt
I
I
I
I
I
I
'e
I
I
New Hanover County Health Department Organizational Analysis
the state with a clear view of its strategic priorities. Approximately 79% of the on-line
survey respondents agreed or strongly agreed that the major goals and priorities of the
NHCHD staff were clear to them and clear to most people who work in the organization.
This is a rather outstanding endorsement of the clarity and meaningfulness of
organizational goals to most staff. Both of these observations underscore the strength of
the strategic direction of the organization to most of the employees and speak directly to
the professionalism and dedication of the staff.
Strongly Disagree Agree Strongly Don't
Disagree Agree Know
The major goals end priorities of the NHCHD are
clear to me. 2.4 15.5 67.5 12.2 2.4
he major goals and prlorttles of the NHCHD are
clear to most people who work here. 0.8 16.1 70.2 8.1 4.8
Recommendation 1: Reduce the number of administrative levels
between the Health Director and the line staff.
Structure
Experienced organizational executives and academics alike continue to debate the
impact of structure and of structural change on organizational effectiveness and
efficiency Should ''form follow function" or should ''function follow form?" Loosely
organized systems provide a fertile environment for professional discretion and
creativity, but struggle constantly for improved coordination and control. Tightly
organized systems provide a high degree of control at the top, but lack the kind of
flexibility and responsiveness that modern organizations require in a rapidly changing
world. The result is a continual tug-of-war between the pressures for greater
organization-wide integration and coordination and those for greater differentiation of
specialized services.
.
This struggle has taken a unique twist in the NHCHD. Historically, for a number of
reasons, the Department has moved to give more and more autonomy to its Divisions
resulting in a loose structure at the top that is characteristic of many modern professional
organizations. However, while Divisional leadership styles vary widely, the prevalent
tendency in many Divisions has been to become more hierarchical. The result is a very
mixed situation - a loose, "lIar structure at the top allowing maximum flexibility for
Divisions which, themselves, may take the form of more tight, "tall" structures that allow
limited room for staff flexibility and creativity.
Perhaps the biggest challenge in organizations in the last 15 years has been in the
demand for change in leadership. "Flatter" organizational hierarchies resulting in
increased spans of control, introduction of information technology, emphasis on teams
and teamwork, and recognition of the "knowledge worker" are but a few of the
developments that have forced re-examination of and changes in leadership paradigms.
Tight organizational hierarchies may offer top down control but they also limit capacity.
Supervisors who followed tight control patterns in modern professional organizations
The North Carolina Institute for Public Health
13
I
Ie
I
I
I
I
I
I
I
tt
I
I
I
I
I
I
'e
I
I
New Hanover County Health Department Organizational Analysis
became "bottlenecks" that limited the creativity, information sharing, and initiative of
those they were supposed to lead. It was the leader who made decisions, set goals,
solved problems, established schedules, and enforced procedural rules. Obviously,
under that system, the group could only produce as much as the leader could handle.
Too often, the group was nothing more than the extension of its leader, and capable of
no more than the leader was as an individual.
As organizations have responded to the demands of the changing environment, such as
global competition in the private sector or budget constraints in the public sector,
management layers have been eliminated and the span of control (employee to
supervisor ratio) of the typical manager has increased from the old paradigm of six or
seven employees to 15 to 20, and in some cases as high as 25 to 30 employees. As a
result, managers are spread so thin you can almost see through them. There is simply
no way for a manager to have enough time, knowledge, or energy to "be in control" in
these circumstances. In team-based organizations, managers are transformed from
controlling every facet of production to facilitating the production process; they no longer
channel the efforts of others, but instead become instrumental and contributing members
of the team.
The Health Deoartment leadershio needs to carefullv review its overall oraanizational
structure and adoot a more flexible and less hierarchical svstem from the Health
Director's Office throuah the Divisions to the line staff. Ideally, there should probably be
no more than four organizational levels between staff and the health director in this size
organization. Several possible examples of this kind of organization are provided in the
discussion of Recommendations 2, 3, and 4.
First-line Supervision
No single facet of any organization is more important to its overall productivity and
working climate than the first-line supervision system. Once policy direction has been
established, management and operational goals set, and resources arranged, the basic
work of any organization falls upon the individual work units and their leadership. If the
first-line supervisors are knowledgeable in their assigned areas and have skill in
providing leadership to their work teams, the organization works; if not, it is bound to
falter From our interviews, surveys, and review of work assignment patterns and
operations we believe that the NHCHD needs to give top priority to improving this
system. The Department should reassess carefully the overall work unit structure,
redesign supervisory assignments and responsibilities, and and address leadership
styles. This is not meant to be critical of the existing supervisors. They are a highly
dedicated and motivated group. But most supervisors have been appointed from line
roles, have had little or no training in supervision or leadership, and may perceive less
risk and more gain from "over-interpreting" what they understand to be the rules and
regulations of the Department. The Deoartment should consider restructurina its work
units. develooina clear auidina oolicies and orocedures (see Recommendation 10). and
orovidina basic leadershio trainina to all existina and newlv aooointed suoervisors. A
minimum investment in these steps could make an immense difference in organizational
productivity and morale, even in these difficult times.
The NHCHD is, as one employee put it, "administratively rich." Of its 181 employees, 39
or almost 22% hold supervisory positions. The average span-of-control is 4.6. Thirty of
The North Carolina Institute for Public Health
14
I
Ie
I
I
I
I
I
I
I
tt
I
I
I
I
I
I
'e
I
I
New Hanover County Health Department Organizational Analysis
those 39 supervisors have five or fewer employees "reporting" to them. By comparison,
the New Hanover County Department of Social Services has approximately 260
employees of which 40 (approximately 15%) are supervisors. The average span of
control in that department is more than 6.5. In the private sector, as organizations have
adapted to the new business environment of instantaneous communication, knowledge
workers, teams, and environmental chaos, the "appropriate" span of control is now
considered to be between 15 and 25.
When people are given supervisory positions and authority they "supervise," often
without considering whether supervision is required or what kind or amount or
supervision might be appropriate. With this many supervisors in place, the NHCHD has
a lot of "supervision." Not only is all of that supervision not required to assure quality
service delivery and staff performance, but it also often gets in the way. Such "over-
supervision" or as several staff label it, "micromanagement," makes communication
unnecessarily complicated and inefficient, adds bureaucratic requirements that do more
to justify the supervisory function than to add value to operations, and makes staff feel
''watched, controlled, belittled, and untrusted." The NHCHD needs to recognize that the
vast majority of the supervisors are conscientious, positive, and responsible workers, but
include many whose positions have not been well defined and who lack even the most
basic training in their supervisory role. With this in mind. the roles and resoonsibilities of
suoervisors should be examined to determine which of those could be more
aoorooriatelv and oroductivelv oerformed in a "team leader" role.
Recommendation 2: Strengthen the central administrative staff
of the Health Director's Office
The historical pattern of extensively delegating authority to divisions that has existed in
the NHCHD over the tenure of several Health Directors has exacted a cost to the kind of
precedent and resources needed to work for greater organizational integration and
coordination. The Health Director can be aided in his work by an Assistant Director, and
is, of course, able to call upon the help of a variety of staff for special tasks and projects.
Beyond this limited assistance, however, the principal professional resources available
to assist in overall integration and coordination of the department as a whole are the
Division Directors themselves. From all we could tell in our interviews, most of these
directors do have some concern and interest in the Department as a whole, but their role
also places them in the position of being advocates for their Division, of trying to build
the strongest and most effective work units that they can - even if at times this goal
becomes a cost to the Department or to other Divisions.
Health Director's Staff
The NHCHD should consider establishina a Health Director's Staff that includes four
newlv confiaured Associate Director Positions: Associate Director of Pooulation-Based
Personal Health Services: Associate Director of Education. Trainina. and Develooment:
Associate Director of Budaet and Finance: and Associate Director of Information and
Administrative Services. Each Division Director should reoort to one of these Associate
The North Carolina Institute for Public Health
15
I
Ie
I
I
I
I
I
I
I
t'
I
I
I
I
I
I
'e
I
I
New Hanover County Health Department Organizational Analysis
Directors or to the Health Director. Also. the Associate Directors should. in some cases.
directlv manaae ooerational units that are not assianed to a soecific division.
The newly formed Health Director's Staff would be responsible for overall management
of Department operations. This group likely would have reasonably brief meetings
weekly or perhaps even daily to ''take the pulse" of the Department and address
priorities and emergencies. On those occasions when the Health Director is not
available a specific Associate Director would be designated as "Acting Health Director. "
Rotating that assignment would demonstrate trust and confidence in a more broadly-
based Department leadership, provide professional growth opportunities for senior
management staff, reinforce the "Departmental" view of the NHCHD, and permit the
reallocation of the current resources to more valued-added activities of the Department.
It is critical that the Associate Director position not function as a new layer of
administration. Quite the contrary, the intent is to operationally flatten the organization.
In the proposed new configuration, the current Division Directors would assume more
"front-line" supervisory roles.
If the above suoaestion to form a Health Director's Staff or some similar desian is not
adooted. we believe that the resoective roles of Health Director and Assistant Director
should be carefullv assessed and realianed.
Supervision of the Division Directors currently is shared by the Director and Assistant
Director on a rotating basis. Each year, work plans are developed by each Division
Director with either the Director or the Assistant Director. Supervision is then "switched"
and the Job Performance Appraisals are conducted with the "other" Department
Director. For example, a Division Director would develop a personal work plan with the
Health Director but have the Job Performance Appraisal for that work plan conducted by
the Assistant Director This "discontinuity" in supervision is unnecessary and potentially
dysfunctional in terms of understanding and communication about the appropriate
responsibility and performance of Division Directors.
This situation, coupled with a lack of specificity about the roles and areas of authority of
the Health Director and Assistant Health Director, encourages some Division Directors to
selectively take questions and issues to one or the other of them based upon the
perceived likelihood of getting the most desired result.
Redefined Management Team
Should the Health Director's Staff concept be adopted, the Management Team might
then consist of the Health Director, each of the Associate Directors, and Division
Directors. We stronalv uroe that the ouroose and role of the Manaaement Team be
redefined as that of a Deoartment oolicv-makina and leadershio arouo. As Management
Team meetings are currently conducted they are largely information sharing events, with
few and infrequent substantive discussions about the role and performance of the
NHCHD. Information sharing should be done in a more efficient manner, such as via
memos, e-mail, newsletters, and Internet site. The meetings should be devoted instead
to substantive discussion of issues like the Department's progress toward realizing the
goals established in the strategic planning process; determining Department priorities,
programs, policies, and procedures; developing creative responses to emergency
situations and changes in the regulatory and budget environment that reflect appropriate
The North Carolina Institute for Public Health
16
I
'e
I
I
I
I
I
I
I
it
I
I
I
I
I
I
'e
I
I
New Hanover County Health Department Organizational Analysis
Department responses; and positioning the Department to garner community support
and recognition. As a routine schedule, the Management Team should meet either
every other week or twice monthly
Amona the manv aaenda items for the Manaaement Team. we believe that decisions
reaardina service orovision and resource allocation. oarticularlv as thev involve service
exoansion or cuts and staff deolovment. currentlv made within Divisions should be
routinelv reviewed and olaced in the context of the Deoartment orior to imolementation.
Items for Board of Health for Review, Discussion, and Action
The current working relationship between the Board of Health and the Health Director
appears excellent; still some questions were raised in interviews about the
appropriateness of issues that are taken to the Board for action. This is often a difficult
problem for the boards of many public and non-profit organizations. Clearly, the role of
an organizational board is to deal with major policy issues, not with the management and
operational issues that the organization's executive is hired to handle. The problem is in
the definition of what are "major policy issues" and what are not. Boards and executives
often disagree on this and the members of many boards do not agree among
themselves. This has not appeared to be a pressing issue in the case of the NHCHD,
but because the issue has been raised we believe that the Health Director. in concert
with the Board of Health. should delineate a demarcation of "oolicv" and "ooerational"
decisions in order to clearlv identify the aoorooriate ranae of decision-makina authority.
Generally, The Health Director is responsible for on-going operational decisions
regarding the functioning and performance of the Health Department. The Board of
Health is a policy making body that should have extremely limited operational
responsibility
Several years ago the NHCHD began assigning Board of Health members responsibility
for helping Health Department program leaders prepare their budget requests. Although
this process may help get the Board involved in the budget early in the process and
assure that they have greater knowledge of what is involved, it also leads to Board
members developing a certain loyalty to and investment in the particular program area to
which they have been assigned. This process runs the risk of putting the Board
members in an advocacy role for their assigned Division, further reinforcing a partitioned
view of the priorities and services of the Department. Furthermore, the practice does not
contribute to Board examination of the organization's budget as a whole. We believe
that the oractice of Board assistance in develooina oroaram budaets should be
discontinued. Alternatively, Board members could be "assigned" to different program
areas and become "experts" in those areas. Their expertise would then become a ready
resource to other Board members about the role and function of the Health Department.
At present, the Department budget is more like the aggregation of the individual Division
budgets than a manifestation of Department policies, priorities, and programs.
Many individual leaders and staff in the Department have developed personal
acquaintance and working professional relationships with individual Board members,
sometimes as part of organizational contact and sometimes through community or
church activities. This is appropriate and can often contribute to improved mutual
understanding. However, both groups should be careful to avoid crossing the invisible
line that separates the Board role in policy decisions from organizational leadership and
The North Carolina Institute for Public Heafth
17
I
--
I
I
I
I
I
I
I
t'
I
I
I
I
I
I
'e
I
I
New Hanover County Health Department Organizational Analysis
staff responsibilities to manage and direct the organization within the overall policy
framework. We suaaest that the Board of Health adopt a specific policv that refers anv
concerns brouaht to individual Board members to the Executive Director of the Health
Department for follow-up and resolution with a "report" back to the Board.
Recommendation 3: Promote an internal and external image of
the NHCHD as a single organizational unit.
The Pros and Cons of Strong Divisions
The individual Divisions and programs of the Health Department are unquestionably
among the major strengths of the organization, and the sense of pride and
accomplishment they build among staff and the public they serve must be maintained.
The Environmental Health, Animal Control, and Nursing Divisions, to name a few, each
have indillidual staff and community advocates. The image of expertise and public
service that the staff and leadership of these Divisions enjoy contribute to the overall
credibility of the Department. To a degree, work group pride and loyalty can build a
healthy element of competition among Divisions and increase the enthusiasm and
productivity of team members, so long as it is accompanied by an even stronger pride
and loyalty in the overall organization. All staff, but particularly the top leadership, need
to be aware of the importance of strengthening visibility, staff loyalty, and organizational
pride for the Department as a whole. It is only with this broader outlook that the common
aims of greater public support, funding, and resources will be realized. In this respect,
the individual Division-level newsletters emphasize the partitioned nature of the
Department, fail to capitalize on opportunities to widen awareness and knowledge
among both employees and community interest groups, and consume more resources
than are necessary in duplication of effort and costs. We believe that Division-level
emphases should be continued only as sub-sections of a broader Department-level
Newsletter.
Although the individual Divisions and pride of accomplishment serve the Department
well, we are convinced that the Divisions in the Health Department have evolved to a
point where the Division lines are demarcations that significantly limit collaboration,
cooperation, and communication across the Department. There does not appear to be
any regular mechanism in place that systematically reviews initiatives and assignments
within individual Divisions in the context of the needs and priorities of the Health
Department. If an individual Division needs assistance and requests it from another
Division, that Division makes.8 decision to assist or not based solely upon its view of the
situation. Individual employees in one Division have been admonished not to assist
employees in another Division on even routine questions like how computer software
works. On the Staff Survey 60% of respondents disagreed or strongly disagreed with
the statement: "Communication between different job levels in this organization works
well."
Significantly, more than 60% of management and more that 65% of supervisors
disagreed or strongly disagreed with that statement.
The North Carolina Institute for Public Health
18
I
Ie
I
I
I
I
I
I
I
t'
I
I
I
I
I
I
Ie
I
I
New Hanover County Health Department Organizational Analysis
Communication between dlflerent Job levels In Strongly Disagree Agree Strongly Don't
this orgenlzatlon works well. Disagree Agree Know
Oversll 15.0 45.0 34.2 2.5 3.3
Clerical stafl 30.8 30.8 34.6 0.0 3.9
L1nestafl 13.5 42.3 38.5 3.9 1.9
Management 0.0 61.5 30.8 7.7 0.0
Supervisors 4.4 60.9 26.1 0.0 8.7
Forty-five percent of all respondents disagreed or strongly disagreed with the statement,
"I think people in similar job levels across the department communicate well with each
other. Even more significantly, fully 50% of management and 56% of supervisors
disagreed or strongly disagreed with that statement. Clearly, the Divisional
demarcations impact the functioning of the Department at the leadership levels of the
organization.
.
I think people In similar JOb levals across the Strongly Strongly Don't
health department communicate well with each Disagree Agree
other. Disagree Agree Know
Overall 8.9 36.3 48.4 0.8 5.7
Clerical stafl 7.4 33.3 51.9 0.0 7.4
L1nestafl 7.6 34.0 54.7 0.0 3.8
Management 7.1 42.9 42.9 0.0 7,1
Supervisors 13.0 43.5 34.8 0.0 8.7
The variation in the survey responses would tend to indicate that there are Divisional
differences in effectiveness of communications and coordination. The focus group
participants also made it clear that opportunities for sharing information and ideas across
Divisions were few, except for staff members who worked together routinely. Focus
group members were dismayed that "people in different Divisions who do the same
things do them differently."
One staff member expressed this demarcation and its impact on clients, "We ought to
not hear so much, 'MY STAFF;' it should be 'our staff.'" The whole Department should
be a team to serve our clients." The role, responsibilities, services, and activities of the
Department need to be viewed as primary. Divisions exist to further the mission and
purpose of the Department; the Department does not exist merely to house the
Divisions.
A clear and significant exception to this situation is in the case of an emergency. As one
employee said, "In an emergency we become one big, effective team. When the
emergency is over we each go back to Ol-!r Divisions and the cooperation and
communication stops."
Several of the following recommendations address the pros and cons of the existing
divisional structure, but whatever else is done to improve the situation, the Divisions
must take everv oDDortunitv themselves to contribute to the Deoartment's overall imace
and substance. to learn to see their activities in the context of the DeDartment as a
The North Carolina Institute for Public Health
19
I
Ie
I
I
I
I
I
I
I
"
I
I
I
I
I
I
Ie
I
I
New Hanover County Health Department Organizational Analysis
whole. and build full staff awareness and aooreciation of the contributions of the all
deoartmental units.
Departmental Orientation
Departmental pride does not need to be manufactured. Its presence was evident in the
survey, and in group and individual interviews. Overall, the members of the NHCHD
appear to be very positive about the general contribution of Health Department to the
community. Employees already have a strong sense of organizational pride, a deep
sense of culture and tradition, and impressive core values. The Department needs to
examine how it can best capitalize on this in order to build a shared sense of identity and
communicate it to the community. Interestingly, in an organization where one hears
repeated complaints about the number and quality of meetings that staff attend, the one
meeting that many staff apparently miss is the regular monthly meeting of the full staff.
As one interviewee said, 'When staff meetings were changed to only once every few
months, we lost something. We need that meeting to feel connected to management
and co-wOrkers. It also allowed different groups to interact and discuss thoughts and
ideas."
External Image of Department
The current Health Director is well respected within the county, region and state. His
position places him in the role of being the lead spokesperson for the agency, and from
all reports he plays that role well. The spokesperson role is among the most important
for any organizational Chief Executive and requires an extensive investment of time and
effort, one that on many occasions competes with internal management responsibilities.
As already noted in Recommendation 2, we believe that the Health Director's Office
needs to be strengthened to provide more depth for internal direction of the Department
as a whole. The crucial need for the Health Director to cive even more time to external
reoresentation functions in the face of increased communitv chance. reduced budaets.
and disaster and bio-terrorism threats further suooorts the need to strencthen that office.
In making the role of "representative" a top personal priority, the Health Director also has
the responsibility of coaching and developing other Department leaders in this regard.
Organiza~ional images are built around people and symbols as much or more than they
are constructed upon solid and substantial contribution to the community. The NHCHD
leaders and staff consistently expressed their personal convictions that the department
was, in fact, making a meaningful impact upon the health of the community. That story
needs to be told and told again by a few key leaders, not so much by hard data and
statistics as by emphasizing the direct impact upon individuals and groups of citizens.
We often see major political candidates or campaigns recognizing specific individuals or
referring to a ''family in the balcony." The leaders of the Department appear to be
conscious of the importance of this function, and certainly are respected by their peers
and the community at large. This area was civen serious attention followinc the
Deoartment's 2000 Stratecic Planninc effort. The more emohasis this is civen the
better. esoeciallv from the Health Director who is the recocnized sookesoerson for oublic
health in the communitv.
The North Carolina Institute for Public Health
20
I
Ie
I
I
I
I
I
I
I
t'
I
I
I
I
I
I
'-
I
I
New Hanover County Health Department Organizational Analysis
Local health directors typically are involved in many state and regional meetings, and at
times the Health Director has assigned Division Directors to serve as his representative
to these meetings. Such "representation assignments" can help distribute the load of
multiple meetings, but they also can help build an organization-wide perspective among
the top leaders, serve as recognition for their past contribution to the Department, and
provide them greater exposure to the broader public health community However. these
assionments must be made carefullv with the ouroose and anv soecial interests or ooals
fullv exolained to the individual assioned. Otherwise, these assignments might be
viewed by the assignees as irrelevant burdens, and overuse of poorly prepared
designees could diminish the influence of the NHCHD.
The Health Deoartment should also exolore a varietv of soecific steos to 'morove staff
and communitv oride and aooreciation. includina: oublicizino the Deoartment name.
motto. and 1000 in everv oossible wav. For example, the Department might work In
conjunction with other local health departments and with the state to have department
logos added to restaurant rating certificates. NHCHD employees who work in the
hospital should be clearly identified as Health Department employees providing a service
offered by'the Health Department. Whether this identity is established by some uniform
dress, prominent name badges or other insignia is not as important as is that the Health
Department being recognized for the services it provides. The Department might also
investigate the production of logo clothing items like tee shirts, caps, etc.
Recommendation 4: Adopt a team-oriented management style.
Patterns of Error Correction and Coaching
There is a deep and widespread feeling among staff that supervisors not only emphasize
errors and mistakes, but actively seek to find them. "Micromanagement and focus on
policies and procedures has replaced customer service and human relations as a
priority We sense a definite need by supervisory staff for us to be controlled." "It would
be nice for supervisors to recognize the good points instead of looking for the bad." "In
my division, there is a tradition of 'you must be doing something wrong, but I just have
not caught you yet.'" "Everyone is guilty until proven innocent."
Slrongly DI.agree Agree Slrongly Don't
DI.agree Agraa Know
When aomebody makes a mistake here, the
leadership Is quick to notice It end lake action to 11.7 24.2 49.2 7.5 7.5
correct the situation
Mistakes land to be handled here by pointing out
he error and outlining the correct way to do 14.8 23.0 52.5 3.3 6.6
hlnos rather than blamlna
This area poignantly reflects one of the significant "disconnects" about the Health
Department. Staff at all levels throughout the Department are lavish in their praise of co-
workers and of the Department as a place to work. In fact, throughout the study it was
quite common to hear staff follow very critical comments with statements about "what a
The North Carolina Institute for Public Health
21
I
'-
I
I
I
I
I
I
I
t'
I
I
I
I
I
I
'e
I
I
New Hanover County Health Department Organizational Analysis
good place the Health Department is to work," how much they love their jobs, and praise
for their co-workers. The irony is that they do not appear to tell each other.
Supervision is generally perceived to be oriented much more toward finding fault, placing
blame, and avoiding "real issues" than to recognizing positive employee performance.
The administration is viewed as being more likely to side with citizen complaints about
regulatory enforcement than to support Health Department staff. The staff reports
numerous incidents of being "dressed-down" in front of other staff and clients for
"infractions of the rules." Supervisors are seen as operating under an "accuse now, ask
later" view of employees. "Supervisors probably think they're doing a great job, by
keeping staff under their thumb."
In contrast, supervisors believe that errors and "problem employees" are addressed
quickly and discretely. The line staff does not share this view. "Punitive, angry
interactions" among employees, or supervisors and line workers don't seem to be
handled appropriately "A lot of bad stuff is overlooked [e.g., cussing-out, childish verbal
attacks]." "Formal complaint mechanisms are in place but management doesn't want to
invoke them; proper complaint channels are not utilized. And management 'plays
favorites.''' 'Working around" problem personnel is fairly common. When the staff have
complaints about problem personnel, they may be told, "Never mind; everybody has
trouble with 'X'," or "Don't worry, that happens all the time." Staff seems often to be
asked to accommodate or 'humor' problem personnel. "On 'Heavenly Hall' problems
seem to mysteriously dissolve, or nothing at all happens."
Rewards and Recognition
The "Super Staffer Award" and "Praise Coupons," while mildly appreciated, are generally
viewed as either too limited or based more upon longevity and popularity than actual
performance and appreciation. Rewards and sanctions in the Health Department largely
reflect the "command and control" approach to supervision that is so dominant. As one
nurse expressed it, "performance has to 'look good,' not 'be good.'''
Strongly Olsagree Agree Slrongly Don't
Disagree Agree Know
I feel that my work Is recognized and appreciated. 9.1 29.8 48.8 8.3 4.1
I feel that rewards here are pretty well distributed
given the different levels of training and Job 18.2 37.2 25.6 0.8 18.2
demands.
"This is a 'discouraged' staff. Supervisors and managers need training in how to be
encouraging, which is more of a peer-to-peer process than a hierarchical one." 'We
need rewards that don't cost anything." Specific suggestions included a
cleaning/restocking day, a day without uniforms (dress-down day), and closing clinics
and field services one day a month to offer in-service training. "People would love logo
tee-shirts." "The number one perk in Environmental Health is the shirts."
'We are at an intersection. We need somebody to inspire us, not tire us."
The North Carolina Institute for Public Health
22
I
'e
I
I
I
I
I
I
I
if
I
I
I
I
I
I
'e
I
I
New Hanover County Health Department Organizational Analysis
Leadership Styles
There may be about as many individual leadership styles in the NHCHD as there are
leaders, but given the high degree of professional specialization, dedication, and
commitment of staff, it is somewhat surprising to see how prevalent the "command and
control" model of management is, especially among the middle managers. The Health
Director himself employs a "Servant Leader" approach that portrays the top leadership in
the role of vesting maximum authority to the people closest to the work of the
organization. This ''vesting of authority" may be perceived more as "indecisiveness or
inappropriate delegation" by employees at the next level down in the organization. In any
case, there appears little evidence that this style transfers any further than the
management team.
Strongly Disagree Agree Strongly Don'l
Disagree Agree Know
The leaders In the NHCHD are pretty clear and
consistent In setting expectations for staff 9.0 30.3 47.5 6.6 6.6
performanoe.
Although the workload and tension levels vary,
leadership style and expectations tend to remain 18.0 32.8 37.7 4.9 6.6
clear and consistent.
There Is somebody with a leadership role In the
NHCHD that I can go to If I need help or 5.0 10.8 67.5 14.2 2.5
Instructlona In accomDllshlna a aoeclflc task.
I feel that there Is somebody with a leadership
role In the NHCHD that I could talk with If I felt 18.9 21.3 37.7 18.7 3.3
treated unfairly or if I really became unhappy wllh
mv work.
I feel that my oplnlona and auggestlons on how to
better get my Job done are (or would be) 7.4 23.0 51.6 11.5 6.6
welcomed here.
There is nothing wrong with different leadership styles. Individual managers have
different personalities, and "see things through different eyes." Situations vary, as do the
maturity and responsibility of staff. A wise and experienced leader often will adopt
different styles to deal with different individuals in different situations. Major problems do
result, however, when individual managers or supervisors, either through natural
preference or lack of knowledge, adopt and maintain leadership styles that are not
appropriate to the people and the situation. They become "one trick ponies" in a situation
that requires immense talent and imagination. Mature, responsible professionals usually
do not work effectively under tight and restrictive leadership direction. Immature and
irresponsible staff, professional or otherwise, usually do not respond well to indirection or
indecisiveness.
Given the virtual lack of supervisory training and support provided to Health Department
employees is it very likely that, as they became supervisors, people simply began to use
what they had experienced themselves. As one author in the field of health
administration once put it, there are four essential leadership types: The Consciously
Competent, the Unconsciously Competent, the Consciously Incompetent, and the
Unconsciously Incompetent. Supervisory training can do wonders for the first three
categories and careful selection and placement can deal with the fourth. As stated
The North Carolina Institute for Public Health
23
I
Ie
I
I
I
I
I
I
I
t'
I
I
I
I
I
I
'e
I
I
New Hanover County Health Department Organizational Analysis
elsewhere in this report, supervisory training should be a major priority of the
department, but so should a careful review of the qualifications, attitudes, and styles of
the current supervisory group.
When asked what they would do to change how good performance in the Health
Department is recognized one staff member said, "Supervisors have to change their
approach and they probably couldn't change if they wanted to, and they don't want to."
"I feel like we are in a rowboat having to row as fast as we can. Lots of people are telling
us how to row, but not rowing,"
Employees offer this approach to resolving the problem, "If troublesome people are
going to keep their roles, maybe we need a facilitator to deal with staff concerns. Either
an employee or a consultant," "Change can't happen from the bottom-up. If it could, it
would have happened already. It has to come from the outside or else there would be
retaliation,"
A common complaint among focus group participants was that protocols that reinforce
rigid, '~iered" lines of authority hinder effective communication and action. The survey
data, however, indicate that a large percentage (63%) of respondents agree or strongly
agree that structure and reporting channels are appropriate. This strong variation in
viewpoint would seem to point to differences in the way protocols are interpreted and
applied among the various Divisions of the Health Department.
Strongly
Disagree
Strongly
Agree
Don't
Know
Disagree
Agree
I think that the structure and reporting channels
In the NHCHD are appropriate given Its size and
complexltv.
8.1
31.7
4.1
9.0
47.2
From reviews of the on-line survey results, the focus group data, and interview data (see
the discussion in other areas as well as the Appendices), it appears there are strong
differences between how those in management positions and higher see the
organization and how line professional and administrative staff see the organization.
This discontinuity is so impressive that one almost gets the impression that there are two
organizations. We do not believe that this situation results from anything other than two
honest but distinctively different views of the organization. The two groups simply see
things with different eyes and come to entirely different views about many aspects of the
organization. The Deoartment will benefit bv takina everv possible oooortunity to close
this aaD of oerceotion.
Meetings
Regularly scheduled meetings are held within the Health Department weekly, bi-weekly,
twice a month, monthly or quarterly for a total of 226 meetings every quarter. It is
imperative that this level of commitment of staff time and resources be used as
effectively as possible. Many of these meetings, and particularly regularly scheduled
staff meetings, consist largely of information sharing. One has to question whether staff
meetings are the most effective means of sharing information. According to recent
research, 91 percent of professionals who meet regularly admit to daydreaming during
The North Carolina Institute for Public Health
24
I
Ie
I
I
I
I
I
I
I
t'
I
I
I
I
I
I
'e
I
I
New Hanover County Health Department Organizational Analysis
meetings; 96 percent miss meetings; 95 percent miss parts of meetings; 73 percent say
they have brought other work to meetings; and 39 percent say they have dozed during
meetings. When busy professionals meet, they must have reason to be engaged in the
meeting.
The NHCHD should develoo a model for "effective meetinas" that includes a "team
orientation" toward substantive discussion. oolicv makina. problem identification and
resolution. orioritv settina. and task assianment and follow-uo. At a minimum, the
Department should develop "procedural norms" of:
1. Hold a meeting only if necessary
2. All meetings must have clear objectives
3. All meetings must have an agenda, distributed in advance, which includes:
a. Topics for discussion
b. Presenter or discussion leader for each topic
c. Time allotment for each topic
4. Meeting information should be distributed to each participant prior to the meeting,
and should include:
a. Meeting objectives
b. Meeting agenda
c. Date, time, and location
d. Background information
e. Assigned items for preparation
5. Meetings should begin precisely on time so as not to punish the punctual and
reward the tardy. Punctuality sets a tone of being serious about making the
meeting effective.
6. Meeting participants should be expected to:
a. Arrive on time
b. Be prepared
c. Participate in a constructive manner
d. Be concise and to the point
7 Notes should be recorded, distributed appropriately, and archived for future
reference
8. Decisions should be documented
9. Assignments must be documented and should include who is responsible for
following up until an assignment is completed, and the date for completion.
10. The effectiveness of each meeting should be reviewed, and suggestions made to
improve future meetings
Information sharing can be accomplished more effectively within the NHCHD by the use
of e-mail, memos, internal written announcements, the agency Internet site, and a
Department newsletter.
Emphasis on Rules rather than Goals
One staff member emphasized that, "I love the work. I hate the restrictions of this job."
"Creativity, collaboration, and seeking new information are discouraged, not facilitated."
No single characteristic of effective leaders is cited more often by experienced health
professionals than the ability to define work roles and expectations. It is leaders who are
The North Carolina Institute for Public Health
25
I
'-
I
I
I
I
I
I
I
"
I
I
I
I
I
I
'-
I
I
New Hanover County Health Department Organizational Analysis
able to set clear goals for their work team and balance this by building an effective work
team who excel. The information gathered from interviews and the Staff Survey indicates
that the Department does moderately well in this area, but that there is substantial room
for improvement. This adds reinforcement to the need for clear modeling from top
leadership and management and for additional supervisory training with goal focus and
work team development as major emphases. The role and functions of suoervisorv
resoonsibilities should be reviewed. the ''team leader" role exolored. and the number of
suoervisors adiusted.
Strongly Disagree Agree Strongly Don't
Disagree Agree Know
My personal role and responsibilities In the
NHCHD are clear and well defined. 0.8 19.5 61.0 17.9 0.8
Most people who work at the NHCHD have a clear
understanding of their role and responsibilities. 2.4 13.7 69.4 5.7 8.9
The leaders In the NHCHD are pretty clear and
consistent In setting expectations for staff 9.0 30.3 47.5 6.6 6.6
Iner1ormanC8.
It Is pretty easy for people to know when I am
doing my job well and when not. 1.7 29.8 52.1 10.7 5.8
Productivity
The scope of the organizational analysis did not permit us to measure directly individual
staff, unit, or divisional productivity, but the survey results indicated that a strong majority
(almost 85%) of staff believe that, "Most people at my job level do their work efficiently
and effectively."
Strongly
Dls.gree
Strongly
Agree
Don't
Know
Dls.gree
Agree
I think that most people at my lob level do their
work efficiently and effectively.
1.6
10.5
57.3
27.4
3.2
We observed nothing to contradict this, yet we cannot help but believe that productivity
is negatively influenced by the high differentiation, specialization, and limited
coordination and cooperation among the numerous separate clinics within the NHCHD
as well as by the degree of fragmentation in financial management and billing
operations. We believe this needs serious attention.
Equity of Work Distribution
With relatively few though pointed exceptions, most people interviewed seemed to
believe that most staff were carrying their load equally. The on-line survey results tended
to be somewhat equivocal about this with 39.5 % or respondents disagreeing or strongly
disagreeing with the workload equity question and 49.6% agreeing or strongly agreeing.
It is interesting to note that 56% of clerical staff respondents disagreed or strongly
disagreed that there was a balanced workload.
The North Carolina Institute for Public Health
26
I
'-
I
I
I
I
I
I
I
"
I
I
I
I
I
I
'-
I
I
New Hanover County Health Department Organizational Analysis
Most people In the same job areas, or In similar Strongly Disagree Agree Strongly Don't
roies, tend to contribute equally. Disagree Agree Know
Overall 10.1 29.4 45.4 4.2 10.9
Clerical staff 8.0 48.0 32.0 0.0 12.0
Line staff 11.5 21.12 50.0 7.7 9.6
Management 7.1 35.7 42.9 0.0 14.3
Supervisors 9.1 27.3 45.5 4.6 13.6
Although according to the survey many staff (-68%) believe that their knowledge and
skills are being used effectively by the Department, we are not entirely convinced that
the resources these staff could provide are being sufficiently captured. We believe that
staff could be more effectively utilized for training and co-training of fellow staff (for
example computer applications, leadership and supervisory methods) and in cross-
training that would allow greater flexibility in assignments, program planning and
evaluation. This area stlould be explored and staff resources used wherever possible to
help with these specific needs.
Strongly Disagree Agree Strongly Don't
Disagree Agree Know
I feel that my knowledge and skills are well
utilized In the NHCHD. 5.7 25.8 51.6 16.1 0.8
The work that I do here Is Interesting and
motivates me to try to continually do a better job. 2.5 9.9 54.6 31.4 1.7
My job Is demanding and stressful.
4.1 22.1 37.7 35.3 0.8
~he work of most people In this organization Is
highly demanding and stressful. 4.07 21.1 35.0 36.6 3.3
Job Satisfaction, Dedication, and Trust
Two factors are especially interesting in the following excerpts (next page) from the Staff
Survey and were reinforced in the focus groups and program review interviews. One
was how the staff has managed to stay so relatively upbeat about the Department in
these times of severe budget cutbacks, staff reductions, and limited if any increases in
salary and benefits. The other is, why is the apparent trust level so marginal given this
general positive reaction and expressions elsewhere about staff sense of contribution to
the community. This observation also was reinforced in other interview and group
discussions but the reasons are unclear and deserve further study.
The North Carolina Institute for Public Health
27
I
Ie
I
I
I
I
I
I
I
t'
I
I
I
I
I
I
Ie
I
I
New Hanover County Health Department Organizational Analysis
Strongly Dlssgree Agree Slrongly Don'l
Disagree Agree Know
Working In the NHCHD provides a high sense of
accomplishment. 2.5 19.7 57.4 17.2 3.3
I think that most people In this organization really
enjoy working here. 4.2 11.7 65.0 12.5 6.7
People In the NHCHD tend to trust each other a
great deal. 15.5 35.8 38.2 2.4 8.1
Recommendation 5: Improve strategic and management
planning systems.
Strategic Direction
.
As noted in the foreword to these recommendations, the Department's strategic direction
and the prevailing sense of clarity of goals and priorities are major strengths of the
organization. This is particularly true because these are not characteristic of many local
health departments. The NHCHD stands out in this regard, but it still has a good deal of
work to do improve on this process.
Several persons who were interviewed reported that the level of detail in the quarterly
summary reports and their focus on very specific activities detracted from their
usefulness and meaning. Our own impression was that the display of the strategic
priorities throughout the NHCHD and their use in quarterly reports was very positive from
the standpoint of reinforcing the priorities and making them visible and real to staff,
Board, and visitors. The high level of "activity" rather than goal or achievement oriented
reporting does require attention. Several subsequent recommendations deal with this
topic. The NHCHD should revise its strateoic olannino uodate svstem to make it more
ooal oriented and understandable to Board of Health members and Health Deoartment
staff.
This goal-oriented reporting approach is recommended in order to build staff, Board, and
community awareness of the Health Department's achievements, and not just the
activities that may be involved. This difference between activities and goals is subtle but
important, and core to the concept of results-oriented management. lt also can serve as
a healthy antidote to perceptions of "micromanagement." The more the organization can
begin to take on a goal and achievement focus and to hold staff responsible for what
they get done rather than how busy they seem, the better and more flexible the working
environment can become. This is not an easy concept for health workers who by nature
of their role are forced into detailed activity reporting on a day-by-day basis. Even a
relatively basic degree of training in leadership, planning, and management could have
important yields to the department in this regard.
Emphasis in the coming strategic planning cycle should be placed on extending the
awareness and "buy-in" to the priority areas throughout the Health Department and
among critical stakeholders, including the Board of Health and County government
The North Carolina Institute for Public Health
28
I
'e
I
I
I
I
I
I
I
tI
I
I
I
II
I
I
'e
I
I
New Hanover County Health Department Organiza(ional Analysis
administrators. These priority areas should be manifestly evident in Department
decision-making regarding programming, priority setting, and resource deployment.
Mission
The current mission statement is, "The mission of the New Hanover County Health
Department is to protect the public health and environment, promote healthy living and
optimize the quality of life through preventative, restorative, environmental, and
educational services." While that statement conveys information to health and public
policy professionals, the general public would not take the time to try to understand what
it meant to them personally. Absent understanding some personal impact, benefit, or
value, they are not likely to be enthusiastic supporters of the contribution and value of
the Health Department to their community. As one asoect of the strateoic olannino
orocess. enoaoe the entire oroanization in develooino and adootino a new. concise
mission statement that will have meanino to external stakeholders and the oublic.
Vision
The strategic dimension is not clearly evident in Department discussions and decision-
making regarding operations and performance. Vision or strategy is about what an
organization wants to be. In today's extremely uncertain economic environment, an
organization's continued success and relevance, perhaps even survival, depends as
much on the quality of strategic thinking-and on how well that thinking becomes
imprinted on every decision an organization makes-as it does on the effectiveness of
operations. We think it will be useful if the NHCHD adds a ''visionino exercise" to its
strateoic olannino orocess in which the Deoartment enoaoes in imaoinino what it "wants
to be" in the future. Once this vision for direction is determined. each oolicv and
manaoement decision should be assessed in terms of whether it is movino the
Deoartment in that direction.
Vision takes nurturing. Vision dies when it is left untended, or when it fails to touch
every major aspect of operations. Operational pressures are very intense, and easily
overwhelm strategic vision. Many people do not know how to think strategically because
operational pressures inhibit such thinking. Operational thinking done in a strategic
vacuum assumes the world will stay pretty much as is and that whatever is being done
currently will continue to payoff.
Vision provides a framework to guide the choices that determine the nature and direction
of an organization. Vision is what an organization wants to be. Operations are the day-
to-day planning and decision making which guide the development and provision of
services to clients. Operations are how an organization is run. The strategic planning
continuum begins with articulating the vision and ends when that vision is an integral
part of day-to-day operations. To accomplish this, three broad points along the
continuum must be addressed:
1) Articulating the vision and formulating a focused, strategic direction. This
requires three kinds of decisions: determining the direction or thrust for future
development; deciding on future service and market scope, emphasis, and mix
and assessing the requisite capability or resource requirements; and projecting
The North Carolina Institute for Public Health
29
I
'e
I
I
I
I
I
I
I
t'
I
I
I
I
I
I
'e
I
I
New Hanover County Health Department Organizational Analysis
growth and development expectations. Then the vision must be linked to
operational plans and budgets.
2) Ensuring that the strategy is effectively implemented, maintained, and revised.
This involves developing indicators of success, tracking key assumptions,
resolving critical issues, and planning for ongoing review and update.
3) Ensuring internal strategic consistency. It is not always possible or even
desirable to have a single vision dominate every facet of the organization.
However, each major area of the organization must have a strategic vision that is
consistent with the overall vision for the organization.
Goals
Approximately 79% of the on-line survey respondents agreed or strongly agreed that the
major goals and priorities of the NHCHD staff were clear to them and clear to most
people who work in the organization. This is a rather outstanding endorsement of the
clarity and meaningfulness of organizational goals to most staff.
Strongly Olssgree Agree Strongly Don't
Disagree Agree Know
The major goals and priorities of the NHCHO are 8.9 15.5 67.5 12.2 2.4
clear to me.
The major goals and priorities of the NHCHO are
clear to most people who work here. 0.8 16.1 70.2 8.1 4.8
This general level of concurrence was also evident in the focus group discussions when
discussing the "main responsibilities of the health department." There was broad
agreement among all groups that the main responsibilities of the health department are
to protect the health of the public through education and services and to assist the
needy.
Another striking piece of information is that about 97% of staff (83% of management)
agreed or strongly agreed with the statement, ''The activities and services of the NHCHD
are important and valuable to the community we serve."
The aellvlllee and sarvlcss of the NHCHD are Strongly Strongly Don't
Important and valuable to the community we OIB.gree OIB.gree Agree Agree Know
serve.
Ovarall 2.5 0.8 31.2 65.6 0.0
Clerical alaff 3.9 0.0 42.3 53.9 0.0
L1nealaff 0.0 1.9 35.9 62.3 0.0
Management 7.1 0.0 14.3 78.6 0.0
Supervisors 4.4 0.0 13.0 82.6 0.0
However, one of the several confounding variations in this otherwise positive picture is
that the majority of line staff, clerical workers, and even supervisors agreed or strongly
agreed with the statement, "I think that most people get mixed messages from top
The North Carolina Institute for Public Health
30
I
'e
I
I
I
I
I
I
I
tt
I
I
I
I
I
I
Ie
I
I
New Hanover County Health Department Organizational Analysis
leadership about what is important," while the majority of management (61.5%)
disagreed or strongly disagreed with this statement.
I think that people here get mixed messages Strongly Disagree Agree Strongly Don't
from top leadership about what Is Important. Disagree Agree Know
Overall 1.7 29.8 38.0 28.1 2.5
Clerical staff 0.0 26.9 42.3 23.1 7.7
Line staff 3.9 26.9 34.6 32.7 1.9
Management 0.0 61.5 30.8 7.7 0.0
Supervisors 0.0 30.4 39.1 30.4 0.0
Focus group participants communicated the belief that while the NHCHD provides
excellent services well appreciated by its clients, it does not promote its programs and
accomplishments effectively throughout the greater community. Focus group members
also expressed concern that the presence and impact of the health department in the
community was diminishing as a result of budget and program cutbacks.
The observation elsewhere in this report that in emergencies staff pull together
extremely effectively is indicative and typical of a highly specialized and complex
organization such as the NHCHD. What makes this.so is the clarity of and strength of
understanding of common goals, an understanding so deep and so meaningful to staff
and departmental leadership that turf issues and "focus of operating rules" are
temporarily unimportant. This is a perfect example of how higher goal clarity can affect
an organization.
Strongly Disagree Agree Strongly Don't
Disagree Agree Know
I think that people In this organization recognize
hst they depend a lot on each other to get the 4.1 21.5 58.7 11.6 4.1
ob done.
Whim things get very busy and hectic around the
NHCHD, people tend to pull together to get the 4.1 19.0 55.4 17.4 4.1
ob done.
Priorities
The survey data reported for goals also applies to staff opinions on priority setting, but
our program reviews and interviews with a variety of Departmental leaders and Board
members suggest that this area requires serious attention. The general pattern of
opportunistic grant writing and special project funding and the severe recent funding
cutbacks both contribute to this.
Management Planning
There are three important levels of planning and decision-making in any large Health
Department:
The North Carolina Institute for Public Health
31
I
'e
I
I
I
I
I
I
I
tt
I
I
I
I
I
I
'e
I
I
New Hanover County Health Department Organizational AnalysIs
1. Setting the broad goals and policies of the organization;
2. Managing the resources of the organization to meet the established goals under
existing policies; and,
3. Organizing and supervising the day-to-day work to get the job done.
The first of these levels involves the Health Director and the Board of Health. The
second and third levels constitute the bulk of management planning, and are the work of
the Health Director and the leadership team of the Health Department.
Many of the decisions currently made within Divisions are made unilaterally with little or
no reference to the Departmental mission. Decisions that reflect "policy" level actions
that represent the Department need to be assessed by the Department within the larger
context of the Department. Department-wide, as opposed to Division-focused,
management planning can be the key to developing a greater Departmental focus and
placing a host of program and grant decisions in perspective. We are convinced that the
NHCHD would benefit bv buildino an onooino Deoartmental Manaoement Plan nino
Process that comolements the strateoic olannino effort and fits within the county budoet
cvcle. Once a management planning process is developed, most if not all future staffing,
funding, and program development decisions should be made within the context of
Departmental-level strategic priorities and management planning goals.
At the present time grants and contracts to individual Divisions appear to drive a
significant portion of Health Department activity, but their relationship to Department
priorities is not clearly articulated. Grants and contracts should be viewed as endeavors
and commitments of the Department, not individual Divisions. The NHCHD should
develop a policy and process for reviewing all grant or contract applications to determine
their appropriateness and potential contribution within the context of the mission and
priorities of the Department.
Decision-makino about onooino ooerations should be linked to the Deoartment's
strateoic oriorities. and decision-makino and orooram develooment within individual
Divisions should be conducted and assessed in the context of their contribution to the
orioritv areas.
In further consideration of current tioht budoets. the NHCHD should collaborate with
other local deDartments in reauestina that the NC DeDartment of Health and Human
Services and its Division of Public Health reassess the aoorooriateness and orioritv of
the "mandated services."
This last stage of operational planning is applying the plan(s) to everyday work. How will
the work be structured to accomplish the larger goals assigned to the work unit? What
specific tasks need to be accomplished and when? Who will do the job and what goals
and objectives should be assigned to them? How will the supervisor monitor task
accomplishment? Operational planning at the unit level can be an important tool to a
goal-oriented leadership style but is at the discretion of the individual supervisors.
Training and coaching are essential. Consequently, operational planning takes place at
the work unit level, whether the specific work unit is in the field, the clinic, or in the
Health Director's office. The following data from the on-line survey suggests that this
area can be improved.
The North Carolina Institute for Public Health
32
I
--
I
I
I
I
I
I
I
tt
I
I
I
I
I
I
--
I
I
New Hanover County Health Department Organizational Analysis
Strongly Disagree Agree Strongly Don't
Disagree Agree Know
When I see a better 'way to do my job, It Is pretty
easy to explain the needed changes to the peraon 9.8 32.5 43.1 9.8 4.9
I work for and, If they agree, change the
Drocedures.
I teel that my opinions and suggeatlons on how to
better get my job done are (or would be) 7.4 23.0 51.6 11.5 6.6
welcomed here.
Similarly, many of the decisions about how to respond to the recent cuts in budget and
staff appear to have been made exclusively within Divisions. There apparently was little
or no deliberation about how the programmatic and service changes would impact the
Department's mission, priorities, and clients, or the community.
Strongly
Disagree
Strongly
Agree
Don't
Know
Disagree
Agree
The NHCHD Is quick to recognize and change the
way we do things when It appears that we are not
meeting the expectations of patients and the
community at large.
41.5
3.3
6.5
39.8
8.9
There is no reliable way to know how seriously the Department has been affected by the
recent budget cuts and losses of positions. These factors have had a major impact upon
organizational programs and upon the staff's morale and the sense of worth. If the staff
answers to the survey question related to this factor are accurate, it is clear that the
majority agree that there are not currently enough staff to keep up with the workload
most of the time.
Strongly
Disagree
Strongly
Agree
Don't
Know
Disagree
Agree
There are enough qualified staff here to keep up
with the workload most of the time.
23.6
35.0
8.9
2.4
30.1
This issue must be monitored closely in light of the recommendations elsewhere in this
analysis and, if the staff shortage situation continues, an even greater reduction in
services and possible negotiation with the state about the continued feasibility of
mandated services should be explored.
This may not be the most opportune time to begin a concerted effort to improve the
revenue planning and forecasting activities of the Department, but the very existence of
financial duress, about which much of the staff is concerned, underscores the need for
improving this process. We believe that this should be an important part of the strategic
and management planning efforts of the Department.
Strongly
Disagree
Strongly
Agree
Don't
Know
Disagree
Agree
I feel reasonably secure about the financial health
snd stability of the NHCHD. 15.5
31.7
3.3
6.5
43.1
The North Carolina Institute for Public Health
33
I
Ie
I
I
I
I
I
I
I
"
I
I
I
I
I
I
Ie
I
I
New Hanover County Health Department Organizational Analysis
Evaluation and Monitoring
Evaluation of a health department involves attempting to assess periodically how
effectively it is meeting its goals, what activities it has conducted and how efficiently they
have been handled, and, ideally, what overall health outcomes have been achieved in
the community. The NHCHD has used the Strategic Planning process and the
associated quarterly updates as one kind of evaluation tool. Additionally, categorical
grants and state programs require activity reports that also serve evaluation purposes,
and studies such as APEx/PH and the current organizational analysis provide other
examples of evaluation efforts. If a general management planning effort is established
as recommended elsewhere in this report, it also should incorporate significant
evaluation components to monitor goal achievement and overall program efficiency.
Without standard evaluation process feedback, employees can have a difficult time
knowing whether or not their work is having the desired effect.
Strongly Disagree Agree Strongly Don't
Disagree Agree Know
It Is pretty easy for people to know when I am
doing my job well and when not. 1.65 29.75 52.07 10.74 5.79
It Is pretty eaay for people to know when anyone
In the NHCHD Is doing their Job well and when 11.6 46.3 26.5 4.1 11.6
not.
Measuring the effectiveness of public health services involves being able to document
the changes in population or environmental health status that directly or indirectly result
from specific services, or using surrogate measures such as those proposed by the
National Public Health Performance Standards Program. Both were beyond the scope
of this analysis, yet there is a strong sense among the staff that the health department
does have a meaningful effect on the community health. While difficult to document in
any specific way, the immediate impact that a given clinic worker has on the health of a
client or the obvious results an environmental health specialist can see when correcting
a specific problem are what keep them on the job. The Deoartment should. throuah the
strateaic olannina orocess. beain to svstematicallv identifv. measure. and track
oerformance measures of Health Deoartment oroarams and activities.
Survey results indicate that NHCHD employees overwhelmingly believe that the Health
Department is an important community resource.
Strongly Disagree Agree Strongly Don't
Disagree Agree Know
[The activities and services of the NHCHD are
Important and valuable to the community we 2.5 0.8 31.2 85.6 0.0
serve
Focus group participants communicated the belief that while the NHCHD provides
excellent services well appreciated by its clients, it does not promote its programs and
accomplishments effectively throughout the greater community. Focus group members
also expressed concern that the presence and impact of the Health Department in the
community was diminishing as a result of budget and program cutbacks
The North Carolina Institute for Public Health
34
I
Ie
I
I
I
I
I
I
I
t'
I
I
I
I
I
I
Ie
I
I
New Hanover County Health Department Organizational AnalysIs
Program reviews and staff discussions demonstrated very clearly a general consensus
that most individual workers in the Department work hard and conscientiously. This is
consistent with data from the on-line survey in which 80% of the respondents agreed or
strongly agreed that, "Most people in the organization do their work efficiently and
effectively."
Strongly Strongly Don't
Disagree Disagree Agree Agree Know
I think that most people In this organization as a
whole do their work efflclenUy and effectively
1.6
12.3
67.2
13.1
5.7
But there is a major difference between individual efficiency and organizational
efficiency. There does appear to be opportunity to improve organizational efficiency in
regard to the proportion of supervisory to line staff, the frequency and utilization of
meetings in departmental operations, and the organization and degree of coordination of
clinic services.
Service capacity is closely related to organizational efficiency, and it does appear that
the staff's maximum performance level is being reached and even exceeded with the
Health Department's current structure and operations. Almost 54% of staff disagreed or
strongly disagreed with the survey statement, "There are enough qualified staff here to
keep up with the workload most of the time."
Strongly Disagree Agree Strongly Don't
Disagree Agree Know
There are anough qualified staff here to keep up
with the workload most of the time. 23.6
30.1
35.0
8.9
2.4
Without doubting the severe impact of budget cuts, we believe that there is room for
improving service capacity with existing staff. However, declining budgets and staff
reductions have a pernicious effect that leaves organizations poorly prepared to explore
alternatives for improvement and change. It is an unfortunate fact that the best and least
replaceable people in an organization are the most mobile and will tend to move on if
they see their jobs to be at the slightest risk. So, although we believe that organizational
efficiency and service capacity can be improved, we are also concerned about the
impact of existing or any future budget cuts on these same factors and on Health
Department morale.
There is little evident use of data influencing decision-making within the NHCHD above
the level of individual patients. The critical mission of providing services, coupled with
the current fiscal constraints, make it difficult for most managers to see beyond
immediate service needs. Future trends, demands, and environmental factors are not
generally addressed. Socio-economic and environmental trends have specific
importance to the future of local public health departments and need to be incorporated
more directly into the strategic and management planning processes.
The North Carolina Institute for Public Health
35
1
--
1
1
1
1
1
1
1
t'
I
1
1
I
1
1
'e
1
1
New Hanover County Health Department Organizational Analysis
Recommendation 6: Provide for greater unity, flexibility, and
coordination of nursing and related personal health service
programs.
The nurses in the NHCHD comprise a large, professionally competent, and personally
caring group of people who are committed to providing quality services to their clients.
Similarly, the administrative support personnel assigned to the nursing divisions
demonstrate a very strong commitment to patient care and quality services. This
dedication is a major strength of the Health Department and should be exploited to the
benefit of both patients and the Department.
"Specialization" is often mentioned as both the cause and benefit of the current
demarcation of nursing services in the Department. It is doubtless true that for some
individuals, working exclusively with a specific client group is perceived as a benefit and
an opportunity to exercise passion for an individual group or service. However, others
see that same specialization as limiting or narrowing their clinical practice and
contribution.
With the increasing demands to "do more with less" accentuated by the recent budget
cuts and changes in program funding, it is imperative that the Department be able to
deploy its resources adeptly, quickly, and flexibly. The current separation of nurses into
four Divisions makes this virtually impossible. Workload frequently is distributed
unevenly. Division-based agendas drive the decision-making process, causing a wide
and dysfunctional variability in the application of policies, rules, and procedures. This
variability results in disparate treatment of employees, low morale, and, in some cases,
far less than optimal client service.
Too often, the individual Nursing Divisions are portrayed and treated as though they
were independent units with no mutual interests or responsibilities. When a Division is
faced with a short-term crunch it may have to "ask" the other Divisions for help. Help
often is not provided on the grounds that the other Divisions are "too busy" with their
clients, or that the service they provide should take precedence because it is a
mandated service more in line with core public health responsibilities. In some instances
short-staffed Nursing Divisions who are in need of help have redoubled their efforts and
provided the service without any additional assistance. Unfortunately, the result of this
has sometimes been a conclusion that they therefore did not need the additional staff
and could perform at that same level consistently. Applying this same logic to running,
one would argue that if you can run the 100 yard dash in 10 seconds you should be able
to run a mile in 2.93 minutes.
Nursing Divisions
We suaaest that the Health DeDartment should combine the four Nursina Divisions to
reDort to a newlv desianated Associate Director of PODulation-Based Services. The
existing Nursing Divisions should be reorganized into three sections or teams: Clinical
Services, Community Services, and Institutional Services. The Clinical Services section
would house all clinic operations presently within the Health Department. Community
Services would include all services provided in client homes, community outreach
services, and dental services. Institutional Services would include the schools and the
The North Carolina Institute for Public Health
36
I
--
I
I
II
I I
I
I
I
t'
I
I
I
I
I
I
'e
I
I
New Hanover County Health Department Organizational Analysis
jail. Other direct clinical service operations of the department should be studied to see if
their overall effectiveness and efficiency would be improved by reporting directly to the
Associate Director of Population-Based Services. Under this arrangement, we would
envision significant cross-training between the Clinical Services and Community
Services sections, and assignment of nursing resources between programs within each
of these sections based upon current demand.
The school and jail health programs do not readily lend themselves to the same
approach. In each of these programs staff are assigned off-site on a permanent basis
and their responsibilities are carried out exclusively at that site. Jail health may become
a moot point depending upon how the County deals with the question of privatizing that
service. In the school health program, we suggest that additional positions be sought
from the school district so that each school will have a full-time school nurse. In
addition, we suggest that two new positions be established in the school health program
as "floating" nurses who can be assigned to individual schools in the event of staff illness
and to allow school nurses to pursue continuing education and development
opportunities.
Nurses aptly express the impact of the current four Nursing Divisions on themselves and
on patients. 'We're limited; we are more versatile than we are allowed to practice.
Everyone is too territorial and compartmentalized in their separate Divisions." "Divisions
tend to be very territorial, rather than seeing the Health Department as one entity and
working cooperatively."
Clinics
The plethora of nursing clinics can be burdensome on some clients. "Every clinic is
separate, and clients can't take care of multiple problems or multiple children at the
same time. For example, patients with no insurance, with insurance, and who have
Medicaid are all separate audiences with separate clinics." "It is ridiculous to have one
clinic slammed with patients while two or three nurses in another clinic have almost
nothing to do." "How can you justify three clinicians seeing three clients in a clinic all
day long? You can't."
Other staff comments relevant to the nursing situation include: "If I don't get relieved of
some of these administrative duties and allowed get back to providing clinical services I
am going to leave here;" and 'We need a Nursing Director with assistant directors."
We believe the NHCHD should consider movina to an "ODen clinic" format. The current
schedule of separate clinics for different services and even different types of client
eligibility (Table 1) limits client access, pigeonholes clinicians, causes unnecessary
administrative redundancy, and frequently results in significant workload mal-distribution.
Adopting an "open clinic" format would alleviate each of these issues and result in more
efficient and effective use of the clinical resources in the Health Department. The open
clinic format provides appropriate services to clients as the clients present themselves
for services. The clinic conforms to the client rather than expecting clients to conform to
a schedule of specialized clinics based upon programs, services, or funding sources. An
open clinic also takes advantage of the breadth of clinical skills of all service providers,
and does not limit professional clinical practice to a particular program, service, or
population. Flexibility is greatly enhanced for both patients and staff. Patients are able
The North Carolina Institute for Public Health
37
I
'-
I
I
I
I
I
I
I
t'
I
I
I
I
I
I
'e
I
I
New Hanover County Health Department OrganIzational Analysis
to access services during expanded hours and have multiple conditions and even
multiple family members treated during a single clinic visit. Staff enjoy flexibility of
deploying resources based on patient demand instead of type of clinic or the particular
division offering a clinic.
Even within an open clinic format, it still may be necessary to operate some small,
specialized clinics, such as Neurology and Orthopedics, on a separate and defined
schedule.
Reception and Registration
We suaaest that clinic receotion and reaistration activities should be centralized. Each
individual clinic currently operated by the NHCHD has its own registration process and
administrative staff. In some instances, this causes clients to have to register for each
individual clinic from which they or their family members receive services. As a result,
administrative support personnel typically are able to register clients only for "their"
clinics. Tliis arrangement not only inconveniences clients by requiring redundant
information processing and longer clinic visits, but also severely limits staff flexibility and
deployment options.
Ironically, the dedication and concern for "client confidentiality" is confounded by the
current spate of separate clinics with their separate registration services. As patient
"flow" is now conducted, you can know what services a client is receiving by seeing
which window they register at and which clinic door they go through. Open registration
and an open clinic would eliminate that client service identification in much the same
way as what occurs in the offices of private primary care physicians.
Whether or not it adopts the open clinic system, the NHCHD should identify a single
distinct phone number for "appointments," and have it displayed prominently in the
phone book. The way Health Department services currently are listed in the local
telephone directory a patient has to know what service or clinic they need in order to call
the appropriate number. How many clients know that they need "Navigator home visits,"
or understand the differences among Well Child and Kindergarten," "Health Check and
Immunizations," and "Child Care Nursing and Child Service Coordination"? A direct
consequence of multiple phone numbers is a large volume of misdirected calls that have
to be re-routed to the appropriate division or program. Providing a single phone number
for appointments will reduce confusion among persons who want to access the services
of the department but lack knowledge of the range of services available and the
differences among them.
The North Carolina Institute for Public Health
38
I
Ie
I
I
I
I
I
I
I
t'
I
I
I
I
I
I
Ie
I
I
...
al
j5
{!2.
o
c
o
~
"2
~
E
.5
~
x
ii
.c
()
C;
C
'"
~
I-
..
0>
.~
;;
o
c
~ .
8i
>
J:
g~ >-
ijJ: .g
.II'ij l!
al~ ~
I- ::;~ fE
z ",.-
W I-.~
i! i~
IX: all-
<C - c
D. .el1il
~ .!~.;,
CJ .Sl.!;
:J: en ,!; 13
I- ()
..J .2i!1~
<C c ~_
w = CI)~ >to
:J:O~;;: -l!l
U II
~~~~ c:
Z 0 lln ~
::>> O. I- li
OO.~.g~
Q",I!
IX: CIl~~
W C.~E
>;;;~ii
o "ZJ:
Z ::J c;
<C z.~ Iii
:J: j~
::. a. ~
;:> 2> -g
W eS2
z f~
II. ._
~=
~g
a.E
e..
,,"
8~
~~
Il .
~~
H
~~
H
I~
",fg
,0
@1
",e
~~
~c:
...
-l!l
"C
...
'"
'"
~
:l!
,2
:<S
,r
...
.Ii!
~
~
..
S
..
.S
e
a
€
~
<I>
f3.
I.
'e
I
I
I
I
I
I
I
tt
I
I
I
I
I
I
Ie
I
I
New Hanover County Health Department Organizational Analysis
Recommendation 7: Centralize finance, budgeting, and billing
systems
The preparation, monitoring, and reporting of NHCHD budget information has been
inconsistent and sometimes resulted in confusion and miscommunication both within the
Department and with the county. Timely and accurate budget information is crucial,
particularly in tight budgetary times.
In reviewing County and Health Department budget documents, and in talking with the
responsible personnel, it appears that, depending upon how you count it, there are
somewhere between 13 and 38 separately designated program line items within the
Department. Many of these are managed separately within the Health Director's Office
and the Divisions. These budgeting, financial management, and accounting
responsibilities were delegated throughout the department years ago for specific
reasons that may have been relevant at the time, but may not be applicable now. Each
program area is maintaining its own informal bookkeeping system so that it can keep up
with revenues and expenditures with the belief that the on-line system of the County will
not allow them to track such entries on a short-term basis. This no longer appears to be
the case, so this practice should be reevaluated.
Nearly 38% of the survey respondents who expressed an opinion about, ''The financial
systems for billing, collecting, and managing funds appears to be working well" strongly
disagreed or disagreed with the statement. Clearly, something is amiss.
Strongly
DI.agree
Agree Strongly
Agree
Don't
Know
DI.agree
The financial systema for billing, collecting, and
managing funds appear to be working well
12.2
25.5
23.6
2.4
36.6
Budgeting
The budgeting process as it currently functions is widely dispersed throughout the
Department, with each individual Division developing its own budget. Each Divisional
budget then is aggregated into a Department budget. Subsequent budget monitoring
and reporting is distributed throughout the Department. The current process involves
too many people and does not permit timely and accurate oversight of the Department's
complete budget status. When "everyone is in charge, no one is in charge."
Absent a central "control" point, reliable information about the budget is sometimes
difficult to ascertain accurately. Financial management skills vary from excellent to
adequate among the Divisions, and County, grant and contract requirements are
interpreted differently in different Divisions. The dispersion of budgeting responsibility
has sometimes made communication with County budget officials less efficient and
effective that desired.
Divisions tend to see only "their budgets" and perceive the Department to be taking "their
money" when resources or allocations are redirected to other Department activities or
priorities. Given the multiplicity of budget "centers" within the Department it is
The North Carolina Institute for Public Health
40
I
Ie
I
I
I
I
I
I
I
t'
I
I
I
I
I
I
'e
I
I
New Hanover County Health Department Organizational Analysis
sometimes difficult to confidently interpret the actual meaning of the aggregated
numbers when they are combined as the Department budget.
The NHCHD should consider aooointina an Associate Director of Budaet and Finance to
be resoonsible for overseeina all monetarilv related activities within the Deoartment.
The creation of this position would centralize all budget related functions. Improved
comprehensiveness, consistency, clarity, and control would be natural outcomes of this
step. Uniting the budget staff, currently spread throughout the divisions, would very
likely permit some economy of scale that would maximally leverage current staff
knowledge and skills and may yield some staff resources that could be redeployed to
other departmental functions. A "single site" budget process would also facilitate the
integration of the strategic planning and budgeting processes.
We suaaest that one of the near term oriorities of this oosition be to establish a svstem
to monitor and collect accounts receivable. It is our strong suspicion that several tens of
thousands of dollars in accounts receivable are outstanding and have been for more
than 120 days.
The budaetina orocess should be examined and revised as necessarv to reflect and
reinforce the strateaic olan. The budgeting and planning processes of organizations are
so inextricably linked that many experts argue that, '1he budget is the plan." Without
endorsing that perspective, the benefits of directly linking planning and budgeting are
undeniable. In tight budget times the benefits become imperatives. The ability to link
priorities, goals, and objectives to revenues and costs is critical to priority setting and
building support for programs and initiatives. In the public sector, being able to
demonstrate the costs of providing services and reaching objectives, and the
consequences of budget reductions on individual citizens and the community, are of
inestimable value in the budgeting process. While we would not accept the assertion the
'1he budget is the plan," we do agree that "a plan without a budget is a dream."
Billing and Accounting
Like budgeting, billing, accounts receivable and grant and contract administration are
currently lodged in individual Divisions. All billina. accounts oavable and receivable.
budaetina. and arant and contract administration should be united in the Finance and
Budaet Office. Consolidating these functions will yield economies of scale, result in
consistency, leverage existing staff knowledge and skills, facilitate cross-training of staff,
enhance Departmental resource allocation, improve communications with the County,
and, very likely, improve the cash-flow position of the Department.
All staff positions related to budgeting and billing within the department should be
carefully assessed to determine whether the overall efficiency of the Department would
be improved by their reassignment to the Office of Budget and Finance. It should be the
responsibility of individual Divisions to demonstrate clearly the benefits of retaining any
of these functions for each individual position.
The North Carolina Institute for Public Health
41
I
Ie
I
I
I
I
I
I
I
t'
I
I
I
I
I
I
'e
I
I
New Hanover County Health Department Organizational Analysis
Contracts and Grants Administration
The fiscal administration of grants and contracts is widely variable and the conditions of
grants and contracts are sometimes not understood by the grant or contract
administrator. This often results in misinterpretation of responsibilities and constrained
assignment of staff time, which dampens staff morale.
Grant and contract solicitation is initiated almost exclusively by individual Divisions with
little, if any, communication or collaboration with other Divisions. There is effectively no
support for grant and contract preparation within the NHCHD. Administration of grants
and contracts that have been awarded to the Department is inconsistent, often
dependent solely upon the discretion of individual supervisors. The County Finance staff
is often in a position of having to ''fine-tune'' grant applications and reporting
requirements.
Grants and contracts should be viewed as endeavors and commitments of the
Deoartment. The Deoartment should develoo a oolicv and orocess for reviewina all
arant or contract aoolications to determine their aoorooriateness and ootential
contribution within the context of the mission and oriorities of the Deoartment and for the
administration of arants and contracts.
As envisioned in this report, application for grants and contracts is an appropriate
discussion item for the Management Team. Potential grants and contracts should be
assessed in terms of their relative contribution to the realization of Department goals and
priorities prior to their submission. It is also essential that policies be developed that
define how the termination of grants and contracts will be addressed by the Department,
particularly in terms of employees hired based upon short-term, temporary funding. The
County has recently begun including a notice in position announcements funded by
grants and contracts that they are contingent upon continuing availability of funds.
The roles, responsibilities, and uses of positions funded by grants and contracts need to
be defined and understood by managers and staff throughout the Department. The
distinction between County positions and grant- and contract-funded positions results in
lines of demarcation and conflict that are largely unnecessary. Being a "grant and
contract" employee is frequently used as a justification for not being able to do other
(non-grant and contract) tasks or to help other employees. It should be understood that
in the vast majority of cases grants and contracts fund positions, not individuals. It is
quite rare that a grant or contract funds a specific, individually identified person. In those
instances where it does, it is always explicitly included as one of the Terms and
Conditions of the funding. The current tendency to prohibit individuals from doing
anything other than tasks specifically associated with their grant limits options for staff
deployment. More importantly, however, it hurts staff morale when the funding sources
is used as an excuse to not provide assistance and to insulate some people from the
increasing demands being placed upon staff. Many administrative support staff reported
that while they have been told they "have to do more," other staff cannot help because,
'1hey're on a grant, and they can't do that."
Whether a grant or contract funded program will require an exclusive individual
supervisory position should also be addressed prior to submission of the application.
The Health Department currently has a number of grants that fund between one-and-a-
half and four staff positions for which a supervisory position has been created or
The North Carolina Institute for Public Health
42
I
Ie
I
I
I
I
I
I
I
tI
I
I
I
I
I
I
Ie
I
I
New Henover County Health Department Organizational Analysis
dedicated. It is hard to envision a program of that size that could not be appropriately
overseen by an existing supervisor
The matching requirements of grants and some contracts do not seem to be understood
throughout the Department. We believe that the actual "match" provided by the Health
Department is frequently underestimated because of incomplete or inaccurate indirect
cost accounting allocation. The Health Deoartment should develoo a consistent.
reasoned aooroach to determinina the indirect costs of arants and contracts and
distinauish between recoverable indirect costs and matchina funds.
The "flexibility" and "discretion" associated with some grants and contracts creates a
perceptual problem that occasionally results in upsetting staff morale. This situation is
clearly exacerbated by the current budgetary climate. It is frustrating and disheartening
to some staff to be told that essential service supplies are not available because "we
cannot afford that" when grant funded programs are seen as having access to "luxuries"
like travel funds and catered luncheon meetings. A clear policy needs to be developed
governing the financial control and accountability for individual grants. The discretionary
authority of the grant manager should be clearly and consistently defined. The
Department must retain oversight authority for grants administration.
Co-Payment Policies
Policies and procedures covering co-pays are not understood by the staff charged with
collecting them, as a result, in some cases they simply do not charge patients co-pays.
A consistent fee oolicv. includina the aoolicabilitv of co-oavments. should be develooed
and adhered to uniformlv across the Health Deoartment.
Student Fees
The oolicv reaardina fees oaid bv UNC-Wilminaton and Caoe Fear Community Colleae
students should be reexamined. Many students are receiving family planning and STD
services either free of charge or with minimal co-payments. Fully 12% of clinic patients
are not residents of New Hanover County. An effort should be made to explore
alternative means of collecting fees for these services either from individual patients or
perhaps through a contractual arrangement with the respective institutions. We
recognize that the Health Department is required by some funding authorities to provide
services without regard to "categories" of patients. However, we believe that the Health
Department should explore possibilities for collecting co-payments from students who
are in a dependent status and could well afford to pay for services. It is generally
acknowledged that students "take advantage" of Health Department policies to avoid
claims on their parents' health insurance that would document that they are seeking
family planning or STD services. The reality is, however, that their parents' health
insurance and/or University Health Services cover many of these students.
Furthermore, the co-payment for most services is little more than the cost of a six-pack
of beer We estimate that the revenue generated may well only be in the $5,000 to
$10,000 range each year, but in such tight budget times the Health Department could
put even that relatively modest amount to good use in enhancing services or providing
training opportunities for staff.
The North Carolina Institute for Public Health
43
I
Ie
I
I
I
I
I
I
I
it
I
I
I
I
I
I
Ie
I
I
New Hanover County Health Department OrganlzaNonal Analysis
County Review of New Financial Procedures
Subsequent to establishing streamlined internal budgeting and contract management
procedures, the NHCHD should initiate a ioint meetina with County Finance and Budaet
staff to clearlv identify roles. resoonsibilities. exoectations. and accountabilitv. It may be
beneficial to include the Budget Officer from the Department of Social Services in that
meeting as a model of Department/County coordination. The County Budget Offices are
interested in and supportive of the idea of strengthening the overall budget operations of
the Health Department. It is our opinion that they would greet the reorganization of the
departmental budget functions enthusiastically and would be willing and active partners
in improving the overall system to the benefit of both the Health Department and the
County.
Recommendation 8: Strengthen information systems
management and resources.
Budgeting and information technology responsibilities presently are combined into one
position. This arrangement is simply untenable in an organization as large and complex
as the NHCHD. Each of these functions is large, complex, and essential in and of itself,
and lodging both of them in one office staffed by only two people virtually assures a lack
of proficiency and success in either endeavor. Earlier in this report we suggested the
creation of the position of Associate Director of Information and Administrative Services,
to be part of the proposed new Health Director's Staff. This position would be
responsible for managing, maintain, directing, and enhancing the use of technology
throughout the Health Department.
Information Technology
Information Technology (IT) no longer is a support or subsidiary function within
organizations. Technology has changed the way we work, communicate, deliver
services, and organize our days, projects, and lives. This trend is not going to reverse,
but in all likelihood accelerate. The Health Department has made tremendous strides in
making technology available to virtually all staff. Maintaining technology, enhancing its
reliability, and extending its capability requires full-time attention.
Beyond facilitating current technology, the Associate Director of Information and
Administrative Services should work with direct service providers throughout the
Department to determine and assess the extent to which new technology might
contribute to productivity. The use of mobile devices such as cell phones, pagers,
personal digital assistants (PDAs), and laptop computers by field staff is but one obvious
example.
Portable computing devices have significant potential to allow staff to "do more with less"
and to ''work smarter, not harder." The Health Department performs a number of field
services, which might be conducted much more efficiently if the "paperwork" tasks could
be completed on-site. For example, inspectors in Environmental Health might have their
inspection checklists and criteria on a personal digital assistant (PDA) that could be
The North Carolina Institute for Public Health
44
I
Ie
I
I
I
I
I
I
I
tt
I
I
I
I
I
I
Ie
I
I
New Hanover County Health Depertment Organizational Analysis
completed while they did the inspection and simply downloaded at the office. Maternal
and Child Coordinators might be able to complete the client records while on the home
visit instead of doing it later "back at the office." Efforts like these to change the work
process allows staff to complete the administrative aspects of their responsibilities while
providing the service itself resulting in more productive hours for service provision.
Technology Training
The Department has made significant strides in recent years in making technology
available to staff throughout the Department. However, as in many public agencies,
there has not been an accompanying training effort for staff to assure that people can
use the new tools. The Office of Information Services and Administrative Services
should have as one of its primarv functions the trainina of staff in the use of technoloav
hardware and software.
The staff interviewed seemed to be enthusiastic about the availability and quality of
computers, software, and related technology, but repeatedly cited their need for training
to make optimum use of this equipment. Training needs likely will continue to grow as
technologies proliferate. The approximately 22% of respondents who disagreed or
strongly disagreed with the statement, "I think that the information technology systems I
use on the job are effective and appropriate to the kind of work I do," and the 38% of
respondents who strongly disagreed or disagreed with the statement, ''The level of
automation and computerization in this organization is appropriate to the amount and
kind of work that we do," may have been reflecting a lack of training.
Strongly Disagree Agree Strongly Don't
Disagree Agree Know
I think that the Information technology systems I
use on the Job are effective and appropriate to the 2.4 19.3 66.7 12.2 2.4
kind of work I do.
The level of automation and computerization In
his organization Is appropriate to the amount 5.0 33.1 47.1 13.2 1.7
and kind of work that we do.
In many instances the training required is very basic, such as how to use word
processing and spreadsheet software and Lotus Notes. Other staff would benefit from
slightly more advanced training in PowerPoinl. Elevating the computer skills of all staff
throughout the department will result in almost immediate benefits in efficiency and
improved communication. The Office of Information and Administrative Services would
be responsible for both providing training directly and coordinating information
technology training programs and opportunities with the County.
A number of current staff members have direct previous work experience in the
computer and technology field. Other members of the staff have, through training or
their own initiative, developed significant skills and even mastery over an array of
software programs and computer operations. At present, however, their job descriptions
do not reflect this knowledge and ability, and the current administrative and supervisory
structure and culture make it difficult, if not impossible, for them to share their knowledge
with others in the department. Given the pervasive need for computer training and the
The North Carolina Institute for Public Health
45
I
'e
I
I
I
I
I
I
I
tI
I
I
I
I
I
I
Ie
I
I
New Hanover County Health Department Organizational Analysis
dearth of training resources it is essential that the department take every opportunity to
leverage the skills it does have and make them available throughout the department in a
systematic manner. The skills of current staff. reaardless of oosition. should be enaaaed
to the oreatest extent oossible so as to leveraoe current Deoartment resources. The
"bonus" of having skilled employees train other employees is that it demonstrates the
"team" nature of the Health Department, and serves as recognition for individual skills
and talents. A relatively brief self-assessment questionnaire that could be administered
within the department via e-mail could serve as both a needs assessment for computer
training and provide at least a cursory initial identification and inventory of current skills
and staff resources.
Administrative Support
Since the immediate need for and quickest benefit from training is largely concentrated
in the administrative support staff, and because there are immediate efficiencies that
could be realized by transforming a large number of processes from paper to electronic,
we further suggest that all other "non-information technology specific" administrative
support staff, except those most directly related to budget and finance operations, be
centralized in this office.
Whether the suggestion to centralize administrative support staff and functions is
followed or not, we stronalv suaaest that the roles. resoonsibilities. and reoortina
relationshios of the Administrative Suooort Technicians be examined and clarified.
The introduction and proliferation of computer technology to individual desktops
throughout business and government has transformed the way offices function. Titles
like "secretary," and "clerk typist" have all but disappeared from human resources
nomenclature and been replaced by "office managers," and "administrative support
technicians." Concomitantly, the way managers, supervisors, and professionals work
has changed. A growing majority of "senior" level employees check their own e-mail,
type their own letters and reports, develop their own spreadsheets, and even prepare
their own presentations. With the relatively recent distribution of computer resources
this process is already well under way in the NHCHD. )
While the functions and responsibilities of the administrative support staff have changed,
they remain tied to specific Divisions in which they are responsible for and conduct very
similar activities on a program or project specific basis. Whether this "specialization" is
required by the complexity of individual program information processing regulations or a
remnant of the division-based history and organization of the department warrants
careful consideration. What is viewed as "specialization" may, in fact, represent
unnecessary constraints on the exercise of administrative support staff skills and abilities
and the flexibility of the department to assign resources based on workload.
Many of the administrative support staff are placed in positions where they are
supervised by one person, but responsible to several people. This lack of clear
supervisory lines places them in a very awkward position. On the other hand, some
administrative support staff have been told by their supervisors that they are "not to
speak with" staff in other Divisions, even that they are not to help with questions about
procedures or software.
The North Carolina Institute for Public Health
46
I
'e
I
I
I
I
I
I
I
tI
I
I
I
I
I
I
Ie
I
I
New Hanover County Health Department Organizational Analysis
To illustrate the "bind" that some administrative support staff are placed in, consider that
they have been told not to leave the reception "cage." They have also been instructed
that if a patient needs an immunization shot at any time other than during the
immunization clinic (unless they are a UNC-W student, because they are given
immunizations whenever they happen to walk-in), the administrative support technician
has to go "find" the nurse and ask if the nurse is willing to give the immunization at that
time. How does one ''find'' someone when you are told not to leave your assigned area
and the person you are looking for is not already in your assigned area?
The as System
The as svstem should be subiected to a cost-benefit analvsis to determine its relative
value to the deoartment. If the svstem is maintained. trainina in as access should be
orovided to all manaaement staff in order to encouraae access and use of the data. The
"as" system (offered by as Technologies) is a comprehensive software system that
provides clinic management, billing, tracking, case management, and data entry and
reporting Systems for public health organizations across the country. The NHCHD
currently subscribes to this service at considerable annual cost and uses with varying
degrees of success in a number of the programs of the department. The as system as
it is currently deployed appears to be providing only a small fraction of its potential utility
to managers. We heard a great deal of criticism of the as system during our program
reviews, including comments that it was awkward, did not provide certain required
program data, and that several programs were "doubling" data entry in both as and the
NC Division of Public Health's HSIS system.
Our study did not allow time or effort to do a point-by-point evaluation of the relative
benefits of the as System to the Health Department but the nature and frequency of the
comments clearly demonstrate that either the as system does not provide value-added
information access OR people do not know how to access and use the system in a
timely and effective manner. The as system should be assessed critically to determine
its current and potential value to the Health Department. If it is superior to the state HSIS
system, people throughout the organization need to be trained on how to use it. If, on
the other hand, the Department is going to employ only a fraction of the potential of the
as system it may not be worth the cost, both in expenditures and in staff time in the
double date entry required to maintain both as and HSIS.
Recommendation 9: Centralize and strengthen health
education, training, and communications capabilities.
There are three common and necessary activities in the Health Department that call
upon the same basic specialized areas of knowledge and skill: community health
education, organizational training and development, and communications and public
information. All three require basic training in educational design and in community and
organizational development. The NHCHD is fortunate in having a small staff with the
requisite knowledge and skill in this area and we believe the Department should use
them to further these important ends. While many of these functions, such as
supervisory training, patient education and media presentations can and will be handled
The North Carolina Institute for Public Health
47
I
'e
I
I
I
I
I
II
I
tt
I
I
I
I
I
I
'e
I
I
New Hanover County Health Department Organizational Analysis
at point of contact and by the resources of other Divisions, we believe that a great deal is
to be gained by providing central coordination and oversight in one location. The Health
Deoartment should consider aooointina an Associate Director of Education. Trainina.
and Develooment to be resoonsible for health education and health oromotion activities.
staff trainina and develooment. and oublic relations and oublic information. The Human
Relations staff should reoort to this oosition.
Staff across the organization expressed particular frustration and dissatisfaction with the
lack of continuing education opportunities. There is also a notable lack of awareness
among staff about what the other Divisions in the Department do. Some nurses do not
know what programs and services the other Nursing Divisions provide. Additionally,
many of the staff are not familiar with basic principles and practices of public health.
The creation of this position focuses priority, attention, and resources on the importance
of education and training both internally and externally. Coordination of personnel
classifications, job descriptions, work plans, and job performance appraisals with staff
development and training will be greatly facilitated by housing these functions in the
same organizational unit.
Community Health Education
There is an increasing need to bridge the gap between what the Health Department and
the public know about prevention and control of chronic and communicable disease.
New Hanover County, like most counties across North Carolina and the nation, has
significant problems of drug and substance abuse, smoking, obesity, sexually
transmitted disease, and other preventable health problems. Many of these problems
stem from learned behaviors acquired as children. Many young and older adults are not
aware of the hidden risks of uncontrolled hypertension, high cholesterol, lack of physical
activity, and improper diets. Even persons who are health conscious are not aware of
the resources in their community and the methods of seeking and arranging for
appropriate care.
The NHCHD health education staff has been active in a number of primary prevention
programs related to stopping tobacco use before it starts, smoking cessation, injury
prevention, childhood obesity, and promotion of physical activity. They have also been
active partners in an innovative and imaginative community based program that has
engaged young people in taking community advocacy roles to limit and prevent smoking
in places where teens aggregate. The job of health education in a local health
department is to do everything possible to raise public awareness of the causative
factors of preventable disease through effective use of the media, and through building
collaborative relationships with other organizations (churches, schools, community
groups, and health advocacy groups). The traditional images of "handing out pamphlets"
and conducting single purpose health campaigns has little role in an aggressive and
imaginative community health education program and have not been priorities in the
NHCHD.
Several years ago the health education program was moved to the Women's Health
Division as part of an administrative restructuring. However, the population"based
perspective of the discipline and the ongoing need for Department-level impact suggest
that the health education program is not well placed in this location. Health education is
The North Carolina Institute for Public Health
48
I
'e
II
I
I
I
I
I
I
tI
I
I
I
I
I
I
'e
I
I
New Hanover County Health Department Organizational Analysis
an inter-disciplinary field that is as applicable to environmental health, vector control, and
media based educational efforts as it is to clinic based educational efforts. The
relocation of health education to a more central role in the Deoartment and co-location
with trainina and oublic information and communications functions would serve the
citizens more effectivelv and reoresent more effective utilization of staff.
Organizational Training and Development
It is clear from the survey and program review interviews that the majority of staff believe
that a high degree of skill and training is required for them to do their job effectively, and
also clear that they believe most people they work with do not understand the complexity
and demands of their work.
Strongly Disagree Agree Strongly Don't
Disagree Agree Know
It takes a high degree of training and skill to do
my lob well. 0.8 10.7 52.9 33.9 1.7
he level of complexity and demands of my work
are well understood by most of the people who 15.6 46.7 32.8 1.6 3.3
work here
Generally, the staff appears competent, effective, and efficient though many do complain
that they have not had the opportunity for the kind of training and continuing education
they need to continue their job well. As we looked across divisions and talked with a
number of staff and supervisors we were particularly concerned that many if not most
staff lacked the kind of common training, especially in basic public health concepts and
methods, that they need to understand when and how more effective collaboration might
be useful, and the importance of population based initiatives to solve community
problems.
We believe there is extensive need for staff development and training in the Department.
Most professional staff begin with solid training in their respective disciplines, but lack
the kind of conceptual and skill training they need to work effectively in the complex and
ambiguous environment of public health. Other than information technology training
needs cited elsewhere, the specific training priorities we have seen in this analysis
include leadership and supervisory training, core public health concepts, and basic
operational and management planning concepts and methods. We believe that any
resources given to this effort can have impressive returns in organizational
effectiveness, staff sense of self-worth, and overall employee retention rates. As it is,
over half of the survey respondents do not feel that the Health Department provides
them opportunities for growth and development.
Strongly
Disagree
Agree Strongly
Agree
Don't
Know
Disagree
There Is opportunity for grow1h and development
In this organization 21.5
30.6
35.5
12.4
0.0
The Health Deoartment should develoo a mechanism to olan. coordinate. and evaluate
continuina education and trainina for its staff. Training and development of line staff,
The North Carolina Institute for Public Health
49
I
'e
I
I
I
I
I
I
I
t'
I
I
I
I
I
I
'e
I
I
New Hanover County Health Department Organizational Analysis
support staff, supervisors, and managers is a crucial precondition to many of our
recommendations and to many of the basic steps needed to improve departmental
effectiveness and to enhance its working environment. This is a very common issue and
can be expected to be equally important to public health organizations in surrounding
counties. Active collaboration among neighboring local health departments to explore
training needs and the feasibility of contractual or other agreements for sharing training
resources might result in more and different training opportunities than a single
department could provide. A collaborative approach could also strengthen the case for
grant funding from one or more governmental or non-profit foundations and should be of
interest to Coastal Area Health Education Center and other regionally oriented
organizations.
Because the individual training resources of the Department are very limited it is going to
take a concerted effort to document the need, develop proposals for specific training
efforts, find funding and training resources, and coordinate the overall training effort.
Although some of the needed training will be very specialized, there are many common
needs that cross divisional and even agency lines. The proposed NHCHD Training
Office coUld explore both regional needs and resources in other local health
departments and work to build cooperative ventures and inter-agency efforts within New
Hanover County when there are overlapping needs and opportunities.
Communications and Public Information
Many staff view the lack of community awareness about the importance and contribution
of the Health Department as one of the reasons the Health Department has not faired
better in County resource allocation decisions. The NHCHD needs a "marketing
campaign" that goes well beyond traditional "health education" services. The Health
Department has a strong and substantial history of contributing to the realization of
public health goals not simply in the county, but in the state and nation as well. As is true
for planning and designing training opportunities, the Department might be able to
extend its effort by increasing involvement of the broader communications resources of
the county and exploring greater cooperation of surrounding counties in the effort. The
Wilmington newspapers and television and radio stations are regional resources, and
their improved coverage of public health issues and public health services will benefit all
governmental, non-profit, and private health organizations throughout the region. One
maior Drioritv in this area should be to educate County aovernment staff and the County
Commissioners about the services and imDacts of the NHCHD.
The Health Department appears to enjoy wide and significant support in the community
among those who are aware of its contributions. However, the majority of citizens are
not generally aware of the services provided by the Department beyond issues that tend
to gain media attention - vicious dogs, mosquito spraying, and restaurant ratings. There
were repeated comments in the program review interviews and focus group discussions,
reinforced in the questionnaire responses, that the NHCHD was providing needed and
important services to the community and having a major impact on the personal and
environmental health of the citizens.
The North Carolina Institute for Public Health
50
I
'e
I
I
I
I
I
I
I
t'
I
I
I
I
I
I
'e
I
I
New Henover County Health Department Organizational Analysis
Strongly Disagree Agree Strongly Don't
Disagree Agree Know
The activities and services of the NHCHD are
Important and valuable to the community we 2.5 0.8 31.2 65.6 0.0
serve
The same respondents, however, emphasized that many citizens and related community
groups in the county were not aware of the Department's activities and services. County
Commissioners may not be aware of the breadth of services provided by the Health
Department and their impact on every citizen and visitor to the County on a daily basis.
It is imperative, particularly in a period of severe budget restrictions, that the
Commissioners are fully aware of the contribution Public Health makes to the protection
of citizens and the quality of life in New Hanover County. Improving public information
and public relations was among the several priorities in the 2000 Strategic Planning
Effort (Priority III, Communication, Education, and Marketing) and, from the reports we
have received, there has been significant advancement in this area.
Recommendation 10: Conduct a comprehensive review of
personnel (human resources) policies and procedures and
develop a written handbook of same that Is consistently
interpreted and applied consistently throughout the
organization.
Currently the NHCHD employs a wide range of personnel policies and procedures that,
according to staff, are not applied uniformly. Reportedly there are disparities in the
interpretation and application of policies, not only between and within Divisions, but also
between positions and even professions. The result is significant frustration for some
individuals and discord among some of the staff. In fact, some of the disparities in
application might be viewed as presumptively litigious. As one staff member explained
the situation, "There are very few policies and procedures that are applied Health
Department-wide. Every Division does their own thing in their own way"
In response to the survey question, "The human resources policies and procedures in
the NHCHD are clearly defined and known to most staff," approximately 17%'of the
respondents strongly disagreed or disagreed with the statement. Some might view this
as a relative minority of the staff, but it represents nearly 30 people and the question
asks about most staff knowing, not all staff. We would also suspect that in many cases
staff know what they have been told the policy is in their Division and they understand
that quite clearly. In some instances that is different than what the policy actually is.
Strongly Dlssgree Agree Strongly Don't
Disagree Agree Know
The human resources policies and procedures In
he NHCHD are clearly defined and known to moat 2.5 14.1 69.4 13.2 0.8
staff
The North Carolina Institute for Public Health
51
I
'e
I
I
I
I
I
I
I
t'
I
I
I
I
I
I
'e
I
I
New Hanover County Health Department Organizational Analysis
The turnover rate for the Health Department is actually lower than might be anticipated
for a public agency of its size. In the eighteen-month period from July 2001 through
June 2002 only 19 employees left the agency. This includes retirements and positions
eliminated as the result of budget cuts. There does not appear to be any significant
difference among the Divisions in the turnover rate. Exit Interviews of those employees
who left the agency during that time period were reviewed as one aspect of the
organizational analysis. Of the nineteen departing employees, nine had been with the
Health Department less than two years; five between two and five years; three between
five and ten years; one between 10 and 15 years; and one more than 25 years.
As would be expected, the feedback provided by the exit interviews covers the entire
range from excellent to poor Certain "themes," however, directly reflect and are
consistent with the information gathered by each of the mechanisms employed in the
organizational analysis. That is to say, the people at the Health Department are (mostly)
wonderful to work with, and the work is rewarding, but there are problems with the way
employees perceive themselves to be treated.
The dominant sense conveyed in the exit interviews is that people found co-workers to
be good and the purpose of their work worthwhile. A fairly typical response to the
question, 'What did you like most about your job and/or the County?" is, ''The people I
worked with, the concept of public service and community improvement."
The exit interviews reflect the same apparent contradiction that is so prevalent among
Health Department staff; that is, even while expressing very deep and sincere
complaints about rules, procedures, policies, fairness, and support issues the vast
majority quickly add, "But, I love my job, and I would not want to work anywhere else."
To a casual observer this might seem contradictory; it is not. The overwhelming majority
of the employees of the health department are sincere, dedicated people who both want
to perform quality work and want to be of service to their community. Their standards for
themselves and their co-workers, are high, and so are their standards for the
performance of the organization in which they work. The seeming "disconnecf' is not
between "bad" and "good" but between "good" (not entirely desirable, but tolerable) and
"better" (what we are capable of being). They are critical of things precisely because
they perceive some of the rules, procedures, and policies, and the behavior of some
supervisors, as not only unnecessary, but dysfunctional. Many of the "ways of doing
business" in the Health Department, while originally conceived and intended to assure
the quality of work and services delivered, have in fact become impediments to the full
realization of the efforts and creativity of the staff.
The concerns expressed in the exit interviews include issues with faimess of supervisor;
need for flexible schedules; "micromanagement and having to account on paper for
every minute of the day and what I did;" "No written policies and procedures;" and
supervisors being closed to suggestions. "[It's an] 'Old girls club'; they say they are
open to questions and new ideas, but they really are not."
This discontinuity is perhaps best illustrated by one answer to the question, 'Would you
recommend the County to a friend as a place to work?" "Yes, but I would caution them
to be as nonverbal as possible."
The North Carolina Institute for Public Health
52
I
Ie
I
I
I
I
I
I
I
t'
I
I
I
I
I
I
Ie
I
I
New Hanover County Health Department Organizational Analysis
Time Accounting
The ouroose of time accountino should be clearlv identified and articulated to all staff.
oarticularlv emohasizino orocedural differences resultino from job functions and
resoonsibilities. There currently is a very wide range of expectations applied throughout
the Health Department with regard to tracking and accounting for employee time, a
variability that again results in frustration and discord for some of the staff. One staff
member emphasized that, "too much attention is placed on personnel issues such as
keeping track of time, leave slips, and so on rather than improving efficiency.
The Deoartment should develoo. aoolv. and enforce a consistent and uniform oolicv for
accountino for staff time. We strongly suggest that this policy allow for flex-time for daily
schedules and lunch periods. Given the nature of the range of services provided by the
Health Department, employees need to understand that the nature of specific job
responsibilities requires different approaches to flex-time. For example, clinic services
that begin at 8:00 AM require that clinic staff be there at least by 8:00 AM. You cannot
"flex" your time by arriving at 8: 15 or 8:30 even if you are willing to work 15 or 30
minutes lcinger that aftemoon.
It is true that the flex time "policy" is widely misunderstood and differentially applied. The
County policy is that Departments can adopt "flex-time" schedules that meet three
criteria.
1 Coverage must be assured and maintained and services delivered;
2. The supervisor must approve and be able to can keep track of the employees
schedule; and,
3. The flex-time schedule cannot create an "undue business hardship."
An "undue business hardship" might be created if a supervisor were to work four ten-
hour days while requiring their staff to work five-day weeks. In this situation, the
supervisory duties and responsibilities of the direct-line supervisor would have to be
assumed and provided by their supervisor 20% of the time.
Several "policies" are attributed to the County in areas where the County either does not
have any policy, or the County interprets the policy differently. For example, a "one-hour
lunch break" is not a County policy. Bymutual agreement, an employee and supervisor
could agree to a thirty-minute lunch period. Consistent with coveraoe and service
rsauirements. establish and imolement a consistent oolicv of "flex time" in the Health
Deoartmenl. includino oivino emolovees the ootion of 30 or 60 minute lunch oeriods.
There are a number of jobs in the Health Department that require weekend and evening
work (e.g. environmental inspection of food vendors at fairs and festivals; client home
visits). Current workloads and overtime policy result in these hours simply being added
to employee workweeks without any form of compensation. A policy that allows
employees who work a weekend to take two days off within the pay period to "make-up"
is not functional if they are also expected to complete the same amount of work in three
workdays as they are in five. Positions that rsauire evenino and weekend work should
be svstematicallv assessed to determine a fair and eouitable oolicv for either overtime
oav or comoensatorv time off. We encourage the department to enlist the assistance of
the County Department of Human Resources and to involve employees directly
impacted by this situation to explore creative alternatives that might be appropriate to
addressing and resolving this workload inequity.
The North Carolina Institute for Public Health
53
I
'e
I
I
I
I
I
I
I
t'
I
I
I
I
I
I
'e
I
I
New Henover County Health Department Organizational Analysis
Many staff report that the current policy and procedure for reporting absences due to
illness is cumbersome and inefficient, often requiring multiple phone calls to multiple
people in the Department. It would be far more efficient and produce less stress and
resentment to have one person at one number who would be contacted in the event that
an employee was sick or had an emergency. That single contact person would then
convey the information to other staff as appropriate. We suaaest establishina a more
"user friendly' Drocedure for emDlovees who have to reDort in sick.
Grant- and Contract-Personnel
The current "free markef' approach to grants and contracts has encouraged individual
divisions to act unilaterally in the pursuit of additional funding. In addition to the obvious
questions about the appropriate alignment of grant and contract programs with
departmental goals and priorities, this approach has also resulted in some personnel
challenges particularly when funding had subsequently terminated. Consider the case of
an employee who was hired on a grant or contract for which funding has ended. Does
that employee have RIF privileges? If so, do those privileges apply only to the Division
that originally received the grant? Or, do those privileges apply to the entire Health
Department? The ambiguity of the current situation has already resulted in considerable
staff angst and less than collegial exchanges between Divisions.
The common practice is for positions based upon "temporary" funding to be contingent
upon continued availability of funding. It is not common practice to treat employees on
grants for which the funding has been terminated as "RIP employees. We encouraae
the Health DeDartment to work with the New Hanover Countv Human Resource
DeDartment in develoDina a clear and consistent Dolicv reaardina staff hired on the basis
of arants and contacts.
Uniforms
Few "issues" were mentioned more frequently during the course of our study than the
"uniform allowance." While we did not encounter anyone who spoke passionately in
favor of it, opponents were unabashed in their criticism. "It creates 'classes' of
employees like they [the nurses] were the only professionals in the department." "I'd
rather wear what I want to wear; blue and white is not a uniform." 'Why don't we just
give back that money and use it for something more important?" Eliminating the
"uniform allowance" would result in a budget savings of approximately $38,500 a year.
We suaaest the NHCHD Eliminate the "Uniform Allowance" and reexamine the dress
(color) code for Dublic health nurses.
One of the arguments in favor of "uniforms" is that "navy blue and white" are the
traditional colors of public health nursing and are recognized in the community. We
wonder how many people outside the field of public health know that.
Phones and Volcemail
Several of the off-site employees have multiple phone numbers and voice mail boxes.
This not only requires them to check multiple message sources, but impedes the
The North Carolina Institute for Public Health
54
.
'e
'.
.
.
.
I
I
I
t'
I
I
.
I
.
I
'e
I
I
New Hanover County Health Department Organizational Analysis
efficiency of communication. Each emolovee should have one ohone number and one
voice mailbox.
Policies Manual
We suggest that the NHCHD completely review and revise the "Policy Manual" (Green
Book). The "Green Pages," policy and procedure updates and explanations that are
distributed periodically to the staff, represent a good beginning for a Department-wide
Policies and Procedures Manual. There are, however, very wide disparities in the
interpretation and application of policies that vary not only between Divisions, but also
within Divisions. We strongly suggest that a committee representing all levels and types
of staff be constituted to completely review the current policy manual and revise and
update it as appropriate with due consideration of County policies, departmental
functions and responsibilities, and recognition of ''family friendly" policies and individual
staff preferences for flexibility. It may be beneficial to ask assistance from the County
Human Resources Department at various points throughout this process.
After a "policy manual" has been developed and adopted, it should be formatted in a
"user friendly" manner and made available to all Health Department staff.
It is also imperative that those policies that are adopted by the department be equitably
applied to all employees. There is a widespread perception that the "rules" are applied
one way to administrative staff, another to nurses, another to social workers, and still
another to supervisors and division directors. Indeed, some instances of this were
observed during the course of our study. Consequently, we suooest trainino all
suoervisors in the aoorooriate Deoartment and Countv oersonnel oolicies to assure
consistent and uniform aoolication across the Health Deoartment.
Recommendation 11: Review current space allocation and use
and explore alternatives for Improvement given existing funding
and resources.
Nursing clinic space is clearly inadequate, but could be improved by closer integration,
scheduling, and management of clinic operations. Similarly, laboratory space currently
is not adequate for the staff and workload assigned. The working space of the Nutrition
and WIC programs appears to be crucially inadequate and does not allow the space to
organize clinic oriented business in an effective manner and, more important, does not
provide the required privacy for eligibility interviews and client education and counseling.
A significant portion of the limited "office" space currently is assigned to staff that work
primarily in other locations. These staff spend less than 20% of their time in the
assigned offices and cubicles in the main Health Department building. Given the
obvious lack of space and the extremely crowded conditions, assigning space to achieve
optimum efficiency, fairness, and quality services is essential. The current cubical size
and arrangement is less than adequate - crowded, impersonal, and cramped, which
produces a "public" environment that makes it virtually impossible to safe-guard client
confidentiality or to conduct supervisory or team meetings in a private, professional
The North Carolina Institute for Public Health
55
I
'e
.
.
.
.
.
.
.
tI
.
.
.
.
.
.
'e
.
.
New Hanover County Health Department Organizational Analysis
atmosphere. Some staff meetings literally are held in the hallways, parking lots, and
bathrooms.
Space, and the appropriate use of it, clearly is an issue for the staff because it was
mentioned frequently in individual interviews and the focus groups. Two questions on
the survey relate specifically to the space and physical facilities of the Health
Department. Nearly 30% of the respondents strongly disagreed or disagreed with the
statement that, "This is a pleasant and functional facility in which to work." A staggering
66+% strongly disagreed or disagreed with the statement that, ''The physical space here
is well arranged and well used in meeting our organizational goals and priorities."
Strongly Disagree Agree Strongly Don"
Disagree Agree Know
This Is a pleasant and functional facility In which
to work. 5.8 24.0 60.3 7.4 2.5
The physical space here Is well arranged and well
used In meeting our organizational goala and 33.6 32.8 27.9 3.3 2.5
IDriorltles. .
The Health Deoartment should develoo a rationale. criteria. and mechanism for the
allocation and utilization of soace in the buildina. We strongly encourage that this
process not be constrained by any of the current assignment or use patterns, but instead
be based upon "functional need" of the occupants while acknowledging the severe
space limitations. More specifically, this process should be approached from the
perspective of the "space" belonging to the Health Department and not to any individual
Division that might currently occupy the space.
It also would be useful to have one central point assigned responsibility for the
scheduling of all meeting rooms in the Health Department. Consistent with the thrust of
many of our recommendations and suggestions, meeting rooms should be viewed as
Departmental resources and not the property of any individual Division.
The North Carolina Institute for Public Health
56
I
Ie
I
I
I
I
I
I
I
~
I
I
I
I
I
I
'-
I
I
SCHOOL o(PUBLIC HEALTH
The UNIVERSITY of NORTH CAROLINA at CHAPEL HILL
. The IiDRXH CAROLINA
Instltute Jor JJlubllC Health
New Hanover County Health Department
Organizational Analysis
Volume 2: Appendices
October 2002
UNGt
SCHOOl. Of PUBLIC HEALTH
I
Ie
I
I
I
I
I
I
I
~
I
I
I
I
I
I
Ie
I
I
New Hanover County Health Department
Organizational Analysis
Volume 2
Appendices
October 2002
by
H. Pennington Whiteside, Jr., MSPH
Deputy Director, NCIPH
Charles T Grubb, PhD
Consultant
William T Herzog, MSPH
Consultant
Janet G. Alexander, MSPH
Research Associate, NCIPH
Sheila S. Pfaender, MS
Research Associate, NCIPH
The North Carolina Institute for Public Health
School of Public Health
The University of North Carolina at Chapel Hill
I
Ie
I
I
I
I
I
I
I
t'
I
I
I
I
I
I
Ie
I
I
New Hanover County Health Department Organizational Analysis
Table of Contents
Appendix A - Organizational Analysis Model .. . . . . . . .. 3
A.1 Overview .. .. .. . . . . . .. 3
A.2. Flow Diagram .................... .. ...... ....... 5
A.3. Basic Elements and Subtopics . . .. ......... .. . . . . . . . 6
Appendix B - Program Review ................ . ........ . . . . . .. 9
B.1 . Methodology.. ..... .............. .. .. . . . . . . . . . . .. 9
B.2. Emphases.......... . . . . . . . . . . . . . . . . . . . . . . . . . 10
B.3. Fact Sheet .... .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 12
BA. Program Interview Guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
B.S. Board of Health Interview Guide. . . . . . . . . . . . . . . . . . . . . . 17
Appendix C - Survey .. ...... . . 18
C.1. Methodology .... ............................. . . . . . . 18
C.2. Emphases . . . ..... . .. ... ... .... 19
C.3. Invitation Letter and Instructions .. .... . . . . . . . . . . . .. . 21
CA. Fact Sheet .... ............. . . . . . . .. ...............23
C.5. Survey Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . .25
C.6. Results.... . .. ..... . ............... . 28
Appendix D - Focus Groups ............................... .41
o 1 . Methodology .. . . . . . , . . . . . . . . . .. 41
0.2. Invitation Letter. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. ........ .42
0.3. Fact Sheet ................................. . . . . . .44
o 4. Discussion Guide. . . ... . . . . . . . . . . . . . . .. ... . . 46
0.5. Summary............................. ... .. . . . . . . . .49
C-
,
Appendix E - Expert Review Panel ................................... 59
E.1 . Methodology ............................. . . . . . . . .. 59
E.2. Panel Members ........ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Appendix F - Health Department Organizational Charts ................ 61
F.1. Agency............... .. . .. . . . . .. .. .. 61
F.2. Administration . . . . .. ....... 62
F.3. Animal Control . . . . .. ... .. ....... 63
F.4 Child Health ....... ....... .... . . . . . . 64
F.5. Communicable Disease. . . . . . . . . . . . . . . . . . .. . . . . . . .. . 65
F.6. Community Health .... ... . . . . . . . . . . . . . . . . . . . . . .. 66
F 7 Dental Health .................................. . .... 67
F.B. Environmental Health . . . . . . . . 68
F.9. Laboratory . . . . . . . . . . . . . . . 69
F 10. Nutrition ................................... 70
F 11 Women's Health .. . .. ............. 71
Appendix G - The North Carolina Institute for Public Health
729
The North Carolina Institute (or Public Health
2
I
Ie
I
I
I
I
I
I
I
fI
I
I
I
I
I
I
Ie
I
I
New Hanover County Health Department Organizational Analysis
Appendix A - Organizational Model
A.1. Overview
The Oraanization Analvsis of the New Hanover County Health Department has focused on
trying to improve organizational effectiveness and enhance the working environment for the
agency's employees.
A framework of eight elements and sixty-one sub-topics was integrated into the specific steps
used to study the organization including: Detailed Proaram Reviews, Staff Survev and Focus
Group Discussions. During the process the analysis team also spoke with a number of current
and former Board of Health Members, representatives of the County Manager's Office, and
several other agency heads in county government. The first full draft of the report was reviewed
by an Expert Panel of experienced public health professionals as part of the overall project
design.
Staff and consultants of the North Carolina Institute conducted the Detailed Program Reviews.
This process focused on the specific divisions and programs of the Department and included:
detailed review of written documents and records; interviews with work group units; informal
groups; individual staff at management, supervisory, and line levels: and, on occasion,
interviews with related county officials and other stakeholders outside of the organization itself.
This entailed extensive time and effort within the larger divisions. Additional special reviews
were also held later in the study focusing on specific functions such as financial management,
information systems, and human resources management. We developed a general statement of
methodology and interview guide for these program reviews, but these were not intended to be
nor were they conducted as tightly structured interventions. We often asked the staff present to
talk about what was important to them and they did. Many of the discussions were confidential
and many recorded only in handwritten form. Often, the meetings were held in the limited
facilities of the particular work unit, sometimes hallways, and the staff present were subject to
constant interruptions. The basic goal of the program reviews was to learn as much as we could
about the operations, issues, and ideas of the individual departmental programs.
The survey component of the analysis consisted of a series of Focus Group Discussions and an
on-line Staff Survev Both of these interventions were deliberately designed to work across
divisional lines in the department, and in so doing, to try to gain a picture of the department as a
whole. The on-line Staff Survev. described in Appendix C, was adapted from a questionnaire
developed by one of the consultant team and used in teaching Organizational Analysis and
Change, and in previous consultations with health care clinics, health departments, and health
research organizations. An experienced team of staff from the Institute conducted six Focus
Group Discussions and, as described in Appendix D, followed a much more structured interview
design and format, from selection of participants to actual conduct of the interviews. The
primary goal of both of these approaches was to try to learn as much as we could in a
structured way about the operations, issues, and ideas about the department as a whole.
The purpose and goals of the individual interviews with Board of Health Members, County
officials, and other agency leaders were varied. In some cases the individual interviewees had
and followed their own agendas. In others the interviewer opened with a series of general
questions that often led into more general discussion of the organization and the analysis itself.
The North Carolina Institute for Public Health
3
I
Ie
I
I
I
I
I
I
I
fI
I
I
I
I
I
I
Ie
I
I
New Hanover County Health Department Organizational Analysis
For example, the interviews with several Board members consisted primarily of suggestions of
points that needed to be included in the analysis. The interviews with representatives of the
County Managers' Office were operational in nature, spent learning about the county budget
and human resources policies and procedures and discussing their points of contact and
experiences with the Health Department. The interview with the Hospital Administrator
consisted primarily of his putting forth a very interesting proposal for consideration by Health
Department leadership and the Board of Health.
Initially, the analysis plan included a series of formal interviews of county, state, and regional
stakeholders. This aspect of the study was never completed for several reasons, the most
important being that a comprehensive stakeholder interview process had been conducted by
Health Department staff and Board of Health members as part of the 2000 Strategic Planning
effort.
Project staff convened an expert panel of experienced public health professionals upon
completion of the first draft of this report and gained immensely from this discussion. The
members of this panel are listed in Appendix E.
The Flow Diagram presented in Appendix A.2. depicts the basic structure of the project.
The appended list of Elements and Subtopic (Appendix A.3.) provided the basic framework for
the program reviews, the on-line questionnaire, and the focus group discussions, and was a
primary reference in compiling the first draft of this report.
The interrelationship of the Elements and Subtopics to the on-line questionnaire is depicted in
Appendix CA The two lists presented in Appendices B.2. and C.2. outline the intended
coverage of elements of the Elements and Subtopics in the Program Review and Staff Survey
respectively. The general guide used in discussions with selected Board Members and former
Board Members is shown in Appendix AA.
The North Carolina Institute for Public Health 4
I
Ie
I
I
I
I
I
I
I
i'
I
I
I
I
I
I
Ie
I
I
New Hanover County Health Department Organizational Analysis
A.2. Project Flow Diagram
Administrative Team
Whrteslde, Grubb, Herzog,
Pfaender, Alexander
..0..
Preliminary Stage (Complete by July 11, 2002)
Organizational readiness for Organizational Analysis, Contract, Staffing, Design, Local Advisory Team
Common Framework: Organizational Analysis Matrix and Elements
-0-
-0-
Organizational Survey
Focus: Organization as a
Whole
Tasks: Questionnaire
Focus Groups
Stakeholder Interviews
Conclusions and recommendations
Program Review
Focus: Specific Programs and
Services
Tasks: Document Review
Detailed Interviews
Observation
Conclusions and recommendations
Target Completion: 8130/02
Target Completion: 8130/02
-0-
-0-
Summary Panel and Retreat (Project Team and Consultants)
Review conclusions and recommendations from organizational survey and program review efforts
Request additional information and suggestions as needed
Develop general conclusions and action recommendations
Target Completion: 9/27/02
Report to Organizational Leadership and Board (by October 26, 2002)
n
Final Written Report (by December 20, 2002)
The North Carolina Institute for Public Health
5
I
Ie
I
I
I
I
I
I
I
t-
I
I
I
I
I
I
Ie
I
I
New Hanover County Health Department Organization.al Analysis
A.3. Basic Elements and Subtopics
1.0 Organizational Mlsslon/GoalsNalues
1.1 Strategic Direction (Sense of organizational movement in a purposeful direction)
1.2 Mission (Clear and concise statement of what the organization exists to accomplish)
1.3 Vision (Definable view of what the organization and its services will look like in the
future)
1.4 Issue Identification (Written definition of important issues facing the organization)
1.5 Forecasting (Analysis of trends in community and environmental health status and
in related social and economic factors)
1.6 Goals (Defined states or conditions to be achieved in community health)
1.7 Priority Setting (Determination of relative importance or urgency of health issues or
goals)
1.8 Culture (Strength of organizational history and sense of community)
1.9 Values (Underlying beliefs and taboos within the organization as they relate to task
achievement)
2.0 TaskslTechnology/Workload
2.1 Professlonal/Technical Competence (Staff qualifications and quality of operations,
services and products)
2.2 Productivity (Achievement level of staff and/or work unit)
2.3 Effectiveness Assessment (Systems and procedures used to measure
achievement and outcomes)
2.4 Efficiency (Activities or "outpuf' as related to human and material resources
required)
2.5 Service Capacity (Maximum possible performance level given available resources)
2.6 Workload Equity (Balance in assignments and performance among staff)
2.7 Technology Currency/Obsolescence (How current are equipment and support
systems as related to tasks and goals?)
2.8 Technology Utilization (Optimal use of technology as related to tasks)
3.0 Structure/Communication/Coordination
3.1 Division of Authority/Responsibility (The organizational chart on paper and as it
actually functions)
3.2 Clarity of Reporting Channels/Protocols (How well employees understand and
work within the established structure, clarity to those outside organization)
3.3 Hierarchical Communication/Coordination (Communication and coordination up
and down lines of authority)
3.4 Inter-Divisional Communication/Coordination (Communication and coordination
across and between divisions, units)
3.5 First Line Supervision System (Importance given to and support systems provided
to persons who directly supervise clinical or field staff)
The North Carolina Institute for Public Health
6
I
Ie
I
I
I
I
I
I
I
i'
I
I
I
I
I
I
'-
I
I
New Hanover County Health Department Organizational Analysis
3.6 Role/Expectation Clarity (Degree to which work units and staff clearly understand
the role and responsibilities)
3.7 BoarcllExecutive Relations (Working relationships between executive offices and
board members, mutual understanding of respective roles in policy, management,
and operations)
4.0 Management
4.1 Leadership (Effectiveness of leadership staff in moving the organization to interpret,
set, and achieve strategies over the long-term)
4.2 Management/Business Planning (Regular planning of division and unit actions to
meet major organizational goals)
4.3 Operational Planning (Day to day planning of unit operations and other tasks
required to meet specific operational objectives)
4.4 Evaluation and Monitoring (Systems and procedures used to measure
effectiveness and efficiency of structures, processes, and achievements)
4.5 Coaching, Directing, and Controlling (Role and functions of executives,
managers, and supervisors in leading and developing staff to meet their highest
potential performance)
4.6 Organizational Representation (Interpreting organizational programs and needs to
public, political, and other org'anizations)
4.7 Error Correction (How single and repeated performance errors and handled)
4.8 Rewards and Sanctions (How excellent performance is recognized and negative
performance is corrected)
4.9 Information Systems Management (Design, currency, and user friendliness of
information management systems, emphasis on staff competency development)
5.0 Human Resources
5.1 Staffing Adequacy (Qualifications and number of staff in relation to required
services and community expectations)
5.2 Policies and Procedures (Availability and leadership understanding of written
human resource policies and procedures)
5.3 Recruitment (Systems, procedures, and overall ability of organization to recruit
qualified staff in a timely manner)
5.4 Development and Training (Resources and actions to train and develop staff to
their maximum potential competence)
5.5 Utilization (How effectively are individual knowledge and skills being used within the
organization)
5.6 Staff/Management Perceptions (Degree of congruence, or agreement, in how staff
and management perceive the organizational climate, culture, and performance)
5.7 Staff Cohesion (Degree to which staff pull together to meet common goals and
respond to common problems)
5.8 Morale and "Espirit de corps" (Degree of basic job satisfaction, self-pride, and
group pride)
5.9 Turnover (Annual turnover of staff tabulated by unit and specialty as seen in a
historical or comparative context)
The North Carolina Institute for Public Health
7
I
Ie
I
I
I
I
I
I
I
i'
I
I
I
I
I
I
Ie
I
I
New Hanover County Health Department Organizational Analysis
6.0 Finances/Facilities/Equipment
6.1 Budgeting/Planning Interface (Correlation and integration of the organizational
planning and budgeting processes)
6.2 Revenue Planning and Forecasting (Relative Effectiveness of organization in
estimating and planning for changes in available revenues)
6.3 Revenue Acquisition (Effectiveness of organization in finding and acquiring the
funds necessary to achieve organizational goals)
6.4 Accounting Systems (Adequacy of the systems and procedures necessary to
account for organizational resources and expenditures)
6.5 Grant/Contract Management (Ability of the organization to provide managerial
support to special grants and contracts)
6.6 Clinic and Laboratory Space (Quality, layout, and adequacy of space to support
existing and projected direct clinical and laboratory services)
6.7 Office and Support Space (Quality, layout, and adequacy of space for managerial
and support functions)
6.8 Facility MaintenanceJImprovement (Funding and resources for facility
maintenance, repair, and improvement)
7.0 Inter-organizational Collaboration
7.1 City/County Political Systems (Working interaction and relationships with city and
county political bodies)
7.2 County Management and Administration (Working interaction and relationships
with city and county administrative offices)
7.3 State Health Agency (Working interaction and relationships with state health
agency leadership and program staff)
7.4 Community Partnerlng (Active collaboration with other community agencies for
inter-related services and joint projects)
7.5 Communication and Coordination (Department-wide and division/unit level
communication and coordination with related community organizations)
7.6 Disaster Planning and Action (Agency role and integration in community-wide
disaster planning and preparedness planning and operations)
8.0 Marketing and Related Functions
8.1 Public InformationlPublic Relations (Public information resources and activities)
8.2 Media Relations (Contacts and working relationships with community radio,
television, and newspapers; staff training and competency in media relations)
8.3 Community Perceptions/Awareness (Degree of community awareness of health
department role, responsibilities, and services)
8.4 Need/Demand Assessment/Forecasting (Community health assessment systems
and procedures)
8.5 Community Participation (Extent and nature of community participation in health
department planning, priority setting, and program operations)
The North Carolina Institute for Public Health
8
I
Ie
I
I
I
I
I
I
I
i'
I
I
I
I
I
I
Ie
I
I
New Hanover County Health Department Organizational Analysis
Appendix B - Program Review
B.1. Program Review Methodology
The program review component of this analysis was intended to identify and describe the
operations, goals, efficiency, concerns, and major issues facing the individual divisions and
programs of the Department. The primary methodology included document review, observation,
structured interviews, and open-ended interviews and discussion with program staff and others
in the organization who work with the program. Typical of many such studies, the end result was
intended to provide insight into the significant strengths and areas for improvement of the
individual unit. The program review effort was initiated by phone call, email.and.incases.by
last minute arrangement with program leadership and staff. Several were conducted by phone.
There was no standard briefing or advance letter, though the following guide was used in many
of the reviews.
In addition to interviews of persons within the health department, project staff conducted a
number of interviews with key officials of the community from outside the health department.
With the exception of those involving county officials, most of these interviews were conducted
late in the study period in order to focus specifically on recommendations. These interview
subjects, representing county government, the Board of Health and other community
organizations, are named below.
Community Interview Subjects
Allen O'Neal, County Manager, New Hanover County
Pat Melvin, Deputy County Manager, New Hanover County
David Weaver, Deputy County Manager, New Hanover County
Andy Atkinson, Deputy County Manager, New Hanover County
Andre Mallet, Department of Human Resources, New Hanover County
Kathy Morgan, Department of Human Resources, New Hanover County
Bruce Shell, Finance Officer, New Hanover County
Cam Griffin, Budget Officer, New Hanover County
Dottie Ray, Grants Administrator, New Hanover County
Gela Hunter, Chair, New Hanover County Board of Health
Robert Greer, Member, New Hanover County Board of Health
Frank Reynolds, Member, New Hanover County Board of Health
Michael Goins, Member, New Hanover County Board of Health
Marvin Freeman, Member, New Hanover County Board of Health
John Coble, Member, New Hanover County Board of Health
Dr. William Atkinson, CEO, New Hanover Hospital Network
Art Constantini, Executive Director, Southeastern Mental Health Program
Karen Vincent, Interim Director, New Hanover County Department of Social Services
Representatives of the Coastal Area Health Education Center (AHEC)
The North Carolina Institute for Public Health
9
I
Ie
I
I
I
I
I
I
I
it
I
I
I
I
I
I
Ie
I
I
New Hanover County Health Department Organizational Analysis
B.2. Program Review Emphases
Primary Responsibility I Secondary Responsibility
Oraanizatlonal Mlsslon/GoaisNalues
Strateaic Direction Culture
Mission Values
Vision
Issue Identification
Forecastina
Goals
Priority SellinQ
TaskslTechnoloav/Workload
ProfessionaVTechnical Comoetence Workload Eauitv
Productivitv
Effectiveness Assessment
Efficiency
Service Caoacitv
Technoloav Currencv/Obsolescence
TechnoloQY Utilization
Structure/Communication/Coordination
Division of Authority/Responsibility Hierarchical Communication and
Coordination
Clarity of Reporting; Reporting Channels Inter-Divisional Communication and
and Protocols Coordination
First Line Supervision Svstem Role/Exoectation Claritv
Board/Executive Relations
Manaaement
Leadership Error Correction
ManaaemenVBusiness Plannina Rewards and Sanctions
Operational Plannina
Evaluation and Monitorina
CoachinQ, DirectinQ, and Controllina
Oraanizational Reoresentation ,
Information Systems Manaoement
Human Resources
Staffina Adea uacv Utilization
Policies and Procedures Staff/Manaaement Percentions
Recruitment Morale and Esoirit
Develooment and Trainina
Staff Cohesion
Turnover
The North Carolina Institute for Public Health
10
I
Ie
I
I
I
I
I
I
I
i'
I
I
I
I
I
I
Ie
I
I
New Hanover County Health Department Organizational Analysis
FlnanceslFacilltieslEauloment
Budoetino/Plannino Interface
Revenue Plannina and Forecastina
Revenue Acaui:>iiion
AccountinQ Systems
GranVContract Manaoement
Clinic and Laboratorv 50ace
Office and Support Soace
Facility Maintenance/lmorovement
inter-Oraanlzatlonal Collaboration
Countv Political Svstem Disaster Plannino and Action
Countv Manaaement and Administration
State Health Aaency
Community Partnerino
Communication and Coordination
Marketina and Related Functions
Need/Demand Assessment and Forecastina Public Information and Public Relations
Media Relations
Communitv Perceotions and Awareness
Communitv Particioation
Volunteer Utilization
The North Carolina Institute for Public Health
11
I
Ie
I
I
I
I
I
I
I
fI
I
I
I
I
I
I
Ie
I
I
New Hanover County Health Department Organizational Analysis
B.3. Program Review Fact Sheet
aUriC
New Hanover County Health Department Organizational Assessment
Program Review Fact Sheet
The purpose of this proiect is to:
~ Understand the goals, activities, and achievements of individual programs and services of
the New Hanover County Health Department.
~ Identify concerns or issues that program leadership or staff believe need to be addressed in
order to strengthen program operations.
~ Identify opportunities for improving operations and services to clients that will produce more
efficient and effective service delivery and contribute to the enhancement of staff morale.
~ Document specific suggestions and recommendations to address these issues or concerns.
Who is doing the project?
~ This is a research project that the North Carolina Institute for Public Health (NCIPH) was
asked to do with the health department. The NCIPH is part of the School of Public Health at
the Uniyersity of North Carolina at Chapel Hill. The NCIPH will use it's "lessons learned"
while doing this assessment to develop a tool that can be used by other non-profit groups
that want to assess their organization. The North Carolina Institute for Public Health is
located at 400 Roberson Drive, Carrboro, NC 27510. The project director, H. Pennington
Whiteside, Jr., can be reached by phone at (919) 966-1069, or by email at
hwhitesi@email.unc.edu.
~ Other project staff includes William Herzog, Charles Grubb, Sheila Pfaender, and Janet
Alexander
What are you being asked to do?
~ You are invited to participate in a face-to face interview. This interview will be scheduled at
your convenience and will last about 1 hour. Participation is voluntary. You may refuse to
answer any question that you do not want to answer.
~ Division managers, and other employees at the discretion of the managers, will be asked to
participate in the program review interviews.
~ If you agree to participate in this survey, please understand that your participation is
voluntary. You have the right to withdraw your consent or stop your participation at any time
without penalty. You have the right to refuse to answer particular questions. If you decide
not to do this survey, this will not affect your job at the HD
The North Carolina Institute for Public Health
12
I
Ie
I
I
I
I
I
I
I
fI
I
I
I
I
I
I
Ie
I
I
New Hanover County Health Department Organizationaf Analysis
What are the risks and benefits of your participation?
~ We are asking you to offer your personal opinion about the health department. Because
these may be somewhat sensitive questions, we can assure you that your individual
answers will be kept confidential.
~ This interview will not be tape-recorded.
~ Notes from the interview will be stored in a locked filing cabinet and on project computers.
Only project staff will have access to these notes.
~ In our report of results we will not report individual responses or opinions.
~ The benefit of your participations is that the results of the survey will be useful for making
future improvements to the health department.
What are the costs of participating?
~ There is no cost to you for participating. The health director has given permission for this
survey to be completed during your normal work time. You will not be paid for completing
the survey.
If you have any questions about the organizational assessment project:
~ please contact Janet Alexander. You may call her collect at (919) 843-5559 or email her at
janet_alexander@unc.edu, or you may contact the project director Pennington Whiteside at
(919) 966-1069 or email him at hwhitesi@email.unc.edu
The School of Public He~lth Institutional Review Board on Research Involving Human Subjects
has approved this project. IRB, School of Public Health, University of North Carolina at Chapel
Hill, CB # 7400, Chapel Hill, NC 27599-7400. You may call them collect at (919) 966-3012 with
any questions about approval of this study
The North Carolina Institute for Public Health
13
I
Ie
I
I
I
I
I
I
I
"
I
I
I
I
I
I
Ie
I
I
New Hanover County Health Department Organizational Analysis
8.4. Program Review Interview Guide
Preamble
1 Opening: Thank you for taking the time to meet with us. We recognize that your time is
valuable and we appreciate your participation.
2. Review Fact sheet: This fact sheet that I have given you tells you who you can call to
find out more about this project or who you can call or email if you have any questions
later
3. In the case that the interview is a group interview --It is very important that "what is said
in the room today, stays in the room." So when you leave today, respect the privacy of
your co-workers and do not tell other co-workers, friends, or family, that "so and so said
this" and "so and so said that."
. Does everyone agree to this?
· Is there anyone that does not want to participate?
4 Questions: Do you have any questions about anything I have said so far?
5. Proceed: Would you like to proceed?
Purpose and Goals of Interview
1 Build our understanding of the goals, activities, and achievements of individual programs
and services of the department;
2. Identify special concerns or issues that program leadership or staff believe need to be
addressed in order to strengthen program operations; and
3. Document specific suggestions or recommendations to address these issues or
concerns.
4 Do you have any special priorities that you believe we must talk about during this
session?
Interview Questions
Mission/GoalsNalues
1 What do you see as the most important goals and services of your program?
2. What do you see as its major strengths?
3. What factors, if any, do you think are most important in facilitating or limiting goal
achievement and/or the effectiveness of services provided by your program?
The North Carolina Institute lor Public Health
14
I
Ie
I
I
I
I
I
I
I
"
I
I
I
I
I
I
Ie
I
I
New Hanover County Health Department Organizational Analysis
TaskslTechnologylWorkload
1. Could you take a few minutes to describe the major services of your program and how
staff and resources are used to provide these services?
2. What enables your staff to be as productive as they are? Do you think staff are reaching
their maximum level of productivity? Are there any barriers that limit their productivity?
3. What kinds of feedback or issues do you hear most often from supervisors and staff
about their productivity and workload?
Structure/Communication/Coordination
1 How does the overall organizational structure contribute to, or impede the activities and
goal achievement of your program?
2. What changes, if any, would you make in the organizational structure of your own
program area in order to improve its performance?
Management
1 How does the overall organizational management system contribute to and/or impede
goal achievement within your program?
2. What do you think that the top leadership and Board need to understand in order to
provide guidance and support of your program?
3. Do you believe that your program, and the organization as a whole, are addressing the
most important public health goals for your community? What could you or the
organization do to improve upon this?
Human Resources
1 How do you think the staff in your program would describe the health department as a
place to work?
2. How are people recognized and appreciated for what they do to contribute to program
and organizational goals and priorities?
3. How much success or difficulty do you have in recruiting and retaining the most qualified
staff?
4 What do you see as the major organizational strengths and barriers to recruitment and
retention of qualified staff?
The North Carolina Institute for Public Health
15
I
Ie
I
I
I
I
I
I
I
fI
I
I
I
I
I
I
Ie
I
I
New Hanover County Health Department Organizational Analysis
FinanceslFacilitieslEqulpment
1 How much responsibility does your program have for financial planning, budgeting, and
financial management? What about facilities and equipment?
2. Have the recent budget and staff cutbacks impeded your programs operations and goal
achievement? How? (Specifics)
3. Do you have contingency plans to handle future cutbacks (or an improved budget
situation)?
4 What is your assessment of the physical facilities available to your program now? What
are your priorities for improvement?
Inter-Organizational Collaboration
1. Could you take a few minutes to describe how your program works with other
organizations within the community (or state)? Specific examples?
Marketing and Related Functions
1 How does your program go about trying to make sure that you are providing the most
essential services needed within the community?
2. Do you involve the clients or customers of your programs in any planning or design
activities? If so, how?
3. To what extent do you think that the public at large and specific target groups are aware
and knowledgeable about your programs and services?
Closing
1 Have we missed any important questions or issues that you would like to discuss?
2. What one, two, or three things should be done to improve the quality and effectiveness
of overall departmental operations or your program services?
The North Carolina Institute lor Public Health
16
I
Ie
I
I
I
I
I
I
I
f'
I
I
I
I
I
I
Ie
I
I
New Hanover County Health Department Organizational Analysis
B.S. Board of Health Interview Guide
1 What are the highlights and strengths of the work of the health department? What keeps
you interested in participating as a Board of Health member?
2. What facets of the organization do you think most need to be improved?
3. If you were doing a study of the organization, what issues would you concentrate on
most?
4 What do you believe are the most important roles for the Board of Health? How well are
these being fulfilled? Where would you like to see improvement in how the Board
functions?
5. How useful have the Strategic Planning Priorities developed in 2000 been to Board
deliberations and decision-making? How can they be improved?
6. What questions or suggestions do you have about the organizational analysis or
strategic planning processes?
The North Carolina Institute for Public Health
17
I
Ie
I
I
I
I
I
I
I
fI
I
I
I
I
I
I
Ie
I
I
New Hanover County Health Department Organizational Anaiysis
Appendix C - Survey
C.1. Survey Methodology
As part of the organizational analysis, The North Carolina Institute for Public Health
administered a survey to all staff at the New Hanover County Health Department. This "quick-
scan survey" asked the employee to rate their opinion of various aspects of the health
department. The survey contained a series of 50 statements. For each statement the
employee was asked whether they strongly disagreed, disagreed; agreed, or strongly agreed
with the statement. A response option of not sure was also available. This survey was
developed by a health policy researcher, and has been used in previous assessments of health
organizations.
The survey was available, on-line, from August 29th to September 12, 2002. Each health
department employee was sent a letter describing the survey, and providing him or her with
instructions on how to access the survey. Each was given an anonymous login-name in order
to provide confidentiality and to ensure that an individual could not respond more than one time.
This survey was an important part of the organizational assessment because it provided every
employee in the health department a chance to offer their voice.
The North Carolina Institute for Public Health
18
I
Ie
I
I
I
I
I
I
I
fI
I
I
I
I
I
I
Ie
I
I
New Hanover County Health Department Organizational Analysis
c.2. Survey Emphases
PrimirV ResDonsibilitv T SecondarY ResDonsibllltv
Organizational Mlsslon/GoalslValues
Culture Strateaic Direction
Values Mission
Vision
Issue Identification
Forecastina
Goals
Priority Settina
TaskslTechnology/Workload
Workload Enuitv Professionalfrechnical Comoetence
Productivitv
Effectiveness Assessment
Efficiencv
Service Canacitv
Technoloav Currencv/Obsolescence
T echnoloav Utilization
Structure/Communication/Coordination
Hierarchical Communication and Division of Authority/Responsibility
Coordination
Inter-Divisional Communication and Clarity of Reporting Channels and
Coordination Protocols
Role/Expectation Clarity First Line Supervision System
Board/Executive Relations
Management
Error Correction Leadershin
Rewards and Sanctions ManaaementfBusiness Plannina
Onerational Planninn
Evaluation and Monitorina
Coachina, Directina, and Controllina
iOrnanizational Reoresentation
Information Svstems Manaaement
Human Resources
Utilization Staffinn Adenuacv
Staff/Mananement Percentions Policies and Procedures
Morale and Esnirit Recruitment
Deveiooment and Trainina
Staff Cohesion
Turnover
The North Carolina Institute for Public Health
19
I
Ie
I
I
I
I
I
I
I
~
I
I
I
I
I
I
Ie
I
I
New Hanover County Health Department Organizational Analysis
Flnances/Facllltles/Eauloment
Budgeting/Planning Interface
Revenue Plannina and Forecastina
Revenue Acauisition
Accounting Systems
GranVContract Management
Clinic and Laboratorv Soace
Office and Suooort Soace
Facility Maintenance/lmorovement
Inter-Organizational Collaboration
County Political System Disaster Plannina and Action
County Management and Administration
State Health Agency
Community Partnering
Communication and Coordination
Marketing and Related Functions
Public Information/Public Relations Need/Demand AssessmenVForecasting
Media Relations
Community Perceptions/Awareness
Community Particioation
Volunteer Utilization
The North Carolina Institute for Public Health
20
I
Ie
I
I
I
I
I
I
I
fI
I
I
I
I
I
I
Ie
I
I
New Hanover County Health Department Organizational Analysis
C.3. Survey Invitation Letter and Instructions
"Quick Scan" QUESTIONNAIRE
New Hanover County Health Department Organizational Assessment, 2002
Date:
Dear New Hanover County Health Department Employee:
Please take time to complete a short questionnaire about the New Hanover County Health
Department. This survey is part of the Organizational Assessment, a research project that the
North Carolina Institute for Public Health was asked to do with your health department. A fact
sheet that has more information about the Organizational Assessment is included with this
letter.
The purpose of the questionnaire is to gather an oyerview of employee opinion about the New
Hanoyer County Health Department, including the Health Department's:
. Mission and Goals
. Tasks, Technology, and Workload
. Structure, Communication and Coordination
. Management
. Human Resources
. Finances, Facilities, and Equipment
. Collaboration with other organizations
. Marketing
The survey will give each and every employee at the Health Department a chance to voice their
opinions in a priyate and confidential way The survey is yoluntary, but the results will be more
valuable if eyerybody participates. The results of the survey will be included in a report of
recommendations to the health department at the end of the organizational assessment project.
If you decide not to do this survey, this will not affect your job at the HD. When doing the
survey, you will be asked to answer 52 questions. It should take about 15 minutes to do this.
You may refuse to answer any question that you do not want to answer.
You can complete the survey on a computer with Internet access. The following sheet tells you
how to do this and whom you can call if you need help or have any questions about it.
This survey will ask you for your opinion of the New Hanoyer County Health Department. Your
answers to this survey will be anonymous. You have been given a login name and password
that only you will know. You will need these to open up the survey on the computer.
When everyone has completed the survey and the results are written up, opinions of individuals
or opinions of employees in specific divisions in the health department will not be identifiable.
The North Carolina Institute for Public Health
21
I
:-1
I
I
I
I
I
I
fI
I
I
I
I
I
I
Ie
I
I
New Hanover County Health Department Organizational Analysis
HOW TO OPEN THE SURVEY
Organizational Quick-Scan Survey
Instructions
. The survey will be available on the Internet on [Date] 2002
. Please send In your survey responses by [Date} 2002
. To see the survey, you will need a computer that has access to the Internet. Open up your
Netscape or Internet Explorer program and type the following address in the location bar:
http://www.sph.unc.edulnciph
. Click on the link that says NHCHD Survey
. You will be asked to sign in to see the survey. Use the following login and password:
Your anonymous login name Is:
Your password Is:
. Click on the link for Welcome to the "Quick - Scan" survey It will take a few minutes for
the survey to open.
. Please plan on taking 15 minutes to complete this survey. Your answers will not be saved
if you leave the website before clicking on the SUBMIT button. Once you have sent in your
answers, you cannot go back and make any changes to them.
. When you have completed the survey and are ready to send In your final answers, click
on the button that says "SUBMIT'
. If you have any questions about this survey, you can call Janet Alexander collect at
(919) 843-5559 or email her at JaneCAlexander@unc.edu, or you can call the project
director, Pennington Whiteside at (919) 966-1069
Thank you very much!
The North Caroiina Institute for Pubiic Health
22
I
Ie
I
I
I
I
I
I
I
fI
I
I
I
I
I
I
Ie
I
I
New Hanover County Health Department Organizational Analysis
C.4. Survey Fact Sheet
IJUtiC
New Hanover County Health Department Organizational Assessment
Quick Scan Survey Fact Sheet
The purpose of this project is to:
~ Understand the goals, activities, and achievements of individual programs and services of
the New Hanover County Health Department.
~ Identify concerns or issues that program leadership or staff believe need to be addressed in
order to strengthen program operations.
~ Identify opportunities for improving operations and services to clients that will produce more
efficient and effective service delivery and contribute to the enhancement of staff morale.
~ Document specific suggestions and recommendations to address these issues or concerns.
Who is doing the project?
~ This is a research project that the North Carolina Institute for Public Health (NCIPH) was
asked to do with the health department. The NCIPH is part of the School of Public Health at
the University of North Carolina at Chapel Hill. The NCIPH will use it's "lessons learned"
while doing this assessment to develop a tool that can be used by other non-profit groups
that want to assess their organization.
How will the Organizational Assessment be done?
~ Group and individual interviews of Health Department employees and of important
community leaders and organizations
~ Survey of all Health Department staff.
~ Focus groups of Health Department employees.
What are you being asked to do?
~ You are invited to participate in an on-line computer survey. You will need to use a
computer that has Internet access. You will be asked to answer 52 questions about your
opinions about the health department. It should take about 15 minutes to do this.
Participation is voluntary You may refuse to answer any question that you do not want to
answer. If you decide not to do this survey, this will not affect your job at the HD.
What are the risks and benefits of your participation?
~ We are asking you to offer your personal opinion about the health department. Because
these may be somewhat sensitive questions, we can assure you that your individual
answers will be kept confidential. Your responses will be anonymous, and we will not report
individual answers in our report of results.
The North Carolina Institute for Public Health
23
I
Ie
I
I
I
I
I
I
I
i'
I
I
I
I
I
I
Ie
I
I
New Hanover County Health Department Organizational Analysis
~ The benefit of your participations is that the results of the survey will be useful for making
future improvements to the health department, and in making the health department a more
comfortable and efficient place for you to work.
When will the Organizational Assessment be done?
~ The assessment will take place during July, August and September of this year A draft of
the results will be given to the Health Department by October 26th.
If you have any questions about the organizational assessment project
~ Please contact Janet Alexander. You may call her collect at (919) 843-5559 or email her at
janeCalexander@unc.edu, or
~ you may contact the project director Pennington Whiteside at (919) 966-1069 or email him
at hwhitesl@email.unc.edu
The School of Public Health Institutional Review Board on Research Involving Human Subjects
has approved this. IRB, School of Public Health, University of North Carolina at Chapel Hill, CB
# 7400, Chapel Hill, NC 27599-7400. You may call them collect at (919) 966-3012 with any
questions about approval of this study.
The North Carolina Institute for Public Health
24
I
Ie
I
I
I
I
I
I I
I
i'
I
I
I
I
I
I
Ie
I
I
New Hanover County Health Department Organizational Analysis
c.s. Survey Questions
ORGANIZATIONAL ANALYSIS QUESTIONNAIRE
New Hanover County Health Department Organizational Study, 2002
Before you begin with the main part of the survey, please tell us a little bit about yourself.
A. Are you a member of the Management Team?
_ Yes (If your answer is ''yes", skip question B and go directly to the survey)
_ No (If your answer is "no" go to question B.
B. If you are not a member of the management team, please choose one of the following that
best describes your MAIN role in the Health department:
I supervise people or programs
I provide lab, clinic, education, or field services
I provide administrative or clerical support services
Other
C. Please take a few minutes to review the following statements and circle the number beside it
that best characterizes your opinion.
Likert Scale Choices: Link to
so = Strongly Disagree, 0 = Disagree, A = Agree Matrix
SA = Strongly Agree, DK/NA = Don't KnowlNot Applicable Elements
1 The major goals and priorities of the NHCHD are clear to me. 1.6
2 The major goals and priorities of the NHCHD are clear to most people 1.6
who work here.
3 I think that people get mixed messages from top leadership about what 17
is important.
4 I think that the people I work with most closely have a very high 4.1
commitment to make this organization work and to be the best of its
kind.
5 The activities and services of the NHCHD are important and valuable to 8.3
the communitv we serve.
6 This is an organization in which customer values and satisfaction are of 8.3
top importance.
7 The top leadership in the NHCHD is aware and concerned about the 8.4
needs and interests of the peoole we serve.
8 The NHCHD is quick to recognize and change the way we do things 8.4
when it appears that we are not meeting the expectations of patients
and the communitv at laroe.
The North Carolina Institute for Public Health
25
I
Ie
I
I
I
I
I
I
I
i'
I
I
I
I
I
I
Ie
I
I
New Hanover County Health Dilpartment Organizational Analysis
9 Working in the NHCHD provides a high sense of accomplishment. 5.7
10 I think that most people in this organization really enjoy working here. 5.7
11 People in the NHCHD tend to trust each other a great deal. 5.6
12 There is a strong sense of values and tradition in the NHCHD. 1.8,1.9
13 My personal role and responsibilities in the NHCHD are clear and well 3.6
defined.
14 Most people who work in the NHCHD have a clear understanding of 3.1,3.6
their role and responsibilities.
15 I feel that my knowledge and skills are well utilized in the NHCHD. 5.5
16 I feel that mv work is recoonized and appreciated. 4.8
17 I feel that rewards here are pretty well distributed given the different 4.8
levels of trainino and lob demands.
18 When somebody makes a mistake here, the leadership is quick to 4.7
notice it and take action to correct the situation.
19 Mistakes tend to be handled here by pointing out the error and outlining 4.7
the correct way to do things, rather than blaming.
20 The leaders in the HNCHD are pretty clear and consistent in setting 3.6,4.1
expectations for staff performance.
21 I think that people in this organization recognize that they depend a lot 5.7
on each other to oet the iob done.
22 When things get very busy and hectic around the NHCHD, people tend 5.7
o pull tooether to oet the iob done.
23 Communication between different job levels in this organization works 3.3
well.
24 I think people in similar job levels across the NHCHD communicate well 3.4
with each other.
25 There is somebody with a leadership role in the NHCHD that I can go to 4.5
if I need help or instructions in accomplishing a specific task.
26 I feel that there is somebody with a leadership role in the NHCHD that I 4.5,5.2
could talk with if I felt treated unfairly or if I really became unhappy with
mv work.
27 There is an opportunity for growth and development in this organization. 5.4
28 Although the workload and tension levels vary, leadership style and 3.6,41
expectations tend to remain clear and consistent.
29 The structure and reporting channels in the NHCHD are appropriate 3.1
loiven its size and complexity.
30 This tends to be a rather informal and flexible organization in which to 3.2
work.
31 The work that I do here is interesting and motivates me to try to 5.5
continuallv do a better iob.
The North Carolina Institute for Public Health
26
I
Ie
I
I
I
I
I
I
I
fI
I
I
I
I
I
I
--
I
I
New Hanover County Health Department Organizational Analysis
32 It takes a high degree of training and skill to do my job well. 2.1
33 The level of complexity and demands of my work are well understood 5.6
bv most of the oeoole who work here.
34 I think that most people at my job level do their work efficiently and 2.2, 2.4
effectively.
35 Most people in the same job areas, or in similar roles, tend to contribute 2.6
eauallv.
36 I think that most people in the organization as a whole seem to do their 2.4
work efficiently and effectively.
37 Mv iob is hiahlv demandinQ and stressful. 5.5
38 The work of most people in this organization is highly demanding and 5.5
stressful.
39 It is pretty easy for people to know when I am doing my job well and 3.6
when not.
40 It is pretty easy for people to know when anyone in the NHCHD is daing 4.4, 3.6
their iob well and when not.
41 There are enough qualified staff here to keep up with the workload most 5.1,2.5
of the time.
42 The human resources policies and procedures in the NHCHD are 5.2
clearlv defined and known to most staff.
43 I think that the information technology systems J use on the job are 2.8,4.9
effective and appropriate to the kind of work I do.
44 The level of automation and computerization in this organization is 2.7
appropriate to the amount and kind of work that we do.
45 When I see a better way to do my job, it is pretty easy to explain the 4.3,4.5
needed changes to the person I work for and, if they agree, change the
orocedures.
46 I feel that my opinions and suggestions on how to better get my job 4.3,4.5
done are (or would bel welcomed here.
47 This is pleasant and functional facility in which to work. 6.6,6.7,6.8
48 The physical space here is well arranged and well used in meeting our 6.6,6.7, 6.8
oraanizational aoals and oriorities.
49 The financial systems for billing, collecting, and managing funds appear 6.3, 6.4
to be workina well.
50 I feel reasonably secure about the financial health and stability of the 6.2
NHCHD.
The North Carolina Institute for Public Health
27
I
Ie
I
I
I
I
I
I
I
f'
I
I
I
I
I
I
--
I
I
New Hanover County Health Department Organizational Analysis
C.6. Survey Results
One hundred and twenty-five out of 171 employees at the New Hanover County Health
Department completed the survey (73.1 %). All of the management team members and nearly
all of the supervisors completed the survey. The participation rate for administrative support
staff was approximately 69%, and 56% for line staff. There were 7 other employees who
participated, but did not identify their role in the health department.
Number In Number
Health Completing
DeDartment Survey
Manaaementteam 15 15
Suoervisors 24 23
line Staff 94 53
Admin. Suooort Staff 39 27
Missina identifier 7
Total 171 125
More than half of the employees who responded disagreed or strongly disagreed with
the following statements:
Percent who disagreed
or strongly disagreed
with statement
The physical space here Is well arranged and well used In meeting our 66.4
oroanlzatlonal ~aoals and orlorltles.
The level of complexity and demands of my work are well understood by most 62.3
of the DeODle who work here.
Communication between different job levels In this organization works well. 60.0
It Is pretty easy for people to know when anyone In the NHCHD Is doing their 57.9
ob well and when not.
I feel that rewards here are pretty well distributed given the different levels of 55.4
raining and Job demands.
There are enough qualified staff here to keep up with the workload most of the 53.7
time.
There Is an opportunity for growth and development In this organization. 52.t
People In the NHCHD tend to trust each other a great deal. 51.2
Although the workload and tension levels vary, leadership style and 50.8
expectations tend to remain clear and consistent.
The NHCHD Is quick to recognize and change the way we do things when It
appears that we are not meeting the expectations of patients and the 50.4
community at large.
The North Carolina Institute for Public Health
28
I
Ie
I
I
I
I
I
I
I
fI
I
I
I
I
I
I
--
I
I
New Hanover County Health Department Organizational Analysis
More than half of the employees who responded agreed or strongly agreed with the
following statements:
Percent who agreed
or strongly agreed
with statement
The activities and services of the NHCHD are Important and valuable to the 96.7
community we serve.
It takes a high degree of training and skill to do my job well. 86.8
I think that the people I work with most closely have a very high commitment 86.2
~o make of this organization work and to be the best of Its kind.
The work that I do here Is Interesting and motivates me to try to continually 85.7
do a better Job.
I think that most people at my job level do their work efficiently and 84.7
effectively.
The human resources policies and procedures in the NHCHD are clearly 82.6
defined and known to most staff.
There Is somebody with a leadership role in the NHCHD that I can go to If I 81.7
need help or Instructions In accomplishing a specific task.
I think that moat people in the organization as a whole do their work 80.3
efficiently and effectively.
The major goals and priorities of the NHCHD are clear to me 79.7
There Is a strong sense of values and tradition In the NHCHD. 79.7
My personal role and responsibilities in the NHCHD are clear and well 78.9
defined.
I think that the Information technology systems I use on the Job are effective 78.9
and appropriate to the kind of work I do.
The malor goals and priorities of the NHCHD are clear to most people who 78.2
work here.
I think that most people In this organization really enjoy working here. n.5
This Is an organization In which customer values and satisfaction are of lop 76.9
Importance.
Most people who work at the NHCHD have a clear understanding of their role 75.0
and responsibilities.
Working In the NHCHD provides a high sense of accompllshmant. 74.6
I think that the top leadership In the NHCHD Is aware and concerned about 74.2
~he needs and interests of the people we serve.
My job Is highly demanding and stressful. 72.9
When things get very busy and hectic around the NHCHD, people tend to pull 72.7
together to get the job done.
The work of most people In this organization Is highly demsndlng and 71.6
stressful.
The North Carolina Institute for Public Health
29
1
Ie
1
1
1
1
1
1
1
fI
1
1
1
1
1
1
--
1
1
New Hanover County Health Department Organizational Analysis
I think that people in this organization recognize that they depend a lot on 70.3
each other to get the job done.
This is pleasant and functional facility in which to work. 67.8
I feel that my knowledge and skills are well utilized In the NHCHD. 67.7
I think that people get mixed messages from top leadership about what is 66.1
Important.
I feel that my opinions and suggestions on how to better get my lob done are 63.1
(or would be) welcomed here.
It is pretty easy for people to know when I am doing my job well and when 62.8
not.
The level of automation and computerization in this organization Is 60.3
appropriate to the amount and kind of work that we do.
I feel that my work Is recognized and appreciated. 57.0
When somebody makes a mistake here, the leadership Is quick to notice It 56.7
and take action to correct the situation. .
I feel that there is somebody with a leadership role In the NHCHD that I could 56.6
talk with if I felt treated unfairly or If I really became unhappy with my work.
Mistakes tend to be handled here by pointing out the error and outlining the 55.7
correct way to do things, rather than blaming.
The leaders In the NHCHD are pretty clear and consistent In setting 54.1
expectations for staff performance.
When I see a better way to do my job, It Is pretty easy to explain the needed 52.9
changes to the person I work for and, if they agree, change the procedures.
I think that the structure and reporting channels In the NHCHD are 51.2
appropriate given Its size and complexity.
The North Carolina Institute for Public Health
30
I
Ie <
~ 11- ", 0 G! 0 ", CO l"- I"- ~ ", I/) I"- G! 0 0 ", 0 G! ~ 0 0 0 0 0 0 ~
'"
N 0 ~ 0 -i -i ..; ui ,..: -i N ,..: ~ 0 0 N 0 ~ ,..: 0 0 0 0 0 0
Q
I N "l N "l ~ ~ I"- ", 0 N'" 0 CO II) ell'" II) II)
< :.l! N I"- eD ", ~ I"- ~ ", cO ..; N I"- 0 en ~~ 0 ~ :lil3~ cO ~
III . ..; ~ -i cO ..; ~ ,..: -i ,..:
~ ~ ", ~ N N ... ... ... I/) l"-
I
I/) N'" ell II) N CO CO ... ell 0 ... II) CO ~ N ... ", l"- I/) C'! ... ell ... 0
C"# ,..: ~~ ..; lli 0 ~ lli c! l:! cO N -i 0 en ,..: en ~ ui ~ ~ ~ ui -i ..;
I II) I/) I"- ... ", ... ... ... ", I/) ... ... ... ~ ~
I/) ", II) 0 ", ~ '": N "I; ", CO ell ell III ", ell co ", 0 I"- CO 0 G! 0 0
I Or/! ui ,..: ~ 0 ,..: eD ~ ..; ~ ,..: en eD eD ~ 0 cO -i en 0 cO 0 0 0 0
~ ~ ~ ~ ~ N ~ N N N II) ... ~ ~
W
..J
I 0 g1l- ", I"- G! 0 ", COI"- 0 0 0 "': 0 ell 0 0 ", I"- G! ~ 0 I/) ell 0 ~ ",
a: N ..; ~ 0 -i 0"; 0 0 0 ~ 0 ..; 0 0 N ..; ~ ,..: 0 N ..; 0 ,..: -i
.!!l W
~ W
'" > ci "'1"-'" ...... "'1"- ... ",... ~II) N ...... "'1"- ... ",... Nil) ... ",...
c:
I <( 0 Z ~N&n ~N ~N I/) ~N ~N I/) ~N ~NLI) ~N ~N I/) ~N
~ ..J
Q. a E !! E E !! E E !! a j !! It: E !!
2 :!: 1i ~ 0 1i lB $I 1i ~ 51 1i j 1i ~ 0
.~ i .!! l! iii ~ ~ S .!!
W .. .. - .. ~ ..
'I: ~ 'I: _ i!: ~ ii Ii ii
I " " e " " " - l! - " e
c: E E E
l:'l. > 0 c 0 0 c 0 0 c 0 0 0 0 c
:J 01 " :J 01 " :J 01 :J 01 " :J 01 "
al :; :; :; " :; :;
c5 .. .. .. .. ..
~ c - -
w '" ~.8
0
ii: - .1:1
.. III
!;t iii 0 0. .clll '\::J
~ E E :E ~;S c
a: 0 0 .. ~1l III
I ~ I- - - .. -
.. .. III III 0 C
'" (/) m m '\::J ~
~ III III-
(/) U U .!! >'\::J 0
C !:i III C 0.
I!! I!! 0. .clll .5
5 0 ~~
I (5 ::::l III III -
(/) Q Q E III 0 I!!
'- w :s: :s: 0 ~ ~ III
~ 0 0 .. -c Q
a: ...
0 :s: :s: .. "'0 :s:
c: > Z Z c;;~
I ~ III 0
W III III 01 0:1 :s: ~
~ > .c .c III E- Z
- - .. c
~ a: ... ... .. .clll III III
::::l 0 0 III =01 .c ..
.. .. E ~ ~ - III
I (/) III III '\::J ~.!! O~
:;:: :;:: III :l~
;: ;: .. O.c ~
0 0 s ~- .2c '"
;: ;: ... ~
0. 0. iii -0 i: '"
I '\::J '\::J" Gi .!!III III E "
c C III 01 0.... .. E ~
III Ill.c 0'" gill 1!8
.. ..~ -c Q.E
0. III
'iii -0 ot: illS III 0 '-
0 lh 00 ;S- ...c .l2
I 01 010 0.0. .. i . 0- l!l
.. ...c aE :;::0 ~
IllE'\::J --
0 .2.~ .2:111
'ij .c- =_.6 .,
III 0 -.. --
E E- ...- "'s'" "'.1:1 S
0. c- .5E.! III III '"
-- 0 1110 -Ill 0'" ~
.c .clll .c.c =0;: .c-
I- 1-0. -~ _uo I-!l! e
c .. a
0 III
:;:: .1:1 '€
.. E~ N ... ", I/)
I III ~
'" '"
aZ "
~
I
I
Ie
I
I
I
I
I
.!!l
~
1U
<:
-.:
1U
<:
:2
.~
I ~
~
g-
Cl
I
I
I
s
~
c
5
(5
...
!l!
o
<:
~
l::
~
I
I
I
I
Ie
I
I
~aS!
C ~
o QI
:;:.c
en E
QI :J
5z
<
Z
:i2~
c
ClOQCOIlll:l''I:t
ui.cw:iU'i.
...
C1~
r--OO)It)Cft
ocauia);i
C"<I........(II)fN
c(tf/.
NOCDIDN
:8~:8~~
Otf.,
II)OUlI'-'Ot
uiC'iN,...:"":
........N ....
100000
O..tooo
ci
Z
....U)C")C")(W)
~C"<ILt),...C\I
E !!
e ~ i ~ I
5(JJ!!e
::i th ::::I
:; III
C
o
:;:
u
~
:;
en
'C
C
'"
en
..
:J
l
~
..
E
o
-
en
:J
u
.c
u
:c
~
.5
6ai
ig
.!:!~
Co
'"CI.
e'E
0_
CCI.
'" 0
.!!=
en 0
:ce
1-,"
Ul
'Ot
COClO!(II)O
uic:i....<<icwi
...
NlnLl!C")'l!:t
.cn....~,..:
....cwi....C")...
OUlUl":1I)
d.oi....ui
CDCIOIl)IIIl:I' It)
Ol'-C'!C')O
ui,..:....cocw)
,... C'l ,...
ocncoC')o
uicwiariaOd
OUlC'lC'lC')
~NU)....t\I
:t: E !!
OJ SilO
i! U en ~ ~
!: i CD - '"
o (3 c E
:J r ~
ai
1:
..
en
QI
'C~
C QI
'"-
..CI.
~ 0
'" QI
~CI.
'" QI
en.c
--
C'O
J:en
<.J_
J:en
ze
.. ..
.co:
- .-
C'C
.- C
CI...
:Cen
f!'C
QI Z
'CC
III QI
-.c
CI.-
s:;
.. 0
.c.c
-..
-..'C
..
.cc
-~
.....
C u
:cc
_0
u
I'-
en
C
0.2
'CO;
..-u
~ ..
:--CI.
'" ..
~ :
...c
.c-
-m
.. C
en;::
:; Z
.cE
u.. ai
'COm
C C ~
<<leu.!!
..~-
N .. ..
c"l;'
m~_
0_ C
U .. :J
~:5 E
o en E
-~o
~mu
.2 D. CD
:J CI..c
0'..-
en_'C
._- C
QC"
J:Qlen
<.J.c-
~ C
J: en'!!!
Z c:n'S
QlCCI.
.c:c...
1-_0
ID"":: G!"'" "'=I'
ui::....,..:~
('l'),...cnOQ
cwicwicwioo
ClONlnC"')C\1
Gialc6..tc-i
C')1IIl:I'C")....1.I)
~cn,....'lI:I;:,....
....uia:i....oi
"I:tC\l.......C")
cn"":ca...."I:t
cO::oi"':.
C')1'-C'l'OtC')
~NlI)""N
:t: E !!
- II 0
'ii tJ a ~ .!!
~ i lU E
00:101
:; ril
co
C')I'-CI!OUl
cwicwi....d.
C'll'-C'!I'-Ul
""':C"i..-uicwi
.... (\1(11)....
'Ot'OtOlllC')
1'-11)' 0 0 c-i"':
1'-1I)'Ot1'-
I'-II)Ool;Ul
oicciui.....
........C\lN
U).....G'!OO
C'it"ior-c:ic:i
C'l1'-C'l'OtC'l
~C\II.t)""C\I
E !!
i! 1j ~ ~ ~
!: ~ CD -
o c3 c E
::il~
...
C
..
E
.c
.!!
Q.
E
8
U
..
'0
51
C
..
en
.c
m
:c
..
en
..
'C
'>
e
CI.
C
J:
<.J
J:
Z
..
.c
-
.5
m
C
:;;:
~
o
==
III
I'-lllllll'-I'-
uicwicwicO",o
,...
II)I'-UlO'Ot
C'i"":criuir-:
,... C'l,...
O...."'ON
..;~..;o..;
Ul ,_ Ul II) Ul
":I'-C')C')I'-
"'-"":"":oOcO
,... ,...
C'll'-lllOO
..t"':<'ioo
OUlC'lC'lC')
~NIt)""'N
E !!
i! 1j ~ ~ ~
II 'i:
~ <3 ! E
::il~
m
C
:;;;
~
~
:--
o
e-
..
~
~
C
o
!
c
..
E'
o
en
:c
-
.5
QI
Q.
g
CI.
-
en
o
E
-
..
.c
-
...
C .
-e
.cQl
=.c
o
,...
C\l
'"
~
'"
~
.\1
~
...
.2
"
~
~
.5
'"
.1;
e
~
~
"
j!:
II
Ie
I
I
I
I
I
.!!l
~
<;;
l:
'"
<;;
l:
.Q
"
.!:j
I ~
~
.,
o
I I
c
5
<'3
I
I
I
I
I
I
Ie
I
I
~
~
o
l:
~
"
~
c ..
o '"
;.0
.. E
'" ::I
c3z
<C
Z
~rf!.
c
~rf!.
oct'#.
C,#-
~~
ci
Z
,","~C"!_Q
cO;:;:"":o
"=f'OCO...O
C\idC"ir'c
N<nLq......'"
:ll:Ei:;~~
ClOCDN....ClO
lli~g~~
Lt)a'>>(\IC')
uiu)<<i~~
,..C\I,...,...
I')CDI')~I')
~NIl)""N
:= E 2!
;;iis...Ba
" "Ul 1:
~ i ! E
oO::;la
Oi
'"
'0
-
..
l!!
Cl
..
..
'"
.c
-
o
.c
u
m
-
..
::I
..
-
o
-
'0
C
S
C
J:
(J
J:
Z
'"
.c
-
.5
'"
'C.
o
If
-
-
c:nocoC") 0
-.:iciui~d
-
cOU').....r-:
cw:idaiU'i,...
_ 1')1'1
..........C\lOC'f
cD~aid""
CD ,- U) 1.1) c.o
o Lt)1I)0 0
cw:iaiC"idcw)
,.. ""'",... ...
"Ct"Ct"!oo
C\ir-.:,..dd
C")......N..C')
~C\lI.l),...N
E r!
'ii fi =UlS ~ j
... 't: r-
eS c3 ~ E
::i'a
c:i
J:
(J
J:
Z
'"
.c
-
.5
c
oS!
-
'6
l!
-
'0
C
..
..
'"
::I
~
-
o
'"
..
c
'"
..
Cl
c
e
-
..
..
.!/!
'"
..
'"
.c
I-
1'1
-
ClOOG!OO
dd....dc:i
cn..ON"
"':,..:"':..;"':
,... ,....,....
~_U)Il)U)
,...~uicooi
CD ,_ LI) ('l') CD
II)II)CD~O
aicONLriM
,....,..N__
ClOCO!OO
dd,...dd
(I')......CW)C")C'l')
~NlI),....N
'I: E r!
-iisBa
I! U UJ I- -
I! i .. ~ ~
o u c E
:::::i CD ;:,
:!! Ul
'0
c
..
..
m
u
l!!
..
C
J:
(J
J:
Z
GI
.c
-
.5
..
'"
~
:a
'jjj
c
o
a.
..
'"
..
'0
c
..
'"
e
Oi-g
c c
o ._
f!-
'" '"
a.~
>-Gi
:E~
I')
-
Cll....ClOI')~
a:i..;..;';"':
- -
r--...... lilt... 0
uiCli air--: d
~~ClOCDCD
ml2m~m
......00,...00
..;.;lrici";
......... ....
~~G!OO
C\i"':,....dci
c:s....I')~1')
...C\IIt)....C\I
Cl
c
'6
c
:l
f!
'"
'0
C
::I
..
m
u
..
'"
>
..
.c
C
J:
(J
J:.,;
ZGI
IDE
.c=
-.0
iiCi
~6
oa.
~:l
0"
.c'O
~ c
GI ..
'C..!!
g e
Q..!::
-'"
"5
0_
:Eo
~
-
- 'ti
~ i
o u
E r!
a ~ ~
! E
::ila
coccoo _OCO(')CO
cddcid ":dcw:i..
-
,........Q')r--o
cD cw:icO lriC"i
,.... ...-e")_
('II')~......CDO
cd""u;cOd
_ 1'1
"! I') III 0 Cll ClO.... I') Gl 1'1
z;;m;~~ ~~~!;j:e
co <DO CW),... co......,...C')C')
lrio;';';a:i o;gc-i.;.;
N N c"),... N ~ C"),...,..
....~....O~
ui"':&rid.
~""I')~I')
~NIl),...C\I
'I: E r!
f 'ii hi ~ ~
!e i C) - ~
o U c i
:::i :e a
c:i
J:
(J
J:
Z
Gl
.c
-
.5
'0
Gl
~
;
::I
Gi
~
l!!
..
~
:;;;
..
'0
C
..
Gl
Cl
'0
Gl
'i
o
c
...
,.,
E
-
..
.c
-
1
-
II)
-
,...NOClO
o;"':";ci.;
-
...1"'ooCW)..,....
~NLt)....N
E r!
f 'ii ~ ~ ~
I! i ~ E 1:
oU:::iCD:t
:!! Ul
'0
S
..
U
l!!
a.
a.
III
'0
c
..
~
c
Cl
o
u
l!!
.!!
...
..
o
~
>-
E
-
III
.c
-
:m
CD
-
'"
'"
,s
~
.<>
~
~
.Q
~
~
..s
<1l
.S
e
~
'E
~
<ll
~
1
Ie
1
1
1
1
1
1
1
tit
Cl
1
1
1
1
1
1
.!!l
~
~
<(
C\i
c:
.51
;;;
.!::!
c:
'"
e>
o
..
C\i
~
i::-
S
<3
~
~
o
c:
:!!
;t
~
Ie ~~
.. E
1 c3~
1
<t
~a!!
c
~~
<("if..
off..
~tf..
d
Z
C'\IC\I~....o
a:icri,...c-:icwi
........NN....
CO 00..... 0
o oc:h': 0
e,o.....COIt)
";";";0";
('IC\I,...C')l!lt
N"''''CO''''
r--:<<ir.iod
C')C').C')C')
NN"!.....O
ccioi,...r--:;cwi
........('\1 ....
"-CDNC")C"')
~NIt)....N
E !!
1! ~ a ~ ~
cS ~ 11 E
::i en :J
:Ii ..
Cl
,c
..
c
Cl
>
"6l
'\:I
.!!
:J
.0.
.- ..
:0'\:1
.. C
.- ..
~E
-Cl
Cl'\:l
~.o
"'0
=.-
l!!'\:I
a.c
Cl ..
-01
.. c
l!!'c
u'iS
,c-
..
..-
'\:10
:a.!!
~ Cl
Cl >
- Cl
.. -
..-
,cc
"l!!
- Cl
$=
-.-
_'\:I
.....
..
It) Cl)c.a r--CD
"':";0;"':";
"'O"'OUl
"':0";0";
..
NCDlt)aqC'\l
9icw:i<<i,...a:i
.....1t)C')U)CD
(\I.... 0.... to-
~cwi&riC"iN
NC'\INNN
I"-;:C'\ILn,...o
...cric.;r--=d
.... ..
OUliN(I')C'\I
~C\lIt)""N
= E !!
- OJ l! II lil
i u .. ... -
o (,)l! 11 E
::i Q) :I
:Ii ..
S
...
U
'S
IT
.!!!
a.
:c
l!!
Cl
'\:I'
Is
--
..
Cl..
,c:J
..=
or"
- Cl
Cl,c
,c..
~~
~t:
._ 0
E U
..S
..c
~.2
"u
E ..
,.,~
'\:I..
0_
.0'\:1
Cl c
E ..
0..
..-
c Cl
Cl~
,c"
:=g
co
-
'\:I
C
.. .
-01
2.5
~ E
Cl.!!!
,coO
-
'55
o,c
..
01_
C Cl
-5
Sf!
o
a...
,.,01
.oc
Cl:C
- -
Cl 0
,c'\:l
'\:10
Cl..
'6,.,
c ..
.. ~
,cu
Cl Cl
.ot:
SO
'\:IU
c Cl
Cl,c
.. -
"01
j.5
:1.5
..;
.- :J
:;;0
c.o.coCW)co
ui....:irl~~
-
(1)0(1).....0
cwidC"i"":d
"'N_
~~~
0.....
ON
"'.....
OLnOCDN
cwiaiuia:iarS
N,...C\lC\I,...
ClOG)C")OCD
q:ui"':c:i~
_N_
N.....N'Il:tC'\l
~NIt)....N
E !!
1! 'ti i ~ lil
~ i i E ~
OO::i:f~
01
..
CD cn..... r--'Il:t
uiC"iuit-:-.:t
Ul..........""O
uir--:Lri.nd
..
"'Ul "'01 N
t::"Iiuicwiui
~"''''''''Ul
C')C')N..
d~duid
C").....C')....C")
oLqC\l.....o
Gi"" C-;,...:: 0
.. ..
C\lcoC")C")C")
~C\lIt)""N
E !!
1! ~ a ~ ~
~ D ! E G)
::i D'I :J
:Ii ..
.5
..
c
~
Ui
c
o
U
'\:I
C
~ ai
.. u
Cl c
-..
U E
~l;
_'t:
a.Cl
Cla.
~i
C"
:I:~
(J.e
:1:..
Zc
Cl 0
,c-
"0;
.5t1
I!! &
-8~
:g0l
_c
Cll:
,cCl
......
o
N
.-o>>cn,...o
";";";"':0
"!..... "'0 ""
....,..:,...:d~
- -
....."lOlNN
cd ... cwi &:nUl' .,;
LDCDIt) CD
"lOIN""""
....cdoiuid
NN........C")
....ocor--c
";0";"':0
""'CDNC")C")
~NIt)""N
:t: E f!
- 'ti l! II lil
i"'.....-
o (,).!! ! E
::i OJ :J
:e ..
'\:I
C
Cl
a.
Cl
'\:I
~
,c
..
..
..
,c
..
Cl
~
C
01
o
u
l!!
oj
c c
.20
0;'\:1
.!::! .0
co
.. -
OICl
a-5
.!!'I
,c0l
"0
c..
.- -
ClCl
'i5.S
00
Cl,c
a.u
....
~Cl
"c
"'0
c..
-0
,c_
..
..
-
N
...
'"
..
C\i
~
.11
~
~
Q
.!!l
:E
OJ
s
'"
.c:
e
~
~
~
Q)
~
I
Ie 0( ~ '"
~ ~ ... I'- Cl! ... 0 '" Gl Cl! 0 I'- I'- '<t CD ... I'- II) 0 Cl! '" '<t '" 0 0 0 '"
. ~ r.: ... r.: d ..; ..; ... d as iii r.: ..; r.: as N d ... as ~ ..; d d ... d
c N
I 0( '<t II! 0 '" CD II) 0 Gl I'- 0 CD 0 0 0 0 N '<t '" ... Gl II! 0 ~ CD
of!. r.: r.: ~ ..; ~ I'- ..; cO as r.: ~
III ... N d ..; r.: d d d d d d r.: en ... ...
... ... ... ... N ... '" N ... ... ... N '"
I
'<t N N Gl ... N lD II) CD ... '<t Cl! I'- Gl CD II) Gl lD ~ N I'- ... I'- Gl CD
<etfl. iii cO ~ N r.: ~ ~ as d cO as ... ~ N ~ ~ cO ..; ... N l:i ..; l:i ~ ~
I II) '<t '<t II) '" '" '" '" N '<t II) II) '<t I'- I'- '<t II) N
0 Gl "l I'- ... 0 CO '" II! Gl '" '" 0 Gl II) CD I'- "l I'- I'- "l II) lD '" I'-
I C(f.. en cO ... iii en ~ d ~ ... d cO ..; ~ ~ f3 d r.: ... cO as ... as N ~ as
... N ... '" ... '" lD lD '" '" '" .- .- .- N '" N ...
C ... I'- I'- 0 0 0 CO II) 0 '<t Gl '<t lD ... 0 0 I'- CO 0 I'- Gl Gl lD 0 I'-
I ~ iii d ..; ..; as cO N
III . ~ r.: iii d d d ~ as r.: r.: r.: iii r.: ..; d as d as
.- '" .- .- ... N N
.!!j
~
~ ci "'lD '" '<t.- OlD N "'''' '<tl'-'" '<t'" OlD '" N'" NlD '" '<t '"
I <( Z ~N II) ...N ~N II) ...N ~NIt) ...N ~N II) ...N ~N II) ... N
i;; !! !! !! !! !!
c:: = E ~ E = E ~ E ~ E
~ 1j .l! ~ 0 1j ~ j 1j .l! ~ 0 1j ~ j i! 1j ~ !l
~ .!! J ~ .. i!
.~ li Ul 'l: li Ul ! 'l: li !
.. - - .. e ~ .. - ~ .. -
I c:: E .. .. E .. E E
~ 0 tl c tl c 0 tl c 0 tl c tl c
:i '" " :i '" :i '" " :i '" :i '" "
::; ::; " ::; ::; " ::;
Ul Ul tIl Ul Ul
~ Cll C c
a. c - III
0 C U ::c Cll
2 ~ Cll u (J E
D. E 1U!E ::CB
g- o N t: .cU ZCll
'E _Cll
Cl III D. Cll.c
::c III D. C Ul =>-
I ii (J CI Ql ::c
.. '0 III c=
'" ::c 0 (JCI
~ -III
Z .c ,!!I!!
Ul - ::Cc
C. Cll :c iij z- o-
S .c - Cll Cll.c ..=
- .5 .c .c.!l!
I <3 '0 -- D...
C .. Cll D. :co
.c .5E
... :I 1ii - I!~
!f e ~ .. Cll 0 Cllo!::
cl -u
0 III .. o U '0111
c:: C 0 .. III :l'l:
I ~ .20 .c ..
1i~ .2- u .!!-C -:I
~ III . .c- 111'0
- ,!!at .. ..
~ .co c .. c .cCll
'O- Il! Cll.c Cll 0 ='&
CCll ~ i)o '0- :I: Il!
IIIU
I 111= -.c .!!:I >--
>-- '6 .cu .. 'O~ S
..Cll 0111 111- o Cll
:lCI C -Cll .c" .c'" i;;
.co J ".c _c Cll- . ~
.!!- -- E......
~: :I: .. - ..
I 'E'i 0 O.c 0 .\1
Cll Cll Cll >-D. .. ~ :I: ~
>.c .c Vi= '0_ ..:1:>-
- c Cll OCll
t;Cll c e:!!SE
CIS' 0 _:I: .c.c ...
CllCll Cll'O J2
..- ;: -- ~ B CllS.c
I CI= B= D.III .c'O~ ~
ou -_:I:
C :I -Cll Cll- .. C -:1>-
:CD. 5:1: D.C ..- 1II0D. .,
-0 :I -... fiua. .s:
c- E III "'E Il!o .
Cll'O E~ .5E --III '"
Cll-'" B'lii.c .S
Ie .cc 8~ =0 .co"
3:.!! ....cc e
u t- tD.! --:I
c .. ~
0 Cll
;: .c '<t lD ~
.. E N '" II)
I Cll N N N N N ~
:I :I
OZ '"
~
I ---- ,
I
Ie < 0 II! II! ~
~ 0 0 0 0 0 CO ..... GO 0 '" ~ 0 ..... 0 G! 0 ~ "": 0 '" 0 0
<P- O 0 0 0 0 cD ,..; ..; 0 ..; cO - ai 0 cO cD - - 0 '<i - 0 ..; 0 0
c - - -
I < ~ ~ It) ..... 0 '" '" GO ..... ~ - '" GO - ~ .., '" GO 0 0 ~ 0: ..... .., -
::l! N cD ..; ,..; ..; '<i ..; ..; ,..; '<i '<i ..; ..; ,..; '<i ..; ..; cD 0 0 - - N cO ai
III 0
- - - - .., - .., It) ..,
I .., It)
It) CO - II! N ..... '" .., It) - N GO GO 0 '" It) .., ~ 0 GO CO - -
c(fft cD ~ ..; - N ,..; cD ~ cO ai ,..; 0 N 0 0 N fi ~ 0 ,..; ~ t! ~ ..; cD
I .., N co It) .., N .., .., ~ .., It) It) co ~ It) ~ .., It)
co - co - - GO .., It) It) - "": .., co ..... - GO GO ..... 0 It) G!~ It) .., ~
C,#- 0 ..; ~ ..; cD N N '<i cO ai - N N cD cD cD 0 ~ 0 rj ..; cO '<i
I .., N N N .., ~ N .., .., .., ~ N .., N .., .., It) "'..... -
ljl<P- II! '" '" ..... ..... 0 N CO ~ ~ - II! "l - 0 .., II! N 0 ~ It) ~ G! 0 0
I - cD cO ,..; cO cO ai N cD '<i cO - - ,..; 0 ..; - ai 0 '<i N ..... - 0 0
N N N - - N - - - - - -
.!!l
~
!! 0 -CON ..,.., NCO .., ..,.., "'CO .., ~ .., Oco N N'" -..... N N..,
I <<: z ~Nlt) _N ~N It) _N ~N It) - N ~N It) _N ~N It) _N
~ ~ E r! = E r! ~ E r! ~ E r! = E r!
g B ~ 0 B s ~ 0 B ~ 0 B ~ il - B s ~ ~
1i .. ~ .!! ~ .!! ~
.~ ~ III j ~ III
~ 1: " E i " ~ i " ~ i " ~ " ~
I " " 8- E E E E
" 0 c 0 0 c 0 0 c: 00 c: c
e> ::J 01 ::l ::J 01 ::l ::J 01 ::l ::J 01 ::l ::J 01 ::l
:! III :! III :! III :! III :! III
0
~ ., .s
>. c
- ::t: .5 ~
Ul
Ul 0 C -
1S :E CI. ::t: 0 0
0 - :E z .. -
~ .5 l!! . ., III .,
I N E
" - .,- .e e
:l! c 'Oc - 11
., :ll~ .5 III
C E -..'in III e' !l!
is CI. 0
I 0 ~c 'ii ., :g
<3 'ii III 0 ci- :0
> U c_ E
... ii Ul'O III >< 11
11 '0 -c .e" '0
0 ., III u'Q. ;;:: C
" '0 ii .. OlE '0 III
I ~ c -'" .50 01
'" c.!! c
,. '\:U III C
.e o u 0'0 ~
~ i iii
iiic Cl.c E l!!
e c- l!! III
., III .. .,
I 01 -E '0" 0 -
'Ol!! cll - c
.. .5 ';; .a ~
0 Co III Ul
- ., Ul .. _0 "
~ 111_ ..:= ., l!!-= ~
'0'0 .ac .e
c III c - .,! .Il
I :J .2., u ., E .e.,
'\: ...- :J > III 0.1:1 :g
..-
0 .. Ul -01 ~III Cl..
o C Ul ., .,
CI. ~ 0 .I:Ioll! ...
CI. .,- _0 .sa
0': .,:;::: .elll 0" 111'0
.eS -'l: -0 =~ i
I cO -u -CI. Ul ~
III" III 0 ...-
Ul III .e., .e.. '00 .. III
_N 0IC1. -CI. c_ o :J ~
.,e :J >< "'CI. J!l.e ~.5
.. III 0" C III Ul U - "
"01 .e'O :E., :c:E ., c .S
Ie .e.. =c - .. .eo e
1-0 <III III I-~ I-U
c .. 8
0 ., €
~ .1:1 ..... GO '" 0 -
., E N N N .., .., ~
I :J :J
0 Z ~
I
I
Ie < .., '" 0 .., CD .., .....
~ ::l! "": '" 0 0 0 .., ..... G! - CD N 0 0 '<i ..... 0 N CD '<i ..; ..... 0 '" '<i ..... '"
0 - ..; 0 0 0 ..; ..; - ,..; '<i ..; 0 0 cO ai cD 0 cD cO
c - - - - - -
I < '" ..... It) II! GO CI! 0 '" 0 0 ~ 0: - ~ - N 0 ..... 0 CD - ~ ..... .., ~
::l! ..; ,..; cD - t; 0 ..; 0 0 ,..; - N - ai '<i 0 ,..; 0 '<i ..; ,..; cD '<i ,..;
III 0 -
.., .., CD N - '" N '" - - - -
I
'" II! 0 It) N .. '" ..... CD <<! '" 0 CD - N ~ 0 0 '" II) NGO ..... .., CD
c:cfP. N - 0 cO N N ..; N cO - ,..; ..; cD ,..; 1;1 ~ N 0 N cD ~J:: cD '<i ai
I II) CD II) '" II) '" '" '" N C') II) CD It) II) '" II) ~ ~ CD CD CD
..... '" II! 0 0 ..... G! - - ~ II) N ~ - 0 ~ 0 "! ..... .., '" 0: <<! - ~
I cfP, 0 cD - 0 0 cD - cO ,..; cD 0 N ai ,..; 0 III cO - cD ,..; N - - ,..; '<i
- N - ~ II) ~ II) '" - N ~ N '" N - - -
C .. 0 G! 0 0 CD 0: II) - '" CI! ..... G! 0 0 - 0 II! - - CI! ..... 0 0 0
I ::l! 0 0 0 0 cD - ..; ,..; ,..; ..; 0 0 0 cO - ,..; ai ..; 0 0 0
III 0 - - - -
- - - N - -
.!!l
~
!! 0 -CD N "'''' !:I..... N ~ '" ~..... C') ~ .., "'II)N ~ N "'.....- ~..,
I <<: z ~N II) _N _N II) - '" ~'" II) - '" ;:::NIn - '" ;:::N&n _N
~ E E r! I: E l!! E E r! ~ E r! I: E r!
~ B ~ il 1i ~ 0 1i ~ ~ B .. 0 1i ~ 0
i! ~ s .. -; i! ~ .!! f s ..
.~ III ~ u III ~ u III u III ~
1: 1: 1: 1: i
~ " " ~ " .. ~ > " " E ~ " " E ~ " E
I " E " E
" 0 0 c: 0 0 c: 0 0 c: 0 0 c: 0 0 c
::J 01 ::J 01 ::J 01 ::J 01 ::J 01 ::l
e> :! ::l :! ::l :! ::l :! ::l :!
0 III III III III III
~ >- ..
:;::: 0 'ii
I: - .e
! 1 .. '0 -
'ii ';:; I: 0
is .. '0
~ J:l ~ -
I .. iii ..
" .2- l!! ... '0
:l! .. .. .e
>- III 0 e ~
c E ~! ~
!S 0 .. .. .. .. III
O.e 'Iii .!!
I <3 '0 ~... III
0 .e E 01
>-.. -
... - ~~ iii I:
11 0 0
3i! '0 .5 I
0 00
" ., 'ii ..
I ~ '0 1Il.e ~ 0 e
'O~
,. C I: .. ui ..
'" J:l 01
~ 111_ '" ..
01 ECI. .2. l!! o .
I: .. 0 ..~
'c '08, >- III
I E J:l .e..
"i! '0.. ->
- .2. .51:; ~
- I:.e III
- 111_ .. .!!~ "
0 >-- .. E ~
.. :=;0 'Q. '" CI...
I .. ><- 2 ., 0'0 g
.. .. ., .. I:
01 -0 CI. .. . -g
.. ~E .e~ CI...
- -- 'Iii>- Cl..
'0 .,>. III
0>- I: :J 0- ...
.e 0_ .sa
01 UJ:l E .. :!Ii Ec
I :E -'0 _.2-:; ...!! .E!
00 !1l CI... 01 U ~
'" -0 0- .e-
..- 8,.5 ..= ~
., ~ l!! -= .....
] -.. ~.. -.. 1:'" "
.,-
S "'0 -'0 01: - .. ~
Ie .el: ':1: .eo
== I-:J -'" :;;8 ::~ e
I: .. 8
0 ..
:;::: J:l '" '" ~ II) CD €
., E
I .. '" '" '" '" '" ~
:J :J
0 Z "
~
I
I
Ie <C '" "! 0 "! 0 <Xl
Z ~ CO 0 0 0 0 '" '" "! -i 0 CO '": ..... '" 0 cD ..... ..; ., '" "! 0 ., 0')
i2 0 d d d d d ..; ..; ... d iii ... iii cci d ... ... r...: N ..; ... d -i
c ... ... ... ... ... ...
I <C '" ... ..... <:l; C'I ID co ID <:l; co ..... ., C'I 0 ID 0 ID 0 0 '" ..... ., .....
'#. iii ..; N iii cD d ai r;; d ..; ..; ... ...
(f) ... ... r...: d -i d r...: d d cci r...: ai r...: cci
'" C'I '" C'I ID '" '" '" C'I ... ... ...
I
..... '" It) '" ": 0 '" '" '" ... ... ID ..... ": ... It) 0 0 ... 0 0 '" III '" .,
<e'ifl. r...: N cci -i ... iii ..; cci N cD N iii -i ... ai cD N -i ..; ..; iii N ... -i d
I '" ., '" ID C'I '" It) C'I ., C'I It) It) It) ., It) C'I '" '" C'I ... '" ., ., ... '"
... '" '" ... ... '": ..... ., '" ": co '" It) 0 '" '" 0 ..... '" It) ... '" '" 0 ":
I c'ifl. N cD cD r...: ..; ... r...: cD -i ... ai iii -i d r...: cD $ l:i ..; cD d cD cci d ...
C'I C'I C'I ... C'I C'I ... C'I C'I C'I C'I It) C'I ., It) It) '" C'I C'I It) C'I
"! ., ., co C'I '" ID co
I c ~ ... ..... "! ... 0 ... '" CO ... ., ": 0 "! 0 0 0 ., iii r...: ID ai cci cci -i
(f) 0 -i r...: ... r...: d -i ..; ..; r...: -i ... d ... d d ... cci ai ..;
... ... ... C'I ... ... C'I '"
.!!l
~
'" ci C'l1D C'I ., '" "'ID '" .,'" ........ '" C'IC'I "'It) '" "'''' "'ID '" .,'"
c: Z ~C'I It) ... C'I ~C'I It) ... C'I ~C'I It) ...C'I ~C'I It) ...C'I ~C'I It) ...C'I
I '"
~ E f! E .. E f! E f! E f!
~ = = ~ ~ = 1;
~ l! ~ 0 a; .. .. 0 a; ~ 5l a; ~ .. 5l ~ ~ 0
i! .. i! ~ .. ~ ~ ~ i! ..
.~ 0 ~ " Iii ~ " ~ " ~ Iii ~
" 1: ~ ~ 1: E 1: ~ ." ~ ~ 1: .. E
I c: > " " E .. " " " " " E " " E " " "
'" 0 (j C 0 (j C 0 (j C 0 (j c 0 (j C
::; '" ::; '" ::; '" " ::; '" " ::; '" "
e> ::! " ::! " ::! ::! ::!
0 0 0 0 0 0
lit Cl .!!
c
'6 Qi c
c ;!: ::t:
'" .0 0
~ E .2. ::t:
Cl GI Z GI
~ "D > GI ..c
I > E ..c -
~ :E - ..c
Cl -
Cl c .5 'j
.0 :c '0 GI Co
5 .!! "D c :I
I <3 c E ~ Co
.2 '" c GI
... '" ~
!!! ~ -
'" c c
0 - N GI GI 0
c: 0 C ..c ..c -
I ~ 0 '" ;!: ;!: l!!
3: l!! 2' ;!: ;!: . GI
~ 'Iii 0 0 0'0 ..c
"D III C Cc =
c :c ... ...c ~
I '" - 0 o GI
Cl .5 - -..c "D
C GI .!!;!: GI Gi -S
'6 GI a. !E.E Iii
a. Co"D
C 0 o c -- ~
'" 0 GI 8,,,, '" GI
I E GI Co :I..c .\1
GI Co ~ ~= IT_ ~
"D - .S! o GI -a, 0
III -;!:
> 0 > >.0 :1- ...
:E E...: o . .. 0 o III .l2
Cl -:I mg "'.- cO .!!!
I :E 0- GI ~ GI E
0 >C ~Qi .'3
.!! ...0 :t::GI l!!"D '"
~ GI l!!= '" '" CO
.0 o ~ l!!..c GI..!! .s;
.2. ;!:'Iii Co;!: CoCl
en.E ~... '"
Ie GI"D 1Il"D GI ~ ~
> ..cc .- c .- 0 ..cO
:;; 1-'" ~'" ~"D I-;!: e
c ~ <3
0 GI
~ .0 '" 0 '€
E ..... CO ...
I GI '" '" '" ., ., ~
:I :I
0 Z C\)
~
I
I
Ie <C ., '"
~ ~ co 0 0 0 0 ., 0 '" 0 ., ": 0 '" 0 0 '" ": CO ... 0 ID 0 ..... iii ..... 0')
0 d d N d d N d .., d -i ... d .., d d -i ..... .., r...: d cD d ui cci
c ...
I C'I ..... ID C'I co It)", C'I ., C'I ., ": III III .,<:1; 0
<C ., CO ., ..... ... CO CO 0
Ul '#. .., r...: ai ui .., N -i ..,-i -i .., r...: ui r...: cci ai ui .., ci ... ... ... 'It) ..,
... '" ... ... ... ... ... ... ... ... ... C'I ... ... "'... ...
I
., ... It) '" ... ..... ., C'I ..... It) ... '" C'I 0 '" ... It) ., 0 C'I "! 0 C'I C'I C'I
<trft. ai t! t! -i ai cD d ai iii cD r;; .., cD d d :j cci .., ci N ... d r;; ai iii
I ID ID It) ID ..... ID CO It) It) ., It) ., '" ., It) It) It) It) ID ID
... It) CO 0 '" '" '": It) 0 ., ... ID ..... '" '" It) ID 0 '" ": 0 It) It) 0 0
I off!. -i cci r...: d r...: cD ... .., d d .., -i N !;j r...: !:l -i ~ !;j ... .., :li ~ ci ..,
... ... C'I ... ... ... '" '" '" '" C'I '" C'I C'I ...
C It) 0 '" 0 0 ., ..... 0 0 ., 0 '" "! 0 ID CO '" ... 0 ., ., 0 C'I 0 0
I ~ .., iii ..,
(f) 0 N d ui d d N .., d ci -i iii .., ... d ai .., ci -i r...: d d d
... ... ...
.!!l
~
~ ci ........ ... "C'I "'..... C'I .,'" It)ID C'I :!~ "'ID '" ., '" ~1D1;l'" '"
I '" z ~C'I It) ...C'I ~C'I It) ...C'I ~C'I It) ~C'I It) ... C'I ... C'I ... C'I
~ E f! E f! E e E f! E ..
'" ~ :c :c :c ~
~ a; ~ .. 0 ~ .. 0 ~ a; l! ~ 0 i! a; l! ~ 5l ~ ~ l! ~ 5l
i! ~ .. i! ~ .. ..
.~ " ~ ~ " 0 ~ " 0 ~ 0 ~
" "Ii ~ ~ 1: ~ "Ii ~ ~ 1: ~ "Ii .. ~
I c: > .. E " " E > .. E " " " E " E
~ 0 (j C 0 (j C 0 (j C (j C 0 (j C
::; '" ::; '" ::; '" ::; 0> " ::; '" "
::i! " ::! " ::i! " ::i! 0 ::i!
0 0 0 0 0
~ l!! C C . >
'" .0 0 E
c ..!!. ! ~J Gi
::t: GI
..c C. lCCl Cl
~ 0 - GlIlI
::t: III 0 0> ~
~ Z C 2'"D ~
I 0 -GI
'" GI GI . o GI >..c
~ ..c 00 .. :I: ..- .0
... :I~ -- as!:: .s
c .5 ..clll GI .
-... -..c >"D ~
5 01 .. ~ c- :::C
I <3 l!! EO -... l!!~
GI :I: C ~ ..c
... :I -- 00 a.o C .
!!! 'tl r=,o ;:;:1: ..- o l!!
fl . ~o .- ...
0 Ul"D ~6 01 GI
c: ei >c ~"D c..c
I ~ Cl- .c":I: O'tl
a. 'Iii 0'" .!Ic
:1- 0- -GI
3: 'tl- -GI 'liiE
O..c a.... -c
~ c .. c- E"D >0 GI 0
co 0 ..co E .. Clu
01 E u- S Iii ~ Cl-
-88- :I GI
I .!! 0 GI GI "DC .. :I:
u- --
=c c.!!! c :I o GI "D'il -S
0:1: o~ III 0 _..c Iii.o Iii
-a. c E >- .
a.o '&i2 "'0" .."D ~
.. c Ea. ..!lco !:... l! c-
I GI'" -GI ~ .. :I 0:1 ~
l!"D ~a. "'..c _0
,2 co E- GlGI'tl .5:1: -g
:I C ::: g' B
o co C"D 00 a.~ Cl
Ul"D -c -- Glcoo 00 ...
l!! GI GlIlI :lGI .o..c~ - Q
=GI co_ coua. >l!!
I c _co .l!l
c.- -> 0';: alii:! E '"
"'ll ca; -a. 'l;jGl .'3
E"D ..cu ~e "1- '"
-GI - GI ..cC co
:I> ...= Gla. ic~ -0 .s;
..c"C CGI -a. -"D '"
Ie GI'" :EGI GlIlI ..cGlCO al.o .S
..c.!! - ~ ..c.. ~..c..c ~.2. e
I-u _Ill 1-- _ u
c ~ <3
0 GI
;:; .0 '€
.. E C'I ~ :J: It) '"
I GI ., ., ., ~
:I :I
0 Z CD
~
I
I
I Ie < CD CD CD 0
~ II> .... 0 0 0 II> O! CD 0 0 ~ .., II> "': CD ~ 0
>l! <Ii :; ~ cxi ,..: ..
0 N ,..: d d d N ... ...; d d <Ii ~ ,..: ,..: d
0 ... N ~ ~
I < .., .... O! .... .., ... '" CD 0 0 .., '" O! ~ 0 ... .... CD 0 CD 0>
>l! ,..: ,..: ,..: ,..: ...; ...; ...; d d N ...; ,..: d ...; ...; ...; d ~ '" ~
1II 0 ~ ~ 0>
~ .c 0
I I- Ol
0>
u;t;;
~ .... "! '" II> '" '" ... ~ ~ CD '" '" .s: ~ ~ 0 .... .s: CD 0> <J
CC;!!. ,..: ...; <Ii ,..: <Ii cxi ...; en ...; <Ii cxi en ~gj ,..: ~ "i:: Q)
5l '" ~ ~ 00>
I II> CD II> II> N N N N ... N N ~ N ... ... N Ol>.
0> 0
CUe.
<J E
0 .., "! II> ~ CD '" 0 III ~ N N '" CD ~ "': "': '" ~ .... 0> 0>
0 >l! ~ .n cxi <Ii N <Ii :; <Ii .n en oci cxi en .n c; N ~.Q
0 ~ ~ ~ ~
I N ~ N ... N ... N CD N N ~ ~ N ... ... ~ ... N 0:1:::
all!
Eo.
0> '"
III CD II> N .s: CD N .., ~ ... II> ~ ... N ~ >.
0 CD .... 0 0 .., "': '" "
I 1II >l! .n ~ ,..: d d ...; oci d II> ~ N .n ~ ~ ~ .n ~ .n ~ oci .Eos
0
~ ... ... ... ~ ... ~ ~ ~ ~ ~ ~ ~ ~ ~ ., ~
.!!l .c.E
~ -."
:l! 0 ~CDN ...... NCD ... ...... "'CD ... ..,... !':l.........,~ '00>
.,1:
I <( Z ~Nll) ~N ~N II> ~N ~N II> ~N _!Nit),.. " 0
~ l!! I!! I!! I!! Og.
II: E II: E II: E ~ E o ~
'ii J!l ~ 0 'ii J!l ~ lil 'ii J!l ~ lil B ~ lil -'"
'ii .. i! i! ~ ,,-
.~ u '" ! u tIl ! u tIl :0"5
~ 'li 1: 'li 'li
.. E !1 .. .. ~ !1 .. ~ .. ~ 0> '"
I t: E E E
& 0 c 0 0 c 0 0 c 0 0 c .- ~
:::i 01 " :::i 01 " :::i 01 " :::i 01 " :!:
::E tIl ::E tIl ::E tIl ::E tIl '" .,
"'.c
os_
~ tIl '0 0"
'\::l >. .,:C
"
:> ~ .co>
--
.. :is 0"
l5- .5 III J!l " .,
Q " .,,'"
:Ii '6t .. -(I!
€ -g "'0.
I .. .. '\::l o .,
'" 0 .. " C <J ~
~ ~ :> .. .. 00
<!:- 0 'ii E .c .c"
- '\::l - ;: .,
5 .c ~ ui iii
c .. "'~
I 8 " '\::l.!! .. "os
j .c
c~ Iii iii .,-
"- .. .. .,,'"
11 0 " 'll ".c
.5 -g';: ~ 0'-
0 " 0.-
t: ~ ilia. .. ",l!!
I :l! c'\::l C !~
III C '0 ;;::
~ u c" " Il ....0
~ .. Ill.. Iii .c ., .
.. ="ii - ~ ~
iii ;8, ~ - ~.g
I c :>
0 '"
0 :is 0>=
1l ..- .a ~ '" ;5
_Ill ..= III ., '"
C es .2; e =e C;j
:> ..;: cO> ~
.. .c" "'Ill :>
I '\::l 8'~ E c " o.c g
.. .- -
c S:sc .. Oi" '5
.. Ill" .... >. E:C Q.
1: a.fl >.0
.. ~ :is o ., "-
III ~o III -." .E
.. III .. iiill C . .5 ::I ~
I .. " :> 'u .c 00 010
..
is. 'iij 0 co ":E: .5.5
>'Ill ..- :!U '" ., .,
.!! .cc c .. ..:E: '" ~ .s
a.;: ';1 -z .- os
.. E '" '"
Ie :E GIll .ca. II.. - - ~
~E ".c o " e
I- 1-.. - - 0> 0>
C .. ",'" <'3
0 .8 '" "
:;:: 0 os 0 €
'" E .... CD en <Jo.
GI .., .., .., II> 0> '" ~
I :> :> aJ~
0 Z ~ "
~
I
I
Ie
I
I
I
I
I
I
I
fI
I
I
I
I
I
I
Ie
I
I
New Hanover County Health Department Organizational Analysis
Appendix 0 - Focus Groups
0.1. Focus Group Methodology
The North Carolina Institute for Public Health conducted six focus groups with New
Hanover County Health Department employees during September 10-12, 2002. Both
county employees as well as contract employees were invited to participate. Each
individual group convened was comprised of employees with similar characteristics. For
example, there was one group of administrative support staff; 2 groups of nurses, or
those providing clinical services; one group of supervisors; one group of employees that
have offices located of-site from the main health department facility; and a group of
professional staff. On average, 15 people were invited to attend. Invitees were selected
randomly, but in a way that ensured that each division of the health department could
potentially be represented in each group.
Two focus group sessions were held each day The morning session was held from 8 to
10 am, and the afternoon session from 3-5 pm. The groups were convened in meeting
spaces that were outside of the health department so that participants would have a safe
and comfortable environment to express their concerns about working at the health
department. The Area Health Education Center (AHEC) provided classrooms in its
facility, which is located in the hospital complex next to the health department. This
location was selected so that most of the participants could walk to the sessions.
In each group there was one facilitator and two note takers, all of whom are from the
NCIPH or the SPH. For reasons of confidentiality, the discussions were not tape-
recorded. At the beginning of each session, the facilitator reviewed the purpose of the
project, who was conducting the project, and how the focus group would progress. Most
importantly she asked each of the health department employees present, to respect the
privacy and confidentiality of their co-workers. Each participant was asked to agree to
keep the responses of their co-workers private, and to refrain from discussing these with
other co-workers, their friends and family The facilitator led the discussion, utilizing a
question guide (Appendix C). Each discussion lasted approximately 2 hours.
The UNC School of Public Health Institutional Review Board approved this project for
Research involving Human Subjects.
The North Carolina Institute for Public Health
41
I
Ie
I
I
I
I
I
I
I
fI
I
I
I
I
I
I
Ie
I
I
New Hanover County Heafth Department Organizational Analysis
Appendix 0 - Focus Groups
0.1. Focus Group Methodology
The North Carolina Institute for Public Health conducted six focus groups with New
Hanover County Health Department employees during September 10-12, 2002. Both
county employees as well as contract employees were invited to participate. Each
individual group convened was comprised of employees with similar characteristics. For
example, there was one group of administrative support staff; 2 groups of nurses, or
those providing clinical services; one group of supervisors; one group of employees that
have offices located of-site from the main health department facility; and a group of
professional staff. On average, 15 people were invited to attend. Invitees were selected
randomly, but in a way that ensured that each division of the health department could
potentially be represented in each group.
Two focus group sessions were held each day The morning session was held from 8 to
10 am, and the afternoon session from 3-5 pm. The groups were convened in meeting
spaces that were outside of the health department so that participants would have a safe
and comfortable environment to express their concerns about working at the health
department. The Area Health Education Center (AHEC) provided classrooms in its
facility, which is located in the hospital complex next to the health department. This
location was selected so that most of the participants could walk to the sessions.
In each group there was one facilitator and two note takers, all of whom are from the
NCIPH or the SPH. For reasons of confidentiality, the discussions were not tape-
recorded. At the beginning of each session, the facilitator reviewed the purpose of the
project, who was conducting the project, and how the focus group would progress. Most
importantly she asked each of the health department employees present, to respect the
privacy and confidentiality of their co-workers. Each participant was asked to agree to
keep the responses of their co-workers private, and to refrain from discussing these with
other co-workers, their friends and family The facilitator led the discussion, utilizing a
question guide (Appendix C). Each discussion lasted approximately 2 hours.
For the results presented in this report, the categorical names of the groups were
replaced with color names, to protect the confidentiality of the groups and their
participants.
The UNC School of Public Health Institutional Review Board approved this project for
Research involving Human Subjects.
The North Carolina Institute for Public Health
41
I
Ie
I
I
I
I
I
I
I
t'
I
I
I
I
I
I
Ie
I
I
New Hanover County Health Department Organizational Analysis
We are inviting you to participate In a focus group to be held on:
Day:
Time:
Place:
(Note that the activity Is scheduled to take two hours. It will not last longer than
that. )
Please contact us immediately if you cannot attend on the date and time shown above,
because it is very important for us to know how many will be coming. If you cannot
attend, please do not recruit someone else to come in you place; we need to do that
according to the research plan for the focus groups. If you cannot participate, or if you
have any questions or concerns, please contact Janet Alexander at (919) 843-5559, or
by email at JaneCAlexander@unc.edu.
We look forward to having you participate, and we think you will find the experience very
interesting.
Janet and Sheila
The North Carolina Institute for Public Health
43
I
Ie
I
I
I
I
I
I
I
fI
I
I
I
I
I
I
Ie
I
I
New Hanover County Health Department Organizational Analysis
0.3. Focus Group Fact Sheet
IU~C
New Hanover County Health Department Organizational Assessment
Focus Group Fact Sheet
The purpose of this project is to:
~ Understand the goals, activities, and achievements of individual programs and
services of the New Hanover County Health Department.
~ Identify concerns or issues that program leadership or staff believe need to be
addressed in order to strengthen program operations.
~ Identify opportunities for improving operations and services to clients that will
produce more efficient and effective service delivery and contribute to the
enhancement of staff morale.
~ Document specific suggestions and recommendations to address these issues or
concerns.
Who is doing the project?
~ This is a research project that the North Carolina Institute for Public Health (NCIPH)
was asked to do with the health department. The NCIPH is part of the School of
Public Health at the University of North Carolina at Chapel Hill. The NCIPH will use
it's "lessons learned" while doing this assessment to develop a tool that can be used
by other non-profit groups that want to assess their organization. The North Carolina
Institute for Public Health is located at 400 Roberson Drive, Carrboro, NC 27510.
The project director, H. Pennington Whiteside, Jr., can be reached by phone at (919)
966-1069, or by email at hwhitesi@email.unc.edu.
~ Other project staff includes William Herzog, Charles Grubb, Sheila Pfaender, and
Janet Alexander
What are you being asked to do?
~ You are invited to participate in a focus group discussion. The purpose of speaking
with you today is to find out about your thoughts and experiences working at the
Health Department in New Hanover County. We will ask you about the health
department's
. Mission and Goals
· Tasks, Technology, and Workload
. Structure, Communication and Coordination
. Management
. Human Resources
. Finances, Facilities, and Equipment
· Collaboration with other organizations
. Marketing
The North Carolina Institute lor Public Health
44
I
Ie
I
I
I
I
I
I
I
"
I
I
I
I
I
I
Ie
I
I
New Hanover County Health Department Organizational Analysis
~ This group discussion should last about 2 hours and will be led by NCIPH staff.
~ The session will be held at the AHEC facility near the main health department
building.
~ Participation is voluntary If you decide not to participate in this focus group this will
not affect your job. You have the right to withdraw your consent or stop your
participation at any time without penalty.
~ The Health director has given permission for this session to occur during your normal
work hours.
~ If you choose to participate in the discussion, you have the right to refuse to answer
any question if you do not feel comfortable.
~ If you choose to participate, you will be asked to agree to respect the privacy of your
co-workers, which means that you will not tell other co-workers, friends, or family
member what individual participants said during the session.
What are the costs of participating?
~ There is no cost to you for participating. The health director has given permission for
this focus group to occur during your normal work time. You will not be paid for
participating.
~ Light snacks will be provided.
What are the risks and benefits of your participation?
~ We are asking you to offer your personal opinion about the health department.
Because these may be somewhat sensitive questions, we can assure you that we
will make the highest effort to protect your confidentiality.
~ We will not tape record the session
~ We will take notes during this interview, but will not record any names of who
attended, or of which individuals had particular opinions.
~ Only the NCIPH project staff will have access to the notes, which will be stored in a
locked file cabinet and on project computers at the NCIPH.
~ We will be reporting summaries of the thoughts from this group, and not the opinions
of particular individuals.
~ The benefit of your participation is that the results of the focus groups will be useful
for making future improvements to the health department, and in making the health
department a more comfortable and efficient place for you to work.
If you have any questions about the organizational assessment project:
~ please contact Janet Alexander. You may call her collect at (919) 843-5559 or email
her at janeCalexander@unc.edu, or you may contact the project director
Pennington Whiteside at (919) 966-1069 or email him at hwhitesi@email.unc.edu
The School of Public Health Institutional Review Board on Research Involving Human
Subjects ha~ approved this project. IRB, School of Public Health, University of North
Carolina at Chapel Hill, CB # 7400, Chapel Hill, NC 27599-7400. You may call them
collect at (919) 966-3012 with any questions about approval of this study
The North Carolina Institute for Public Health
45
I
Ie
I
I
I
I
I
I
I
"
I
I
I
I
I
I
Ie
I
I
New Hanover County Health DiJpai'iment Organizational Analysis
0.4. Focus Group Discussion Guide
1. Opening Remarks
. Thank you for taking the time to meet with us. We recognize that your time is
valuable and we appreciate your participation.
2. Review Fact Sheet
3. Ground Rules
· Participation is voluntary. Right to refuse: I want you to know that you do not
have to answer every question we ask. "at any time while we are talking you
don't want to answer a question, you do not feel comfortable, or you would like to
end the interview, please feel free to let me/us know. If you decide not to
participate, or not to answer some questions, this will not affect your job.
. We would also like to make sure that everyone has a chance to say something.
Please allow each person to talk, and we ask that only one person talk at a time.
. It is very important that ''what is said in the room today, stays in the room." So
when you leave today, respect the privacy of your co-workers and do not tell
other co-workers, friends, or family, that "so and so said this" and "so and so
said that."
. Does everyone agree to this? Is there anyone that does not want to
participate?
. Do you have any questions about anything I have said so far?
. This fact sheet that I have given you tells you whom you can call to find out
more about this project or whom you can call or email if you have any
questions later
4. Discussion
Opening question
. To get started, and to get to know you a little bit, I would like to go around the
room and ask you to share with us the reason that you decided to take a job
here at the Health Department. (How did you come to take a job at the HD?)
The North Carolina Institute for Public Health
46
I
Ie
I
I
I
I
I
I
I
fI
I
I
I
I
I
I
Ie
I
I
New Hanover County Health Department Organizational Analysis
Questions on OrganizationallMissions/GoalsNalues
. What do you see as the main responsibilities of the Health Department?
· Which of these responsibilities does the HD do best?
· Which of these responsibilities does the HD do least well?
· Optional: Do you think that they organization is addressing the most
important public health goals for your community? What could the
organization do to improve this?
Questions on Structure/Communication/Coordination
· By what method do staff at the HD communicate with each other?
o With supervisors?
o With co-workers?
o With other divisions in the HD?
o How does this work?
o Why does it work?
o What can be done to improve it?
Questions on Human resources
· How well are the knowledge and skills of employees utilized in the HD, in
general?
· How are new ideas or suggestions made by employees handled? (What
happens when the HD wants to adopt a new way of doing something?)
· What does the HD do to recognize and reward excellent performance?
. How are single mistakes or major errors handled in the HD?
. Optional: What steps or resources does the HD provide for employee growth
and professional development? What else should it be doing?
Questions on Finances/FacilitiesJEquipment
. How current and functional is the information technology, communications
equipment and other office equipment in the HD?
. Do you know how to use the equipment?
· How does the information reporting system work? (reporting on numbers of
visits in a clinic, number of inspections, outstanding bills) What can be done
to improve it?
The North Carolina Institute for Pubiic Health
47
I
Ie
I
I
I
I
I
I
I
fI
I
I
I
I
I
I
Ie
I
I
New Hanover County Health Depaitment Organizational Analysis
Questions on Marketing and Related Functions
· How aware is the community of the programs, services, and policies of the
HD? (community=high risk community groups, healthcare professionals,
building contractors, restaurant operators, teachers)
· How well received are the community services to the HD clients/to the
community?
Questions on Inter-organizational Collaboration
· Optional: How effectively does the HD work with other organizations in the
community? (social services, mental health, police and fire departments,
hospitals system, schools, etc)
Closing(s):
· Do you have any closing thoughts, or are there any issues that we didn't
bring up the discussion today that you would like to bring up now?
· This is the first of six groups that we are doing this week, do you have any
suggestions about what we can do differently for the next group?
· We are nearing the end of the session. I would like to ask each of you,
what do you like best about working at the health department?
The North Carolina Institute for Public Health
48
I
Ie
I
I
I
I
I .!!2
~
'"
c:
<(
I (ij >.
c: ...
g III
.@ E
c: E
I ~
6 :J
en
c:
~ c..
:J
0
...
"
~ III
I ~ :J
U
~ 0
~ LL
I an
...
~ .
0 C
c:
I ~
il:
~
I
I
I
Ie
I
I
.9 OJ
" <.i
'" ""-
.Eal" '0 ci ~'" ~ii5
o ai ... " >- a.!! g.~
0 ilej I:: " '"
W 32 :!lcn ill ~ ,-"
II: 0" '" -"", I:: I:: ,!.f!! m~'"
-.- Q) ;S =>" " 0 ils-
i~,* 0.1:: 0; "'- ",,,~
~i! "I!! 1ll!l 0", ,...0;
C Q)~ .!!!'" 0. =>1:: ~i.~ am e
'" E ~ ;]~ "'iO a; iE!
~E CD :::l--
11:", :I: (1);;:::'0 () "" 0.
j '0 " 00 "
=> i! 1:.6 ~o; !1
al=lij~ "'''' =>
!l: =~ 0
,,'iiI '"
9 !l-""~ '5- -" I!!
"'- 0 -0 ~""
-I "O~E; 1Ili! 0.'" 5 I:: I:: '"
"':2 I:: 0 I:: I::
W I:: ,,~ H 0 '" ,2 0 0
> ;~~i~ ~ .5 ::c - '" '" E '" I
Gi ,,=> Il I e ~ Il
~li; ~o.
5ig.~(/) I:: "J" => .l2 I!! =>
,,0; " " " '"
J:.c"OQ);t:: -10 al Clo; W 0. .5 0. W .5
" ~
i! .9 '0 I:: "
'" j 3i " I::
~ " " .-.... 0
W '5 0 .. "" il~;go
-I .9 al '~ "'~- , ""I::
-" ..' S .~,5 ~ ~:g
0. ,2. "" "
II: ~" ll! '" Q) ~ >- c: Q) 1:5 0 'C
::> '2 is.. .. OO,!.! ..c:. = ~ U)~-'-'>
0. €~ al " l!l .6::0 -I::.. c>>"ai0'=2
:0 ii ,,=> H~~ "0'- (J) CD
8.= j 'S: Co ._~.QU)c.
'~ I:: 15 S g.'s: > ~ "
" " ~" ~:g:g~~
8"'3' z u: al 0.= D:o..!-a5
ci
" E i! gJECi)
I::
.. " ill -"I::
W I!l 00 ","0
'6 "" 1l""'"
Cl => "
z 0 .S; =,2 ~~,gf
<( "" I:: " 0.
II: "", ~ 0; 00:0 :E I:: ~Q)5
-" 1::" 0 "EE
0 ~ -"- 00 ,- 0. I!l '"
..=> I:: I:: -g" " Il "I::E
Gi gal ]; c. ~ '5 ~.-
I:: 00; " ~ '5"
" .."" ~ a; ~ "
al u.ll! :I: 11:'5 w (Lira
" .. I!! al
E" I " " B
"" I:: "
~~ 0. " '" '0 " 0
III E 1l lij 2:
w ~~ 00 ~ ""
::> ~ ~ '~ '" E "
-I 0. :g~ ill '"
III alO I:: U Iii
.E - "I:: 0 ""
~i! I:: '" ii,l! ~
.. .9 :2E "'",
H " '" 1l ill ~
E .. I:: > E => 0:0 '" =>
I!! ~ .. " " ~8 " ~ => ~~ "
0..l2 () ;;: ::!= W 0.0. ()
i;=B i! ",I!!
" Iii 3l By '0 " .8 0 ~
00 .~--
"'" ~ "00 "" Iii
z '" " il'E .'" ilo Q)lU~ I!! ~
"I:: ,,0 o~ " ~'"
w ~~ ,I! II ~.8 .II '~ 0. ~ cn~"O_ 0;
W :0 Q)c[g oc-Ul B~ '"
II: ..ill 1::_ 8.90 " I:: I:: ~1: {l"~'3 "I:: *
Cl ~~ sai 0. ,2 0 '" 1l > :;g "',,0 -g '2 Eo
.>--~~ E B -8J!!! _e"01D 1::'-
alii '$~ Y ~ 0" 8.~ ~-g 0
I:: I:: I:: 'S: a. E ~~ ...a.Q)C) i
""=> 1::,_ "2 => e => ~g" 8'.51::" "'E '5 0.
alE ,,- ill "'" s..8.E ~8 1::'"
all!! 8_8 0. 0. 0. 0.0; CIl,S! w.E c
"
"" 1::- -
-.c: -0 c
ll- ~:l a> a>
",;; =~
"'" ~i t: U,
!i!,.!2. -;855 0"0-
'tl ftIC". !--e ",,-
.- coO .. I:: lit:: iii€,8
"",:c 1ii 8..c II
>-so
~o:c "":la>'" :<:110
_z :=1...:;-8 !l:"""
Ol
'<l'
,s
f
,0
~
...
Q
.!l
:E
OJ
.s;
'"
,S;
e
t'l
~
~
<Il
~
I
Ie
I
I
I
I
I
.!!2
~
~
<(
(ij
c:
.Q
~
'"
~
o
I
I
~
Q
I
I
~
'"
~
~
c:
"
<3
I
...
~
o
c:
~
il:
~
I
I
I
Ie
I
I
-
o
W
II:
c
o
gS;
a; _ >-
"i5.0S cn
0'-.'" "
~l ~~
~~ g.~
Q)cnQ):t:::
- U) ~ (J)
8g~~
l-(J)~O
>-
"
..
1.5
o
.9
11
~
"
~c 0
c3E
!l:
9
-'
w
>
..,
:0
C 5. (J)
,QQ)~
o~.-
E-;~
0" "
...._ (J)
'i'-eS
~.Q.8
w.5 a:l
~- ;;
-::J (J)o.
.5.8 -g.- g
(J) a:I~ a:l~ c..
1:...._ -
.2oai.1a.!Q
g.15.&1l!E-.cs.
O)B(J)Q)~ai~
.5 a CD-Et:CO
~~ja;!:g:;
~'E'~i~.g a
w
-'
0.
II:
::>
0.
~o
.Q"
"'.. "
B~;Q
.~ 0.2>
"j;;
'" "
lD 1:'-
'OCDB
'5 -0 :s
0= lD
d:ii::
w
Cl
z
<(
II:
o
~CD-
- 0; Il
.5~'2
gjti
~~o
E'- c_
Es:8m
o.E 0.0
.... ".~
;;~~"
U)OQ)(J)
w
::>
-'
Gl
"
"
i:::a:l
0'"
0>'" m
"1l "
.Q ::J =
, al'-
~ is
Q;l,g(J)
:g ~.;;; m
~=::I (J)
- " 8'"
a.. ==_ 0
z
w
W
II:
Cl
~
'5 ~
Eilz 0
E..,-E
855~~
lDE_s
~ ~ 55 E
0. '0 (J) E
E > l! 0
_.50.0
E
,,"
~ E_.
-t:::.
:I";;
o 5t ~
"C"C'tj
iii€1I
:c:'O
3:s::"
.E
'"
"
o
.~
"
'"
B(J)
'23
oil
'0
is
'"
..
"
'E
g
0",
0.9
0.5
0.0
"
" "
.2 a:l_
-"'"
~.s; il
~ - ..
~-.D
~~'5
0",0
a:l::l'Q)
I!!go>
s.o!:
0_.0
"
Os::
:;1ij
el!E
.E!CDQ)
.S;= E
",,-E
~:2 !
~j~
.!!1
E
""
€~~
!~~
.n~
.5 ~-g
m 55 8."
:I: .0.
E
"
0>
'6
.S;
.E
'"
1l
.~
"
'"
o
H
,,1l 1:
8 !11 ci ~
U)o(J)CD
..i:::'~..!.m
OlDel!
lBU)CD=
~ alS:: 0
'5lD'Q)m
o C 00
"
.2
~:'m
-""
0>"
"" 0
.- ,,+:
lfi-3::g
1a~~o
Q) 1:! 0.'-
.2og~
l- c a. (J)
"
~
'"
'6
~c
"0
::J:;
E"
E~
ol!!
00.
"Co~
--0
5~;'
~.- 0
C U)"C B
:;::I:,eg
~55~m"C
E E .~.I: a:l
~~~>-
algEe-K
~ .d. lL9
~.9
1::""
8.'o:o.!:: 'C
o.'en a:l Q) I:
e >-Q)= a:I
-a.o Q)(J) 0
0. ooS;"
OQ)_C.2._
g!1ii'O ~.~ 2
,,-Eo $'E gg
o o.l:._'C c..
..
o
"
..
"
~ ~
CDZ"S
OS0
E8.!!!
~ 0; ~
~'3' 8
'"
0>
.S;
;;
..
E
~
'"
>
1
~
"'
J!l
'"
OJ
"
.2 ~
.~ :S
'6:B
:(E
'"
..
o
"
'"
"
:s
a;
E
w
~
.S;
;;
"
E
:(
""
~~
h
e..
=en=E
....R
E>i1S
w.L
'..
E
"
o
g
s::~
-"
Iii!.
""
:;sc;-
i!..!! :I..
OC::Jc
"C~OJ.2
iOe]!.!!!
ooo~
% U U"C
:g
i
'2
"
E
E"
8"
"al
.."
0"
i!!l
~H
UlCD+:I
s 2'....
.- CD CD
.ht
",,>-
e':: fa
E ~ I:
0,,"
O.o-E
$I
>0;
~'i
~.! CD
~.~s
E " 0
cbeai
CDEE
:!38B
"
"
o
s::
0.
"
"
..
'..
Ii'
w
Q)S~
.sa.5 Ul~1:
C CD ::J_._
~1iio'S!~
~8il P
8;.9 2
a:lCD >-(J) 3:
E> a:l.!!! Q)
.g~~'B:8i
c CD~ a:l.r::._
-.......---
'"
0>
"
m
::;;
.9
",
"il -
~"-clB
if) sg.o:U
.=+:1 8.o~
"CB~ ,..
s::.-" " ~
g 5':= B en
E E:li .'-
~~~~~
>
l~
ID ID~l
!l 'B"~
(J) (I)'2~-E
CC::ICo
~.~E~5
J!I:~!l iE
<l.i"Co~a:l
I!!
","
"'"
.25,
.~ '" al
.- Il 0>
'C'c e
"""
~E8
'" eo.!!1
.E8p
~ ,,$1;5
iO iil= 3'
Q)t;a:lCD
dU~l!l
C c.s CD C'-
::1::1':(/)::13
CDEo:JE....
HHU
'..
~
.><
]
"
c.
h
"0;
~"
",F
1.5
e
E'O
s~
~o_
(J)t) l!!
0>.."
c.= .c
o"C E
"0"
0.""
"
0;.
0>'"
.~ C C
~'>.o-
t!a~llc..
..S! n..!!! (I)::J
~+:iQ)Q)"C
0)'0 r ~ CD
:::lIDQ) (J)
255ei:g
~~ :g,EF
.e s.. Q)
, ..8 E
I!l "'r
.!!! .~-a; &
r 1ii CD 0).
~ .Q m~~
a:l~50tUO
EgH ~~~
I-i 8 E~~
o
'"
.!!!
~i
"0>
0>"
.93
g'8
~55
~g
,s
(ij
~
.11
~
...
~
.!l
:e
OJ
.s;
'"
.S
e
t'l
~
~
<Il
~
I
Ie
I
I
I
I
I .!!l
~
1!
<(
I <;
c:
~
.~
c:
I ~
<'5
c:
t4
Cl
€
I <Il
~
0
5
I <3
...
!!1
0
c:
I ~
;!:
~
I
I
I
Ie
I
I
~
It)
."
"'- ,,,is
,,- s
.g~ .Q~ 0
Q -" ,,;;
w ijjB T1.e f?'i
a: E.- .- - " .
~ " Co Q) ~~Ol
0" ~Cn; """
" E E " ... Ul 11).-
~ ~ E.." ":g E
0.., 8 g,,~
::;Q UO" ll.",
j " S ~ ,," ." 0 "1:-
" '" !!l ~~ a
;; "8 0_
.. 12" II
'" ~ '" .., i!! 0).6
;: 00'0 OQ) 0= ~u.- c:0
'" " .,~" "'s"
9 " 0 c - fa e!l: Ul .~ "'F "0" .- 0
o~ ~ c ~ .~~I2S""~ ~ ",eE li
-"1l O~BOl 8.1;;~
.J :~ ~.- _ CD .6 .S; !il.o~.5" 8~!
w '" ._~ :s 8._ ~ cu-5.g ,,;; sa
> '005 al .c. :~E
,,"" ..."'"
.ij CD" E e -,2 E c ""C:~E.io. ~~~~ ,gQ)ECP 1:: .5
E E~EQ) ~:~ a 'a; r~8. EQ1i!! x gg= !~
uJ al~8~ ::J.: 8 E'" Cf.I!!.f2 0" '"'
_" .0 0lU)'C 0 '" '" .0 U"
W
.J
ll.
a:
::l
ll.
-r:: S'
0"
_ ~ 8.
"0'"
.cUll!!
;;-.~ !:!.
""'"
E 0. ~
w~<<i
w
Cl
z
<(
a:
o
i!!
"
'" .,
,2 E ~
~.g ~p
'2!b 2 :g
::J Q).~ Ol
E.~ 2: t'I:l ~
~=~ ~!j
W
::l
.J
Gl
12~
",,,,,,
"i! 0
0,,_
,,~o
l!?-.s
oj ~
'" -
.- "
C:,-.D
8." '"'
"" "
"'FE
.ij
E
uJ
z
w
w
a:
Cl
,;
-s
'"
-0
""
E:c
.. "
E"
..0.
",-8
~.
"'~
-'"
is
..",
:;,-~
g,~ "
,,0.
0" "
"S"
itE!;
~H
"
E
o
"'"
".-
.- "
... !ll
,!!=
il",
"
./1.212
O'~~
3::so
"5
=.o"c
~ef!?ca
....00-
Q)U)11<D
-.- iti 01
C ~ C:.= (p
rf~ g.~ ~ \.
., E "'._" ~
EE.t:!::Jen
al8jg~lij
.:; .~
'i c
0: ai ,2
1:'0> '0
gaiQ)~~
rJ 'C ~ a:l':-.
.2m !il2".,,,
~p'2:1:1; 0
EC8.~aiE
8~~~TJg
'Ee B
~ ~n-g
C)Q)U)U)~
<<Iii a.... c
a3 00; Oa;j
!iiE;;~;
ti~ c g.5
.- ::J ~... CD
::!:.s=.t:ia..c
:2 . _ r'
".::l "
~cn32
enS 5
~"~
"",
.-= 12
c:'iifl
8. i! iti
"0.>:
"'~"
.5
~ ~r'
CD" Q) C
....... fijOJ
<<l ~.. iU
mOo1212o'"'
"" "
~i!!H;;-g
~~ g.g.!m
WrUl0:i:c:
a; 6
~ I.
~ o-l!lo
0.""
~'8;; III
>.&.5: !
;j l!!j'Ci)
Ea:l>.El!?
8s~ ~~
~Ul._'CO
",09
SGI !!
;=i .2
liE 1;; c::
g::J .2.. 0
::J~oc::J'"
~B~~g,~
""a.S:58.
HUH
-s
<;
:'fl
.\1
~
...
Q
~
"
;;;
.s
'"
.S
e
a
€
~
'"
;::
I
Ie
I
I
I
I
I .!!l
~
1!
"
I ..
"
~
.~
"
I "
e>
0
~
Cl
~
I "
~
a
5
I 8
...
!l!
"
"
I ~
"
~
I
I
I
Ie
I
I
'" CD >. Q)
'" .c_<'llE
~'E '" - Iii" 0
c c€"'"
~ ->- '0; :6 '0
c 'Q) CI) -:0 0
w :6"E o! CD:; C:ctl~~
II: 5 Eo ~ite:~
0" 000'-
-E ~",c ""S
"a. "
'ij 0" 15..Q)5E >.c ~ >.
01", Q)~Q)a:lU)
E "a. a:~5 g o<'ll"C"9~
uJ ~-2l ZCDI:OC:
CLoo J::::J_:::J
" C
<;; o _ "
~ - "e: ",j '"
:= '" 'i0J::Q) Ol c >-ll
0 .c ~.1!::€i 5.Q~Q)
-' oe: :g..s ~"o a;[gc
-' ~.Q CD 0" 0.. C '-oe>-a
W 0..,; i Q) <'ll '~'2 B,5
> c1;; ...!.. CD 'C;; '-:J c: -5
.~ E =~5!E!~ ~ E ~Q) CD
'> 0 lB~.8m~ ~U~~
c:S LJ..ctSa:l.co
i~ c 00
o j" -"
0 Ec '" g ~ UJ OIoE
:2 a; :5 e.- (I) 0) ce:o
~ o~ 5~">. = c 012'"
>- ,,1:11.2
w :t:_ee '0
oJ o 0..._ _ += 10 a:l_.~ ~ ".5
CL S:::J C. (/) ci i:i~ o g.~ CD li5 "'ll
II: U)a.c~ 8J,:- .5 ~ - ~a.:o E CD =i~:c POl",
'" >.Ul.Q :i:>; -" m"Eh en ... C c
CL ~ g>~caQ) >-c -l!" CDCU::Jj Olec
-c ~>. g>Q)Q)'O OI>-E E ,,0
t::- -e yo c'2 G.'i-S E ce:~ " ~.-
CI:lQ)og~ ~12 Cia CD .-:c Q) c5 ~ Z a:l"C .~
:::10)- '- 08. (8,g:c.g.s ~.s! ._
o E.5.1/) 0 ZE 0""
>- ~ ~CD ,sa
.0 ~- 8J J2
'" a -Ol 8J>-
!l ",01 'S " >- ~.s -" -
w .5 CD s-c " 11 '" ~ 0>- p.~ g-s :tRa ~
Cl .0 j9'~ " c=
0>:6 - ~ 8. ~~s ,sa ~ -" 'E':":.!"C'-
z a~ ~ ~-ig-g~
<I: E e:- g.g'.~oe 0>
gCRe "" c "
II: .!;;; g.E 01- ~mi
0 ~8~ i~o ~'c1Ui CD [~ Q)~Q)a:lE
.!lE<D-5 .- ::J > 01_ "C .!!l'c
.0-= ~j:2 1!. .-.- 0
~a= E~ ~. 8 f,/) 0 (I) Q) "" ~~e~~
".c: " < ~g ~_08' :=!!l ' e
11:0.0 .....2.5=_ W '" <'ll C. '0 "C
e:
0
1ii "
2 J 12
w u; "
'" c ~
oJ 0
III '" " ~
" ~ 01
C "
"
a. '" e
" ~ ~
Cl I-
>-
~ " "''''
l Q)~.s 0:5 .eel:
~~m~~ ~.~.~
:z "" g's:o.sa
w 1ij .5;~Q):g CD :0 .s ,sa :?
w E llJas:?~.cQ) ==... .c.-
II: Q)"'C_ en
Cl 'S ~~,g ~j ~ g J:: c.. UJ
'E '" 0 8.8Jll!
>- .Q,Q1;'Q)Q)>' "" 5 8J:s"
c: ~.~ ~ ii as ~ 8 ~ g gi
0 UJ:otaE-5S~
S
i
"
:J 11 ki
g..!! S..
co"
o :l c: 5
'OE-._
~ E='!!!
o as'=:
'::UC4og
~
-s
..
~
.s.!
~
...
.E
l!l
~
1;5
oS
"
.10
e
tl
~
~
"
~
I
Ie
I
I
I
I
I .!!l
~
..
"
-.:
I )
.~
"
I ~
0
"
~
. Cl
~
I ~
a
5
I <3
...
~
0
"
I :l1!
"
~
I
I
I
Ie
I
I
c
w
a:
s
..
3lm
~ci
15.. g >
E'" e
a> S 0.
~ i.s
~ '5.8
~
-'
~
~ B
],eL
-glBc::oc:
..;;E~a>
g'~ ~.g ~
'-EC::'ECL~
as:2!,co C
~HZ~
w
-'
...
a:
::I
ll.
o
:I:
-a>
"=
.8e:
~.-
eaf!?
O.,l
E .. 0
alh
Q)-.(: 0
Z.6 $"0
w
Cl
~
a:
o
..
E_
ID =: '(ij
~ 0. E
~!d> =-
= .....'Ul~c::
<<l.::':3CO,l
~HH
~~~8~
~.2. Q) J:: &
W
::I
-'
III
;;;
e:
t
Q)
!i
co
a> "
E..
"a>
8-
oj
8i
"
:>
==~o
1ll-~
.. E c.
~5~
~l~
e:
~
'i
e"
~iij8i
;;..~
~ii
.o,,~
~~o.
z
w
w
a:
Cl
...9
Ca> ..
~i 5
illE '"
.." !l~...
!a!!H~
~:s!PEo.S!
ctI ::I a. E -5 "
~~.58i~
Cli
~.S€
. :;; ~o 8,
;; e:
5l" ,;';l-
, -g.!I! S 'I
.5 <<J~ c: E
-8g'€8:;;
.~ :E. 2 ~ "5
.. ll: C i'
Q. .= 0._ ...
8, .
S= ,flit
Qja;...~m
c Q) o.:~"O
C.c-ro15
~~iiF'~
~a>€'" 5lE
""i!! 11 81 a>
.2~Q)::Ig5
<s"ale:u
't: 1D:S
11_ [Cl
ll:!!! C Cl
::J= CDE .1:
en CD -= CD 0) i
c c cr'E.&:'#i
Q) 0'- ... ca en :i
.."a>alJ2a>I!f..-
Q)a5~cE.cQ)Ef
5 16'c.<gO 2 E'" a> ~
~C::J oaeGo
U)a:In -.!!la>e:~
CEC"" 0.8'-
_ 01_......0 tn "0
~
"
o
o
"
~
1ii.
==
-~
..
2.l'l
r.e.
Cl
e: C
.- 0
su
~ ..
J2s
~E..
;;.i<l ill
~~:s!
U~
WECl
1iiii
2 E
::1l,
a>..
..e:
Z~~
]i) a>
::c ,5
S :;;
Jj1lii
:!.
e:
:s
.. S
I m
""" C
:e -a
15..~ ".il
~5 -
~e:
'II
;Z
-Cl
t'E Ul
"J!!1l
"....
~ ~>
0'-
-"
"
"S_
F~
8,81- 6
.s:S ~y
l~SB
== e liie
S 8Iill
en.8 a.~
"
~'3>-
..,,-
E$-
j ~m
"0 -5.l!::
liaS...
i35.8~
1:-5_0.
.3'iigs.
~E
..J!!
~a;~
=~.-:;
5~CU
E.. E
a> 8,J2
E 1:.5
::J:::: Q)
8i31is
a:EE
..
:g-
i"~
--0
liii5"
Hs
['H'
8~&
a>.
....
"e:
00
Jj=Ui
,,"
-a>
0"
,,~
~l
.1;;
:;;
e-a.
ill&.
-e:
""ll
lii~ 5
-!i:lla>
e:"8
.3ilD
J!i"fi F c:
masitiO
a> a>;; E
;; -a;
Ul5"O.c
_ e:_
u,;.._
J!i! 0 J: ::J
- .~ Q.
a>OE12
ga~<a
~= ~S 1!
Q."~ Co 0 :=
i
Ea>
,,"
-..
5.!1~
i5-g8.
c"a>
a >-~
,,:;:;e:
-"Ea>
..l. o~
Ifrej
o
z
.5
Cd J!~
j[
6E
..a>
-g€
~[
~~
81 al g'
EE g
:;:::I Q) Os
e]j.5 CD
li:'. .8=
'Sl a>.S
~l:i g
.!!2~a.1i.i:e
~ ~E ~, ~
5
~ g
.~~ 8
p 6-
o!~~oo
I;s=a ~g
c~"iIB,;
:I:..c u et).! Q)
..Q)Q)
~~.Y
Eqj
-g~a
et)!c
"0"
~Eu
"e~
"5QSc
0....
03S
5~1
l! ~a.
.."E
- .."
"iii-C"'.
~i~ll
~ o='!::!
UH
e
..
J!l
32
..
a>al
a> "
~-
c.!l!
Eo
We:
"E! i!:'
",a>"
.!!l~15~~
:l2~Eg~
~~Ja>.iiiE
U)c EQ)S
E,g a>.Ii!l!.
Q)as a;enen
:a.t::!~>:J<
e == ca !:ero..
0.. 'S..c Q.cu-,
o
e:"",,
.!Illl "E
is..,,!!!
'" >-E ~
~Ha>
.!let) ..en
8. ~ .~m
cncSc
'"
LO
-g
.5 ~
~~
..-
.- 0
~.s
:"J!!
..u
ea>
0=
h
ClO
e:;;
.- ..
{Iii
~iCl
en 0.6
~!!l0
a>:;;"
5d
e
!-gC)
.!? ~.6
0. a> 0
11.0"
i5. >-!
en,
:-g=
tD.6 'i
t!=gj
s
i'ii
~
.Il
~
0.:
...
J2
l!!
:e
Ol
.s
.,
.S;
e
a
€
~
Q)
~
I
Ie
I
I
I
I
I .!!l
~
'"
<::
<(
I <;;
<::
~
.~
<::
I &
~
Cl
~
I ~
0
c:
:J
I (3
...
!!1
c
<::
I :J!!
;!:
~
I
I
I
Ie
I
I
Q
W
II:
~
.....
.....
w
)0
."
e ~
""
~ "
I!?.t
o
.~ al
~ "
~ ~
a.1ii UJ
~ ~ ..
'" ~ "
==:2
w
.....
...
II:
::I
...
w
CJ
~
II:
o
W
::I
.....
III
~
"ii
.~
a;
0>
"
~
~~
".c
::Ou
z
w
W
II:
CJ
.9
.0
o
';'0
.~ "
~.e al
~iN!.;,.
Q)~5.~
.c'-Clt;
-~C:iD
~~!i
"Oal
".!l
"'-
"O~'"
- .. ~
l!U,::
it ~.!! lU
00==
J:.2i~
e
..
.c
'"
g~
,.,,,
~"'"
..~
alii
:H
.c
Cl
~
o _
Eal...\,
a:l 0 Q) Q)
-;- c:
.5 ~ Kl-8
jg a. ~ ~
0Q)O.e
U)....Q.CIl
o CD E >
ul~,o
Q.
o
r"
~~~
'O\...= 21
Sea a:I
IV ~ c: "C C
l!? Q) c~ i.2
e ~e.a:Z
RQ) a;g3~
s: E 'fi i a.
..
"'..
e.. =
,gllP
~ <<Ie>.
c '0 a:l Q) _..
::JQ)m"fi~8:g
Q) ~E cu (1)-,6
Eo" ",,-
C515..i5 ~ Ol'-~
Cl)egCUC:E!'3
.fCD....r523':CJ)
e
..
"
c.~'t:J .2
~ij~i
'" ~._ Cl
.8~.>5!!
'" E 8~
;ll"E
-~
868il
e
..
'"
~
U
I!? 0
~.l1
Q.~
~o
Z"
II) ~~ >.?
:s .:.-.$ E~
'us ...o~.= _t::.
:~ ::J Ui ::::J 0 ::J ...
'C p'l:!:ctJ) .co
c;. CD.c -'0
c i::i~=a:l>,'~C)Q)
o CI) Q)::J .... C ....5.!:i::
Ul '0 .t: UJ '5 g r g 0)'0
"gj 81ii.c-"~ o':! ~ l5
" ~.!l,,~... ~ 8';;;
c.-c a. ... Q) 0.- C. 'S
~ a li~ 8' ~.~ ~ Iii :0
~.9
H
l(lL
" E 0
" O'~
'-... ~
"Sl- ~
0:" - a.
,"Q.~
~~..
Cl
:c
~ e
="
" ~
o i5
i!l=al
Ii: .- 0
~.~ !
~.~ :m
=16:0
~
~"O
0'"
..EI
ill"
"0"
-.2 0 ('0.
I!! -o:ll
..illE-
=- g lU-g
o ::I >. ell
XC4.C1,c
~g
~Q)J:
~fGj
_.c"
~ g 6)'CD
" 'liH.JI!?
'5 gJ~ ~g
J ! lz ~
i
e-g!F'O
~ a:l e! Ul
Q) e a:l,,-Je
c.~ ~ ~~
i...g~r
~:c '2:.: ~J2
.cQ)Q)::J~
8.8-Q.=."~
CI)......~.E~.g
'"
" ,
" ~"
.2'1i$ e 5
Q.-pe
E~ ..
Q)CI.I-g.E
~""Cl
E E .-
"'.- " ~
, Q) 0) 3:
go E :ii.=
o i5 J: Q)
...Jcno-S
e
..
I!?
o
..
.~
~
~
.....
Gim
.c~
15 .Cl
~o
E=
,,~
0.0
:,;:::li"
!! 15. II
~Q)C)
Q)g!
~~a:1 5
,,~g
B.cCll
..
l(l
.c.
-E
em
1:_
H
....
E.2
'c g
<.
0"
-a
~ti
""
...c Cl
~~C)
"o~
~.."
".~ !i!
12' 5
S 8. g
C ::1._
-.."
,,"
..2
,,~..
""~=
.. =
E.o 'i
t"'(j')Q)
"" "
000
'C;:; 0
.S!l{lc::
Q. Cl""
i ~.5
a. .. =
~
- ..
m ~ ~
~ .9~
5fCi ~-6
fa ~'ijjo
E'- C {,I)
-",8.ll
8J!!?~
.5
'8. ..
Q.- a
e~:;:l
".913
~:~'5
.Cl1' E
=Q;g
..-
m.5
~ ..
o.g';;; ~
c" c: E
.-" 0 Q
a:lc:;:;~
p~m!
~ g gE
,c: ~~
.... ..u
....
I{)
,
g~Gi
~=-e,
.2l~F
=,0;'0
ll'i ..
~Q)15
c: _'_"
~ lB.5 rn
3:og.g.
.5
a;
Cl
..
"
E
11>-
o ~
I!? ~
8!.=
€
<;;
~
.\1
~
...
.l'1
~
'"
~
.s;
'"
.S
1:1
a
~
~
"
~
I
Ie
I
I
I
I
I .!!l
~
~
<l;
I <;;
c:
~
.~
c:
I '"
e>
Q
c:
~
,s
I <;;
~
0
5
I 8
....
!!1
c
c:
I ~
~
~
I
I
I
Ie
I
I
c
w
a:
j-''E _"0
6;rni=O~
'Om m:;::: CI)(I)-O
... >. (I) "0 ~
~!;:.Q:;:::"'mUl
0~0."''''-1<
'00 E en ~D Q)
'5.: <D,8a.... 0.2 C
:e ~ .~ 0 Q) a
w-E-=g>.ES
E Q) S CD .- Q) C
> o >-6.2: Q)O)
OI1J>,CU'o;:OE=
CfJ~Ul.c.:;'Ul (,)
Ii;
"
'"
Iii
~
~
en
;=
o
..J
..J
W
)0
'E~~
~ 8.!!
al is m
iDO ~;::
:;: C1l a.g
S.~ E ~
cel!!:....~
Q)a. 0;:
0."'0 C "0
:J c: 0 c
(I) lU"'O CU
.~~ >,"0
'*Oa:s::a
017''0:=
U;CI)_CD
e~~~
CU~;pO!
0)- ...:t:
ccoc"O
.>m'>.~:;
"'_ '" 0"
:I: aU "C E. ~
W
..J
"-
a:
;:)
...
== iD S!
~~ '"
",^ ~
f/l't:'-c Q)
CCI)Q)_
8.g.1i;8
5(/):2-=-:
(,).i::~E
5l 0>0 eel C
'il; ~ 2 6) ~
0:-; g-e.o
E
"
:€~
~ ~
,,<0: '
"... E
~:;~
ma52
~t:o.
.- :J al
0",
o
c
o
"
>.
"
.<:
I-
w
Cl
~
a:
o
. 0
'Ecn-o
'" 8J >.
~:JCtl.s~
;8l551~
:C::CD-:::Ic.
_S.!Q.~~>
ou) e.o ~ ;0-
Q)Qia.e.c$
... a. a to E 0
gJ:::I'O_Q) 0
.!:CI) C:::I.c. 0
..... a CU.c __
mj
"'-
~~
0."
<0:"
a.'"
...,.... >.
c'(ijc
e 'E ~
~a:::l ~
c.!!:! :::I
~>. " "'-
11~ c: Ccu_
~ft ",0 ~5~jj
~ E
w '" ....
o c ~O O:aS.g.c
;:) Ii; -g ';; ;t:i:a>_ Y E 0 >'.~
..J " .E.Ei c'" '"
.. '" ;;:::: .9 :6Ba;=c~
'il .s~ i-;;;2: ".~ 5'.~.l::
" ~]; C . g
0. ~ 0." ~-~~~~
~ H 0(1).- is ~ g,-S-6
en u.s..!!:!
" "
-oj.c "" 0.
.... ~ C
~<g~ ~ilO 09
z a:l.~ S g "'lli l!l
w CD :J C 'A .....0 ~ ~
W :;: gO) l: hJ!l
a: .<: S....~,g ~
Cl g 'I!.2l!!~
E ces~~~ " '" 0 c'"
Q)-c 0'- en !;: :l't: ~~
0 g.51-g~~ :::I 0 a. Q)
Z C/J::I CD c'O Cf.lCa:l0 ...,'"
"
_c
C"'_
""c
CD of N CU C""
.<: --
iiUI
":iI."E...
'ta-Sns.g
~hh
11
~ ~
e '53
'5.E"S
",0.
"'.- 8.
-g E a "
.- Ul IDS
"'E~~
Q) CD a CD
8~9.g
tf.) CI').c (,)
g
Ii;
r,,, 11
~ C 0 J!!
:c'" .se
a~g5~
E~;'~ ~
"o.",,,e
"e.-o.o.
!II !:Je
z 0.(1)._
"
co
o~
~~
'iiiJ!!
"'"
'<:c
~afQ)
Q)~~
CD~ as
....~i5'
:!1 8. c
"
"
~
'"
",11
-'"
.~ ~
.E.!.!
iDE
-g e "CD
",0 '"
f!? E ="i
~ ~..~ m Ci.
"2:.s g> ~ E
8.f!? '6> Ol,g
:::JQ)f!l:s!-
Ul 0l:::J :::J m
.E 11 8 8 Ii;
a:la:lCC;t:
~ E 1CD 10>:0
~
o
E
f!
:2
~
"
2
~
'"
Q.
Ii:
"-
09
~
~
~
~'"
.... c
o:E
c;:'
~a
j!.g
,
:;
g,
'"
C
'"
.<:
"'c
~!
tJJo
".8
'0 ~ g ('0.
'3(1;:i
8 Ec >
~ 0 Ire
01: a; c.
'" ~.....5
>.
~
'"
.2
~
a.
~o
~j
Ec
,,0
:m~ft::
"'c:l
8 ~~
.E~E
l!!
"
,,~
8.E
"'0
.sc
>...
l~
E'2
~.>
a..:c
o
o~
~.~
~c.
,,"
;;il
.(ii Q)
c>.
~:ij
_E
>.
~
.S
o
~-
Rit'~
='"
:li
E'6
:aia
E'<:
00
tJJc
....
oc
"iO:;;
c;,E.!l ...
C"''O ~
'iiOti:si
e:l.l::1iE
CIS !!~i
~!!gcue-
::I:Ecu='O
'"
'"
"
"..
uqg af e: ,~
aCDf!?!~
.- ~iii '" ~
illIK:l~
.- '" ~ " i.E 8
~e:~~:c:a;"'C
ClEClCDC~O>
~",~&2~i5
.c
ili!"
::~s
coo.
CD> E E
E,6o.!:2
~.s~ a
a:l _ a:l.c
:ij :ij E II
::;~.eE
~
.2>.
SE
l!!~
g~
.~ "
,,>.
c..2
cil8.
l!!
g ~
2: il' ~
~._.E
iil8..E
" >.!;j
Ec..-
00."
CJ)a:l,!;;
.;
e:"C ~
_c~
" ~e:-
o~l!l.o>'5
"COe: Ul
~"~ 1Il.~
._ClOECD
.~..~ '0; g.
E ~'E ~~
8p,giiig
>OCD.9i
'" = 0.
;~h
~jo ~
ii i 91E
"'"C C Ul
0..0 .~ ~ i
&~~15-
... Coa:l
j.8.~ 6.];
"....
~~
~E
"'"
S'"
"'5
~~
=0
"iG~
0._
I!i
.n
.6'0
~.~
....~
i!!.;;;
"c
ijo
",0
c_
oo~
C~O
"
"'.
"'~
E ~ "
~ '"
l!! "" :5
o~e:"C
~1 a:l Ul
... ~ CD ,-
:cmil~
c~ E.-
~1!.~ ,,~
E .... c
"',
"
=
c
o
i!l
~~
"'1J!
,,-
:E
l!!
o
t:"
".2
0'"
-;:
11'5
2~
~o
as
,,0
~.5
,s
<;;
~
.So!
~
....
Q
.El
:E
-.;
s
'"
.S
e
J
~
~
"
~
'c
8..1"' Ul
o.CE
2 ~"
Ulf!?15
"Co2
C~o.
~.2: 1e
m ~-g
o~'"
, ~.<:
e
"'", >.
5:a Q) ~
cnas=e!
~g~Ul:m
8.ui":::J~:S
:::J:::J2Ul'"
UlOasUlO
~:~~.~i
tJJ~~:ll.o
I
Ie
I
I
I
I
I .!a
~
~
'"
I (ij
c:
~
.~
c:
I .,
e>
Q
c:
~
Cl
~
I .,
~
eo
5
I <3
...
~
0
c:
I :'i!
"
~
I
I
I
Ie
I
I
o
w
a:
'" ~
"C
" -"
CD"C .s.!
C._ ~ 1D
E-gC1l"C
Q)as~c
E.c::: CU as
,,-,,1' c
"'" 0
~ti~~:~
as ~ 0 ~
::=.sE-o?=
;=
o
..J
..J
W
>
W
..J
...
II:
::l
a.
w
Cl
~
II:
o
.",
c
._~
[go
,1l~
" ~ l!!
1;j 8.2
c"'>
.-" as
E"C .<:
=CCD
WOl.c
W
::l
..J
III
z
w
W
II:
Cl
In
,,~.
-"~
H
E.c
:!2"ll
,,-
g"g
"
~.<:
0..
"'..,
"C
Ui' "'C ~
ci.55 15.:B 'e
(I)-CDS ...
~~~ .c-~
E~"9 R~~
CD CD Ciii ....._
~SE"O cu c..
._e.E"el!!2
:::I I::: Ol Q) Co
g8Bg.~~
.<:
g>j
.Q..?;-
cu]il-
CDg=E
!5e.o"
oU)cF
" Q) 0 'E
~~~ as
ascuCDQ.
J:~o~
"
6 ..
- !l
0."0
::Ja-
.ll! 12 al
- ~c
c ._
CDS t!
6...::;:
'5$ 55
O"",~
W"C'"
,...
+'c
Co
~"C:t:
~""
Ga~
.!.Q g 0
_ e.-
15"~
EE.<:
.2- g ~
,,_ 0
O""c
W.c-"
.ll!
"
~
'"
.!!!
"
S
.!!!
'"
c
.2
.e
I-
H
c_
1l!:!.
",'"
"'5
al'il
".,
c'"
c'Ol
",j!!
...
i"" -a;
c; !:!.
.~ E
c >.
~E~
" m.5
Eo~
8"C '"
I-~a;
~
In "
1: 5C'o
'alUm 00'"
li,sE li"ii
;:: -CE
'E.!! Rl C ~'5 ftI Q.
~.. il"~ 8'ci~
::I6"C1C'l1C5:JEGJ
"",,sEcEe...
~gm.e'5E"5~
:c .2 .c .5 S 8 it;
ill
:2~
~o"
81S.'"
"'~:
s....'*
"'''e.
-a;=e
.g ~ 8
".-
c:sjga
'"
~
:0"
eg
e.",
"-
='"
.- "
00
.~ ill
--"
c51s
.~
"'-
~ E c
.gCUCD
:!!:os
00'"
.- 0.."'C
~Q)o
o~-
VJ~00
~"Ec~
(SasS U)
...J.c..c .~
~'>.
al~
~...
o.ll!
a~
"'c
c~
.28
'e CD
I-S
"'.<:
.~ 0
._ c
E "0.2
a:l1:... o~
~e.2.!.-
"'C : c >.'8,
c "~"
as e.- 0
'" c ~
'5 .... ~ ~="C'
C ~c CD c::::I
.3Q.8a;2~
<<Del) CD.c
.J::'S =~
:::0 sm
:::leD .8"C
.8=Ulal~'--'
a:l"C3:::: 0.,1:
1a i cn.5CU€"
... >..5';; CD
OCD~Q)""tI:I
cCQ.e.aa.
~~~gg-8
<D
It)
CD
~~
"'~
..,-
Ol~ I Ol
1;.~a..E
o OS-5
"O.Ecn~
CD.E 0 Q)
:>a:las>
>=.c.Q)
'"
S ,...
iACDB
ad;:t:
go~
0- 0
c"2ca.
l'\:I'.::S
OJ:"C 5 a.
'" j.o 8l
z en e~
en
o
"
5
~
o
o
.9
~
.<:
E
'"
.!I en
.90
al~
"CD
ze.
'"
.s C.J:::
-cc4'l
CD"ia=
CD~t
c ~ '"
,,"-
m'" '"
~CD>.
"'.c CD
'ijCD=
.g.~ I:
Q)Q)Q)~
{5 B.a
'"
~ "
og
g>o
.C >.
",,,,
.<:"C
~'ii
"'c"'.I;
Q).- Q)"E
iij.5S 0
J:goE
CD CD
:os
"'0
1l,"C
al~
"i~
g~ g'
.:::.:: 0.'2
j ~~
(JID ~~1;lDt
w.g .g~~1D
~Ul~OOC11S
Q)::S;-5i'2 >.
:;.- E Ul 0 ID
Og>.e;ID~:;
-.- ID c: ~ CD
g,.s: fij.o.,2.e E
f!.c:;; ~CD;
c- "E>
"'~S", ",CD
US!.c >.O).c=
,s
~
.\1
~
...
->1
.l!!
i3
""
.,
.s
.,
.50
12
a
f!
~
<D
~
"
:;
o
J
'0 In
'" "
'tI Eil'!o....
C c" C'"-
31 0l::!j!1ii
..ct:_u
!:eg:;g
~gUiil
I
Ie
I
I
I
I
I .!a
~
l!l
"
I c;;
c:
~
.~
c:
I ~
(5
~
~
I .,
~
~
~
I <3
L.
!!1
0
c:
I ::t!
l:
:11!
I
I
I
II
I
I
o
w
a:
"
E ~
e _ Q)
a:I _o~>.o
(I) ocnecc
- CD '0 <0 CIl
0..-0 > C 8. E >
gC:;~Q)(6"!
Q. a:I._ en '0 Q)
Q)C11~::JJ::O~
e"'''''O;!::'Sc.
o ; R"C ::g 5; 2
Cl)a:las~J::u)c..
i;;
m >-=
"'''
>- = .8,soO
;= ~ ,,0 -c:t::j
0 .<:" "3 i.la
...J .in -5 8.~ i
...J ~oO
w 8. =1/) cn~ >
> ~ l!l1l B...i
;;; l5'~ ~ .~ " "
0 BU (l)t:: Gi
::li cn!:t
W
...J
'"
a:
::>
'"
,,~
CDS
-"
"'"S
~~
_ L.
." "
0.-
"f'!
'" =>
5Sgjil
Q~5
w
CJ
~
a:
o
~ ~ E
:J.::.:: Co Q:l
0.5 !:5
j,s ..'"
'" )l '"
~5o'::t
g..- o.c 0
~~e.g~
Q) f/J;:...o~
J:: Q.) Q)~ 6
1-:5=~'t:l
w
::>
...J
Ol
z
w
w
a:
CJ
~~
~-
~~
""
> "
_:l
0_
" 0
.l!! ~
"0
;:.2
m
"'0
~ "
0"
jt;;
~.&..92
0..-- Q)
o~~
~~'5
'" - -
'<::l:l
t-oo
E 5
i3 ~..
J::0:=
!i:~~
-,,-
f.s5ic;,;
ClIooE>..
~!E8i
:I:~gen
'0"
,,:0
L."
~'iJ
,,>
0:
"'"
(/),2
g~
00'"
:l_
a.1ii
i;;
,s "
o'ii 0
-~ i i'
i~ - "
c._ 0 CD
.!5 ~"'.5
eECi)::J.E.S
C.EEg~8.
~8~e;g.
>-
.<:
15>
"
~
~ ~
'" "
'ihg
U).e c
51 !!l8.
U;g.
m~
.:E~
. ,,-
"[ ~
.gQ).8
0" m
jE~
m".<:
-,,-
0..<:_
il ",."
a..:5.g
.il
,g l(l
Cf).o J: aLe
c:J1ijc-
.Q Co Q) 0 55
U)(D.t:-=
:~=~~~
'OS-e'c
~gg[~
oi.g~1i
L.
:l
ol!l-
(I) Q) C 5
~g~s
~'iii Q) 0
:ai~5i
'(;j (/) 5 Q)
's;::g E ~
:; ~ E ~
0,,8.<:
g'o -0
'E~ ij
':l~!!;r
.QQ):>Q)
ad;~J::
Cij Q) ,20
..92~~~
a.. men's;)!
il-"o;s
o..9:5CiCl
i! ..
i "Cg>>
en i:: ~
5 ca cn~ fI)
'iiig506Q)~
's-:;::; 0'-.0.9
:O~~jl~~i
CD:tc:gc(ija.
cng~ ~&~ti 8
>Oa:lOCtlO
"
="12
CD >. C ~
!5'\1!~l(lgi
fD ~ ii3.c 0
c c...c: c E
'Q; !<<Q)Q) l:
.~ ..,s€!l '"
"""","L.
i5 ell Q) a..~~
"'OJ ca..l; Q) Q)-
o~'C...o
" .
>" '"
2.~= l5
'" 1;j.- '" 1'l
5.8~.~-
:~ <<l,9- fa i
:o=a~ ~E
OQ)OCD....
~1iicGi=s
o CDt:::"C mC
en o!o~ ~
II "
.g ~ =
~ P .5
" ;!: ..
.2: - li~
ii:s c L.._~
Wilt+--
:t:1iiE:sIHi
Q)cut:OcE
~.<: ":s " E
o,! 5t~ 210
~+-"'C~ou
.la~
L.o.
U
.= Q)
":s
='0
ill,
.1:::2
"e
~jU
" -
.s::::. c: 00
... 0) Q):t:
~EQ)~O
.~ m~ ~ Q)
Ol:t: g ~ =
" 00_
"'~!il- '"
~.- .2 ::J
~ ~ Q) 11
-E1::8oO"
OOQ)::Jec:
000 II) CoO)
1;)
E
5 m
,,=~
L." "
C\:l.- ::J
~ -2 E
"ifjE
j!:,,8
.....
It)
'"
.;:~
~l1l
.-.<: [
""",
==0
mo'~
.I::'t:l,Q
'" .iij -g
j!:ii",
;:;
c;;
~
.\1
:g
tl..
L.
.l:!
i!l
'"
~
.s
.,
.S
e
~
€
~
"
~
I
Ie
I
I
I
I
I .!!l
~
:g
"
I ~
:2
.~
c:
I ~
~
Q
c:
~
~
I .,
~
Co
5
I <3
...
~
0
c:
I :l'!
>:
;1!
I
I
I
Ie
I
I
Q
W
II:
;=
o
..J
..J
W
>
~
l1.
II:
:>
l1.
~ 13
'"
w = f'! -
CJ gg
:i = CoO
.~ .- =>
II: so.
0 '" ",,,,
C
~ C~
.--
0 ==
;: ch
w
:>
..J
Gl
z
w
W
II:
CJ
Ol
Ji
=6
5 :J:.ct;
:>0-= c
osglG.l
"C.c:,cE
"'ClIG)'f
~-:511
~h~
'"
C
'2
~
:5
=>gj
g.~-
'" ~.
~:5i
0" E
~>1::
~e..
00.l1.
:!:E"
__"0
i~
C E
" "
~g>
._ C
Jl~
'"
"OJ!!
"3~
8~
-0
Iii~
E= ~
~'j ::;
0" t::
~ g ..
0. 0.
E "
_ "0
~
o '"
- c>.
.~~e~;
:= a:l
~~~Q)Q)
~~,,8'"
Q) ~~_cn"'5!
> ",,-_... .
<D:C cu~ ctl:=
...'x - ,Q)ao.c
~~~;Fj
C "0
o c_
a_ Q) ~.~
Q) <<I > CD l:
e:.c CI:l ~ =
~ ~~ 8. ~
ctl5SQ)~
.!a o~~~ ~
G.I.!a B.- E Q)
Q).c'1: 'E'" t::
~-"'g!ii..
1-.51J._oE
~
00
._ "0
:c .S
=> ~
0."
~=
-5
go
.~ 'E
~~
!!!
_m
(J)~~
co" ~
o e2 ~ ::l
~ ~'O ~
c CD~'"
::l-5'w ~
E_..cc
E:::J...!...2
8lh
o
'x
o.
-'"
"'~
~'"
..~
"''''
li)o..
~o
r~
c
Q)'~~
E'- ~
.-.~ F
-~ >.(15
as ~ CD.c
~",=::
0> Q) 0
cQ)<n-
~_::lai
=>l'l~
-S.8i1S'"
:1ClS.c~
E
'"
:;;
o"'!!!
i5.1l"
<<10 ~
=0 g.
E,,_
o.~"
.- ::l (,)
:z ~.~
o,,~
CJ.Q Co
~ .~
m -g
S ~
.gi~
a =a >.
0.'"
E<<l&5=
$~lii5
cnSo:!::c
_"00
i;;
, "12"0
:2-i:ia:lQ)
~~'5.c E
.J::.e';::i$
l! 2 ~~ en
~-g!015
a. 'C 3: ..Q ....
~ ~.9~ QJ.~
gc..::.::a.oa.
cuoo_a.
.....-C.alQ)Q)<<I
..... (,) .c Q..D.c
o ~ CIS
..:J C - 01
>-s U)'i:: .e
fia.!!~ ~:s.Q
!t::::I ~i:.!! g,s
It 0 ca:2"C_cu
.c= \D'O CD j!=s ('00
:JC)mt)J:_-;I:
0.5:5 :J: -;; >0:2 0
~CIJ __ C'lI:J C
OOCDClc.,'OOo.
Q'i3i::::JS:=:s
'"
'" .0
F.~ 8 S
iil "'_
$,S!i
~E~~:a
~~p~~
C}r' .-= 0
CI:l C Ie OR';
a :g~"~ 0
::2.go'cE
-c'"
:!2o..
5:il
~ 0. m
~ ~
cn 41'2:
0= Q)
~~o.
'c.s: ~ ::l
"'C'"
Q.$,.. ~
~Jii=
Ul~
i:'ii
"'~
cc
1:8
"''''
E~
",0
",E
:g.8
..
::liS
~
~i\%)-
~~= Iii
1;'.11 '" E
colle
.s-5~
.!!~CI:lQ)
U) 0 >''0
c~~=
8i=a;
o"E",
z C '0.c
'" .g
~o"OOI Q)1S
cc:.....c€
' ...-.........
_ ",,"c
o g >..8- II
~oaCIJ~CD~
,$..::.:: o~'i5..Q;
C g'CR .Q.c 0)
Q) - r' a:I Q)::: C
EOc"->a:lo
~ 0 x Q) Q)-
c:(.~'C Q)'C.c a:I
<Xl
L()
(I) ~5i
~ =.8
;l ~ l(l
e .Q~
E <<i~
8 .~ 'C
c.."12 Iii
o,~.8(1)'C
'O! ~~ Q)
<~.s~;g
'" -
15..! lEa:!
g~a:!>.-8~
0.- 0 0 0 Q)
Q) (1)_15..- 0
E"ll"2F'gc
O'2i1S.!1.J!!8
~ 'Q) C "- '5::c::
:s.cQ)~Ul!!
::::J-'o.,;;:IC(I)
E? ar >.= 8 =
=~ ~~ 0";:
,s
lii
~
.\1
~
...
Q
III
:E
1;;
.s
"
.S
e
a
€
~
Q)
~
I
Ie
I
I
I
I
I
I
I
f'
I
I
I
I
I
I
Ie
I
I
New Hanover County Health Department Organizational Analysis
Appendix E - Expert Review Panel
E.1. Expert Review Panel Methodology
Project staff invited a panel of public health professional to review the first draft of the
New Hanover County Health Department Organizational Analysis. These professionals
were invited - by telephone - to participate on the basis of their expertise in several
relevant public health specialties and their experience as public health practitioners. All
were from outside the New Hanover County region.
The members of the panel included representatives from the North Carolina
Departments of Health and Human Services, and Environment and Natural Resources,
local health directors from Alamance and Orange counties, and the Chatham County
Board of Health. Expertise represented among the panel members included state and
local public health services, public health laboratory, environmental health, and public
health nursing.
Panel members received an electronic copy of the draft report five days prior to a face-
to-face meeting on October 10, 2002. The meeting was conducted at the offices of the
North Carolina Institute for Public Health and facilitated by the project staff. The panel
members critiqued the study's methi:Jds, findings and recommendations as they
appeared in the draft report. The panel members offered a number of substantive
suggestions and revisions that were incorporated into the final report.
The North Carolina Institute lor Public Health
59
I
Ie
I
I
I
I
I
I
I
f'
I
I
I
I
I
I
Ie
I
I
E.2. Expert Review Panel Members
Dennis Harrington, Chief, Local Health Services
North Carolina Department of Health and Human Services
Joy Reed, Director, Public Health Nursing
North Carolina Department of Health and Human Services
Vickie Whitaker, Branch Head, NC State Laboratory of Public Health
North Carolina Department of Health and Human Services
Malcolm Blalock, Former Deputy Director, Division of Environmental Health
North Carolina Department of Environment and Natural Resources
Tim Green, Health Director
Alamance County Health Department
Rosemary Summers, Health Director
Orange County Health Department
Rachel Stevens, Clinical Professor, UNC School of Public Health
Member, Chatham County Board of Health
Ex-Officio Members:
H. Pennington Whiteside, North Carolina Institute for Public Health
William Herzog, Consultant
Charles Grubb, Consultant
Janet Alexander, North Carolina Institute for Public Health
Sheila Pfaender, North Carolina Institute for Public Health
The North Carolina Institute for Public Health
I
Ie
I
I
I
I III
1::
III
.!!l .c
~ 0
I ~ iii
'" c
(ij 0
<:: -
:2 :;:; c:
I .~ III Q)
<:: .!::! E
~ C 1::
III '"
a.
I c: Cl Q)
... 0
" 0
E >- .I::
+- CJ -
~ c (ij
Q) c Q)
E Q) I
Cl ~
1:: <C
~ c:
III ::J
I C- o. ,.. 8
5 Q) u.:
c ....
<3 Q)
'- .c e;
!i :: c:
I c III '"
<::
1 Q) I
" :J: :;:
~ I Q)
I Ll. Z
><
'0
I c
Q)
0.
0.
<C
I
I
Ie
I
I
~
co
Q)
Ul e
'" '"
Q)
e Ul 0
- i:5 ~ .I::
c: -
o~ Q) '" 0 "'~
:or:::- -
Oa> -~ "'~ Q)a>
-~ "'C\1 c:~ ....r-- IC\I
"'~ .2- Q) ~ o~ .Ul ~
.... 0 .c
0 .~ c: '"
- ::J ...J c:
() c: E Q)
.... e <( E
0 i5 E 0
U 0 S:
Q) .I:: 0
.... -
(5~ - "'~ I I I I I
Q)~
.I::~ I~ I I I
-
'" -
c: .I::
Q) '" .I:: -
I - '"
Ul -
c: '" Q)
"(jj 0 .I:: Q) I
Ul :;:: -
<( e '" I Cii c:
-~ Q) ~ >-~ -~ .Q-
.!1l CD II'- :!::::LO c:'<t :!::::o
.5:;- ~~ c:M Q)C\1 .;;~
::J~ E~ ::J~
E .I:: E c: Z
"0 0 E e
<( 0 .:;;
0 c:
W
-s
(ij
~
.'-'
~
'-
Q
.El
:E
~
'"
.S
e
<3
€
:1!
co
~
I
Ie
I
I
I
I
.!!l
~
I ~
'"
~
2
I .~ c
<:: 0
:g, 'iij
C) :~
I -
<::
" C
E ~
~ :;:;
III
...
+-
~ .!!!
~ c
I 5 .-
E
<3 '0
... <C
!i
I c
<:: N
1 .
" Ll.
~
I
I
I
I
Ie
I
I
Q) c c
> III .!!1
:;::; :1;2
co .2
- c c
c .c .c
... Q) CJ CJ
0 III ~ ~
III ll:!
"~ 0. t:: t::
Q)
Q) a: 0 0
0. 0. 0.
:J 1Il- 0.- 0.-
00 Q)"- :J"- :J"-
t:: CJ- 00- 00-
.....
0 :J Q) Q)
0. 0 > >
0._ III :;::; ~
- :J..- Q) ~
00- a: - -
Q) c .!!! .!!!
> co .!;;; .!;;;
~ E E E
:J "0 "0
- I <C <C
.!!!
.!;;;
E I
"0 I I
<C
c
co
:1;2
c
.c
u
~
..... t::
Q) 0
U 0.
:;::: 0.
..... :J
0 00_
m-
- m:s,. - m"-
Q) E-
c Q)
"(ij -
:J ~
CO 00
c
0
:;::;
co
E
0
.....
c
-
C\l
co
-s
(ij
~
."
:g
ll.
...
Q
~
1;;
.s;
'"
.S
e
<3
€
:1!
"
~
I
Ie
I
I
I
I
.!;l
I ~
~
q;
"
c:
I ~
.~ c:
~ 0
.-
e> Ul
0 .-
I - .~
ijj C
~
~ '0
...
-
c:
0
I 0
I .e- m
5 E
(3 .-
.... c:
I !!1 <t
0
c: M
~
:t ~
I ~
I
I
I
Ie
I
I
....
0 -
CIJ c:
'2: ctl
-a
Q) c:
0.. Q)
r- :J - -
(J)~ - --
<(C\J
.... -
....
Q) Q)
~ ~
Q) Q)
.c:. .c:.
(J) (J)
.... -
Q) - - c:
0) -
- - ctl
ctl - .sa
c: .sa :0
c: ~ ctl
ctl ,ctl c:
:2: .sa '0 0 .c:.
- CIJ Q) Q) 0
e- CIJ 0..- 0..- Q)-
- - <( (J)~ (J)~ f-C\J
c:~ - Q)- ctl 0)-
0 >~ ctl .c:
U .-- 0 0
- .;;:: ';;:: -
~ Q) c:
ctl - Q) :J
.E .sa u u 0
.1;;; 0
c: 0
<( E T <(
'0 I I
<(
....
0
CIJ ....
'2: Q)
0
Q) ;;:::
0.. -
:J 0
(J) e
L- 0- - --
....~ c:eo
--
c: 0-
0 U
U ctl
ctl .E
,E c:
c: <(
<(
'"
<0
.c:
'1ij
~
<.l
~
....
-2
.El
~
t;
.s
<11
.5;
e
(3
-€
~
<ll
~
I
Ie
I
I
I
I
.!;l
I ~
~
q;
"
I ~
.~ c:
c:
~ 0
c5 'iij
I 1: 'S;
<ll
~ i5
~ J:
-
'ii
CIl
) :r:
I .e- 'C
~ .-
J:
.... 0
!!1 ..;
I 0
c:
~ ~
:t
I ~
I
I
I
Ie
I
I
....
<0
.... c:
0 ctl
.CIJ :0 -
2: c: c:
Q) .c:. ctl
0 -
0.. CIJ
:J Q) 'CIJ
(J) I- CIJ
t:: t:: <(
0 0 .J::
0.. 0.. .:!:::
Z_ 0.._ 0.._ ctl_
O-C\J :J~ :JLO Q)~
....J- (J)- (J) - I-
Q) Q) >-
,> .> :t::
.... - ctl c:
Q) ctl - :J
0) .... ctl E
- ....
ctl ,sa -
c: ,I;;; .sa E
ctl ,6;; 0
:2: E E u
c: '0 '0
0 <( <(
'w I I I I
:> -
~ t-
O -
.c:.
~
ctl
Q)
I
....
0 0
CIJ - - -
..c '2: -
Q) Q) ....
:J Q) Q)
0- Q) c: c: c: ..:.::
0.. ~ ~ ~ ....
:J 0
(J) - - Q)- Q) --. S --.
C\J Q)C\J CIJ~ ClJI"-- ~
Q) - CIJ - ....- --
.... .... :J ctl
~ :J :J
Z Z 0
:J Z 0
Z I I I (J)
I 0- 0- 0-
n..
I I I I I
,s
"
~
.51
~
....
-2
.El
~
~
<11
.5;
e
(3
-€
~
<ll
~
I
Ie
I
I
I
I
I
,!il
~
~
<(
..
c:
~
.~
c:
~
o
I
I ~
~
~
~
It
8
~
~
o
c:
~
"
~
I
I
I
I
I
Ie
I
I
s::
o
'iij
:2E
c
CIl
Ul
ca
CIl
Ul
i5
CIl
:c
ca
CJ
,-
s::
~
E
E
o
o
Lri
u.:
-
-
~
o
13
:0
r-~~
-
-=
c;;
Q)
J:
~
.9
"
l!!
C
c:
o
'in
'S:
52
-=
c;;
Q)
J:
,>1
:0
:0
a.
~
Q)
~
c:
'"
::;:
'"
o
a.
a.
:0
en;::-
Q)~
>
~
e
-
'"
'2
'E
"C
<C
I
~
Q)
"C
c:
Q)
X
w~
~=- ~
'0
.~
.c:
a.
~
~-c-
,_ 0
c:-
Q) ~
0.'-
l :o"E
eno~
Q)o~
f!l () ~
::J.2
Z.5
J:(J
a.~
~
o
'"
'2:
Q)
a.
:0
en
'"
o
a.
o.~
:o~
en~
Q)
>
'"
e
0;
'2
'E
"C
<C I
T
=
Q)
c:
~
.,~
fl::'
:0
Z
J:
a.
.,
fl
:o~
ZLO
J:-
a.
~
c:
'"
'0
'2
.c:
"
~
'"
o
a.
I-- a. ~
:0<0
en~
.,
,>
~
-
'"
'2
'E
l~
c:
'"
:0
2
.c:
"
~
'"
o
a.
o.~
:o~
en~
.,
,C:
'@
-
,'"
.f;
E
"C
<C
E
'"
0;
.~
<C
'"
o
a.
a.
:o~
en::.
~
.~
0;
'"
'E
"C
<C
.,
c:
-~~-tZ~
~:s c.. ~
~ -J-
J:
a.
,!il
c;;
'0
.,
a.
en
c:
,9
-
c:~
Q)~
c:~
.S!
.E
.,
:(l
.,
'"
C
c:
'"
'0
'"
.c:
,,~
~=-
'"
'"
a:
X
z~
a.~
...J~
0;
~:g
0"
.,-
o.()
en'"
","E
00
a."
a."
:0 a: ~
en-~
"'~
~.2
+:l'g
g~
.~ "'C
.5 as
E .,
"C...J
<C~
LO
<0
-
lii
'0
'"
.c:Z
o ~
~5
"''''
R"E
c.8-
:o.,~
ena:~
.~ 7ti
cu.Q
~"C
-.,
,!!!::;:
,c:~
E
"C
<c I
..J
,s
..
~
,51
:is
.t
~
.E
l!!
.2
'"
.,
.s
~
e
~
€
~
Cl)
~
I
Ie
I
I
I
I ,!;l
~
I ~
<l;
~
~
I .~
c:
~
0
I ~
E
~
:1!
Ie
~
'-
~
I g
~
~
~
I
I
I
I
Ie
I
I
c:
o
'iii
'S:
C
.c:
..
iii
CIl
:J:
>.
:!::
c:
~
E
E
o
u
'-
o
'0
l!!
C
c:
o
'in
'>-
i5~
-=
c;;
Q)
J:
,>1
:0
'"
a.
cO
u.:
'- c:
0 '"
en '0 CO
'2: '2 CO
., .c:
a. 0
'" ~
en
'" '"
0 0
a. a.
o.~ - o.~
"'~ ",.0
en~ en~
., .,
> >
.~ ~
'-
0; 0;
'2 '2
'E 'E
'C 'C
<C <C
'-
o
'"
'2:
.,
a.
'"
en ;::- I--
.,~
fl
'"
Z
J:
a.
I
'-
.,
'C
c:
Q) '-
xg
W'-
c: (:
.m ~
" '"
"w cn~
"'Q)~
~f!l
=~
c;;J:
~a.
'(ij
...,
o
'"
'2:
Q)
a.
'"
en~
.,::.
f!l
'"
Z
J:
a.
=
Q)
f!~
",0
Z::.
J:
a.
'-
Q)
'C
c:
Q)
X
w~
c:::'
'"
'0
'~
.c:
a.
=
-
Q)
f!~
",0
Z::.
J:
a.
=
Q)
'"
'-~
"'M
z~
J:
a.
=
z;::-
a.~
.....
~
~
"
~
'-
-l2
~
~
.,
.s:
I1l
,5;
11
~
€
~
..
~
I
Ie
I
I
I
I
.!!l
~
I '"
c:
~
~
2
I .~ r:::
c: 0
~
0 'in
I c: :~
..
~ C
'" .c
~ :!::
III
Gl
:J:
~ iii
c
I 5 ..
r:::
(5 Gl
... C
!i
I 0 ...:
c:
~ u.:
:t
~
I
I
I
I
Ie
I
I
....
CD
.....
C
ctS
.....
C/)
C/)
C/) ...-
<( T"""
'-"
-
ctS
.....
c
Q)
0
,s
<ii
~
."
~
Q..
...
J2
.!!l
.i3
~
'"
.5;
11
<'3
'€
~
..
~
I
5
Ie '"
.~ " "
" 0 0
a.
" a. a.
m a. a. <Xl
" C " C to
" ~ .~ mOl ..
I 8- g!:9 C
> .- ::>
a. :;:;.2 .- C
" i"fi "
m I!l 0 0
;; " 0;" a.
" 'c:~ '2 I- a.
> "
~ 'E 'E m
I ~ "
0; c(
:5
E
"
c(
I ..
I Oi :E ..
"
:I:]! Ol Oi
I " " Ii>
~~ I_ I_
- '" - '" OJ
"a. ~~ ~~ ;:..
.!!l ~m " " Ol " ..5
~ .~ ~ E~ E~ Ii>~
I ~m gm c;=
11 Co> ... ;0 ~
Wo 'S: >
'" .2 Q: C C so
'iii C W W '"
C Ol
c: 0 " ;:
2 'iij m
I .~
c: 's:
~ is 5 ..
I - J: u Oi :Eo; :Eo; ..-
5i - e ~:l1i Cii .~
'ii i5 Ol ,_ Ol ,_ ..
~ ai<<i :!~ "Oi :!~ C
C ::r: '0 ::>
~ CI) 0 c 'Q - &l -" - &l ~
:I: 'in "a. Sa. Sa. Sa.
:~- ~m cm cm cm ~
0- "E " E " E
S .. ,~ ~ ~ I!l ~ I!l E Ol m
C ~ "
Oi <=0> eo> eo> eo> 0
~ c " W 0 'S: e 'S: 2 'S: e If
CI) I CiO: co.. <=0.. <=0..
,51 W W W
I :c. E '"
5 :is "
C " m
(5 0..
0
... ...
~ 's:
I 0 c
c: .. 19
~ W Oi .. .. C
" "
~ :J:.11i Oi Oi E
cO ~o; "
~ j]i =0; c..
ec
I u.: <= &l J!l'ij S'ij 's:::>
"a.
~'" Iii 'I] :;'0 C:E
E~ WOl
e E Ea. ~cn ~
'S: ~ ~m ~m ~
Co>
I We 'S: 'S: :E €
<= C
50.. W W :;:
'" u ~
"
m ,\1
I ~
Cl
.. ~
~ ~
Oi e .9 .9 .. ~
" I!l I!l Oi ..
I:l1i C C ~
I " " " ::>
19]i 8~ a. a. I_ "
<= " ~.9 0 0 - '" e .s:
" " e e ~~
E a. ~ e c '"
cm " " E C " " 0 ,S;
e E >a. 0 0 E~ u e
Ie 'S: I!l ~o u U 2<1.1 5 a
Co> 0 5 5 u
we '" u u 'S: "
" c > "€
5"- m " " W
'" > > ~
"
I m '"
~
I
I
Ie
I
I
I
I
.!!!
I ~
..
c:
<l;
~
~
I .~
c: C
~ 0
I - III
c: oS;
"
€ is
.. >.
...
0
-
~ ca
...
c 0
I 5 .c
ca
(5 ..J
~
~ a;
I c
c: u:
~
"
I ~
I
I
I
Ie
I
I
c:
<tl
:2
c:
.s:::
(,)
~
t:
0
Cl.
- Cl.~
:J..-
cn~
Q)
>
~
-
.!!!
.1:
E
-c
<(
~
Q)
OJ
<tl .~
c: -
<tl 0 c:
lh <tl
:E '2: -
lh
c: Q) '0;
o~ Cl. lh
'0; E :J <(
os:.~ _ cn~ -I- .0 ~
"- Q) T""" - .0"- <tlC'?
Q-~ <tl~ ...J~
.s:::.: ...J iii
""'~
<tl ,~ ,2
Q) -c
I -c Q)
,2 Q) :E
.0 :E
:J
a.
-
,!!!
OJ
0
0
c:
.s:::
(,)
Q)
I-~
..-
.0 ~
<tl
...J
,~
-c
Q)
:E
0>
CD
~
Q)
OJ
<tl
c:
<tl
:E
c:
o
'0;
';;;
is
E
'C::
Q)
-
c:
lh
<tl
OJ
c:
'~
Q)
lh
>-
:;:::
c:
Q)
~
~
:J
U
-s
..
~
.!I
~
~
.l:1
.l!l
~
'ti
.!;
..
.S
e
~
~
~
"
~
.
I
Ie
I
I
I
I
.!!!
I ~
l!!
<l;
..
c:
~
I .~
c:
~
I J
~
~
Ie
5
(5
~
~
I I
"
~
I
I
I
I
Ie
I
I
c
o
"iij
oS;
is
c
o
;::
";:
-
~
Z
c:
~ <tl
0 '(3
lh
'~ 'c
.s:::
Q) (,)
Cl. Q)
:J I-
en t:
t: 0
0 Cl.
Cl. Cl.~
Cl.~ I-- :JC')
r- :J"- en ~
en~ Q)
Q) >
> ~
~ ~
~ -
- lh
lh 'c
:1;; 'C
E E
-c -c
<( <(
~
Q)
OJ
<tl
c:
<tl
:::!:
c:
0 c:
'0; <tl
"S;- '0-
,- ..- I- - ,- C\l
Q~ a;~
.s::: is
-
iii
Q)
I
,2
.0
:J
a.
.~
c:
o~
'- ;(1')
.~-
-
:J
Z
-s
..
~
.!I
:g
Q..
~
.l2
l!l
~
~
..
.S
e
~
~
~
"
~
o
.....
.
o
,...
u:
I
Ie ~
.....
I
c:
..
I :2 -
c:
c: ..
.s:: -
~ '-' 1Il
'" = ~ '1ij ~
"tl '" 1Il 0
c: <( -
I ~ '" c: t:: !'S
- 0 0 .s::
0 x N c. ... ::J
1Il W~ Z~ c.~ ..~ "tl~
'~ "'~
c::::;. f!!~ CL~ ::JC\I "'C\I W:::;.
~ .. ...J~ en~ I~ .s::
'u ::J '" ~ -
I ::J .~ Z > (ij
en~ I e c: '"
~ ::J I
"'~ .s:: CL E
f!! CL -
.!!! ::J ,!e E
~ z c: 0
I 'E <..>
l!! I "tl
"l: CL <(
\ij I
c:
~ c::
I .~ 0 ~ c: c:
'iii .. ..
c: (ij 'u :2
~ 'S: Q; 'u 'c c:
0 Ol - '" .s:: .s::
i5 .. '" c. '-' '-'
I - - en ~ ~
c: c: c:
CD .. '" ~
€ .s::. :: c: t:: t:: t::
- ~ ~ 0 0 o~
iii c: 0 ~ c. c. ~S: ~
., 1Il '" c.~
~ 0 .~ "'~ i!:~ c.~
Q) '1ij 1Il"" o!:e. ::J~ ::J~ ::JOC\l
J: 'S'- '" ~~ en~ en~ en::~
c. ::J S: ~
.- ~ z '" "'~
III Cl~ ::J (ij > >
:5 en~ I ~ ~ ~
~ ~ 't;-
c:: (ij "'~ CL 0 - ~ ~
Q) I!l 1Il u; u;
I a '" en 'c
c: E I ::J :~ :~
" z 'E
8 0 .2 E E
:c I "tl "tl "tl
... 3: ::J CL <( <( <(
~ CL T
I 0
c:
:11! ,...
,...
" u.:
~
I
~ c: ~
00 0_
~ - .- - 1Il
0 !'SE !'S'1ij
I Cti ::J ~ ::J 1Il €
" ~~;::- "tl<(~ .,
::J W-~ ~
"tl CL~ '-'~
W .s:: .s:: '"
"'i':' ~'e .\1
:5~ .. ::J ~
""- "'CL
I (ij:::'" IE I
'" ...
I .l2
~ l!l
.9
c: ~
I '"
en ~
.,
.S
e
Ie ~
€
~
I CD
~
I
I
Ie
I
I
I
I
I
I
I
"
I
I
I
I
I
I
Ie
I
I
Analysis
New Hanover County Health Department Organizational
Appendix G - The North Carolina Institute for Public Health
Overview
The Mission of the North Carolina Institute for Public Health (NCIPH) is to improve the health of
all North Carolinians. It is the organizational unit within the School of Public Health that is
dedicated to training, technical assistance and applied research in public health. Created to
bridge the gap between public health knowledge and practice, the Institute provides practical
applications - products and services - to improve health-related decision-making and service
delivery by organizations such as state and local governments and health departments,
hospitals, community-based groups, health plans, and purchasers of health care. The NCIPH
conducts its work in several program areas: workforce development, consultation and technical
assistance, and special programs and applied research.
Workforce Development Programs
The workforce development program area houses several large outreach and executive
education programs and the School of Public Health's Office of Continuing Education.
Office of Continuing Education
The School of Public Health's Office of Continuing Education (aCE), housed in the NCIPH, is
the largest, most comprehensive continuing education operation for health professionals among
accredited schools of public health. It offers hundreds of conferences, workshops, short
courses, seminars and teleclasses each year that reach thousands of health and human service
professionals from local, state, national and international agencies and organizations. aCE
staff includes experienced continuing education and distance learning specialists, an
instructional designer, a marketing director and assistants, a graphic artist, program
coordinators, registrars and data managers who provide the complete range of services for
planning, developing and managing conferences, workshops, seminars and teleclasses.
The Office of Continuing Education enjoys a particularly strong relationship with the North
Carolina Department of Health and Human Services. This relationship is supported by an
annual service contract from the State of North Carolina that over the last three years has
ranged in value from $650,000 to $1,360,000. The bulk of this contract is for continuing
education programs for public health nursing, environmental health, and public health social
work professionals throughout the state. The training programs that take place each year under
this contract are developed through a formal relationship between aCE and three outside "state
of practice" committees that conduct workforce needs assessments and plan and evaluate
training programs. These committees are discipline specific: The North Carolina Public Health
Nursing Continuing Education Advisory Committee, the North Carolina Environmental Health
State of Practice Committee, and the North Carolina Public Health Social Work Continuing
Education and Training Advisory Committee. The committees are comprised of members of the
workforce appointed jointly by the Dean of the School of Public Health and the State Health
Director for three-year terms. The members represent geographic regions throughout the state
and various levels of job classifications. They include educators qualified to teach the
respective discipline. The state of practice committees are supported by funds in the state
training contract.
The North Carolina Institute for Public Health
72
I
Ie
I
I
I
I
I
I
I
"
I
I
I
I
I
I
Ie
I
I
New Hanover County Health Department Organizational
Analysis
Certificate in Core Public Health Concepts
The Certificate in Core Public Health Concepts is 12-credit hour program of study having the
same content as the five core courses taught in the School of Public Health's masters of public
health programs. All courses in the program have been specially designed and developed for
delivery via the Internet. Students register, receive materials, interact with faculty, complete
study modules, etc., without traveling to the campus. Course credit is at least partially
transferable to the School's master's degree programs.
Management Academy for Public Health
A joint program of the UNC Schools of Public Health and Business, the Management Academy
is designed to improve the efficiency and effectiveness of management personnel in state and
local public health organizations. Aimed at public health managers from Virginia, Georgia and
both Carolinas, the ten-month program trains three-to-six person teams using a project-based
curriculum of both on-site and distance learning courses. Training topics include managing
personnel, finances, projects and data, civic entrepreneurship, communication and social
marketing, and quality improvement. At the present time, participants pay no program or
housing costs but are responsible for their travel and personal expenses.
Public Health Grand Rounds
This project uses Internet webcasting to deliver Grand Rounds where the "patient' is the
community and the "presenting problem" is a public health issue challenging the community. As
in medical grand rounds, a panel of specialists assesses the problem and provides current
information pertinent to the case. The goal of Public Health Grand Rounds is to promote a
leadership-level dialogue on public health issues of national significance. The program is
offered at no charge.
Public Health Leadership Institute
The mission of the Public Health Leadership Institute is to strengthen the leadership
competencies of senior level public health officials from national, state and local health
departments, hospitals, HMOs, government health agencies, and health related businesses and
organizations. Potential scholars apply as teams of two to four individuals who have at least
five years of high level leadership experience in work settings, community organizations,
professional associations, or elected or appointed office. The two-year program, focusing on
understanding public health challenges, expanding practical leadership skills, goal setting, and
improving outcomes, is conducted jointly by the Schools of Public Health and Business and the
Center for Creative Leadership in Greensboro. The first year includes a weeklong residential
session, monthly telephone conferences, computer discussion forums, team project work, and
satellite programs. During the second year the participants serve as mentors and faculty for
regional or state public health leadership programs, such as the Southeast Public Health
Leadership Institute (see below). Participants attend on full scholarship.
Southeast Public Health Leadership Institute
This yearlong regional training program is aimed at public health leaders from North Carolina,
South Carolina, Tennessee, Virginia, West Virginia and Georgia. lt is open primarily to senior or
mid-level professionals with five years of experience in public health and one-year current
tenure in a local, district or state public health department. A few additional program slots are
available for exceptional candidates from outside of traditional public health settings, such as
business or industry, hospitals, managed care organizations, professional associations, city,
state or local governments, and community organizations. The program curriculum, delivered
through retreats, telephone conferencing, and computer-based discussion forums, focuses on
visioning, systems thinking, communication, strategies for political and social change,
The North Carolina Institute for Public Health
73
I
Ie
I
I
I
I
I
I
I
tI
I
I
I
I
I
I
Ie
I
I
1
New Hanover County Health Department Organizational
Analysis
information management, crisis management, partnerships, coalitions and collaborations, and
customer service. Participants also work with a mentor on a yearlong project. States agencies
pay program costs for the participants they send; unsponsored and individual participants pay
their own way.
Southeast Public Health Training Center
The Southeast Public Health Training Center (SPHTC) represents a partnership among the
UNC School of Public Health and academic and practice partners in six states (North Carolina,
Virginia, West Virginia, Tennessee, Kentucky and South Carolina). It is one of several HRSA-
funded Public Health Training Centers across the United States established to strengthen the
technical, scientific, managerial, and leadership competencies and capabilities of the public
health workforce. The goals of the Training Center project are to assess the training need of the
public health workforce, inventory and evaluate current public health courseware, and design
state-specific workforce development plans. Neither a place nor a curriculum, the SEPHTC is
rather a ''virtual'' training center, a World Wide Web-based electronic resource for information
and contacts on a broad range of educational programs, collaborative projects, and student
placement opportunities.
The North Carolina Center for Public Health Preparedness
The North Carolina Center for Public Health Preparedness (NCCPHP) is a regional
representative in a nationwide CDC-sponsored effort to prepare the US public health workforce
to respond to emerging health threats in general, and to bioterrorism and newly emerging and
re-emerging infectious diseases in particular. The NCCPHP project has developed and
implemented models for field surveillance of emerging infectious diseases, assessed the
preparedness level of the regional public health workforce, and developed relevant training
products. Prototype surveillance and training models were developed in four North Carolina
counties: Wake, Edgecombe, Cumberland and New Hanover. Training materials developed by
the NCCPHP were disseminated locally and regionally through the Southeast Public Health
Training Center (see above). The NCCPHP is assisting North Carolina and four neighboring
states to implement assessment and training aspects of their recently developed public health
preparedness and bioterrorism response plans.
The North Carolina Center for Genomlcs and Public Health
The North Carolina Center for Genomics and Public Health is one of three such centers funded
by a CDC cooperative agreement. The goal of the Centers is to prepare the US public health
workforce to respond to advances in genomics and public health research and practice and to
incorporate genomics into the every day language of public health. The NCCGPH will: 1)
establish a knowledge base in genomics and public health by monitoring disease-specific
genomics research and disseminating that information in manuscripts and white papers; 2)
assess the knowledge of the public health workforce regarding the CDC genomics
competencies; and 3) develop relevant training programs to help educate current and future
health care providers. These programs will be accessible either as degree or certificate
programs at the UNC School of Public Health or as distance learning programs through the
Southeast Public Health Training Center.
Consultation and Technical Assistance
Through its consultation and technical assistance program area, the NCIPH serves as an agent
to link the public health practice community with the faculty, students and staff in the School of
The North Carolina Institute for Public Health
74
I
Ie
I
I
I
I
I
I
I
-
I
I
I
I
I
I
Ie
I
I
New Hanaver Caunty Health Department Organizatianal
Anaiysis
Public Health who can provide information, advice or direct service to help address professional,
institutional or policy level issues. The Institute's consultation and technical assistance projects
are client-driven and vary widely as to client type, geographic location, and scope and duration
of work. The NCIPH provides technical assistance to state health agencies, local health
departments and district health departments, community-based health organizations, and
AHECs as well as private sector health care providers. Services offered include assessment,
planning and evaluation, identification of best practices, policy analysis, media relations and
technical writing. Most projects are funded by grants or through contracts.
Special Programs and Applied Research
Through its special programs and applied research focus, the Institute also fosters and develops
a variety of working partnerships throughout the public health practice community
Office of AHEC and Field Services
The AHEC and Field Services Office in the NCIPH coordinates the training and education
activities jointly sponsored by the UNC School of Public Health and the nine regional AHEC
offices. It also serves as the liaison between the regional AHECs and the School's faculty, staff
and students whose activities are supported by AHEC travel funds. These activities include
student field placements and faculty and staff travel to continuing education programs, technical
assistance visits, and other teaching and program activities. The AHEC and Field Services
Office also processes the School's service reports and maintains the service activities database.
North Carolina Prevention Partners
The NC Prevention Partners works to improve the health of North Carolinians throughout the
state by bringing attention to the importance of prevention as a strategy. It fosters partnerships
for prevention, educates the public and professionals, facilitates new prevention efforts,
evaluates prevention efforts, and influences policies for prevention. The NCIPH.provides
support services to NCPP.
Association of North Carolina Boards of Health
The ANCBH is a 501 (c)(3) organization that provides training and technical assistance to the
state's local boards of health. Through an affiliation agreement, the NCIPH provides ANCBH
with training products and training programs, facilitates technical assistance, and provides
support services.
The Narth Caralina Institute far Public Health
75