Guide

Public Health Strategic Planning: the Ascendient Guide

By Brian Ackerman 

There’s never been a more critical time for public health strategic planning.

When Covid-19 was at its peak, some experts thought the lessons of a global pandemic might help strengthen the funding and functioning of public health departments across the U.S.

There were tantalizing signs of progress. The Build Back Better Act, for instance, proposed more than $16 billion in new public health spending, including $7 billion specifically reserved for state and local health departments. But the BBA died in the Senate, and a later law, the Fiscal Responsibility Act, actually clawed back billions of dollars in supplemental funding.

Meanwhile, at the state and local level, public health departments are getting unprecedented – and sometimes unwelcome – attention as politicians grapple with the pandemic’s social and economic fallout. Departmental budgets and boundaries are matters of intense debate, and public health experts are being drawn into the political fray like never before.

All of this is taking its toll on the public health workforce, with studies suggesting that 57% of today’s workers will leave or retire by 2025.

National trends are notoriously fickle, but we can say with certainty that local departments with a strong strategic plan will be in the best position to weather the storm. Of course, “strong” is a relative term, but we’re seeing a clear desire among our clients to do planning that gets “out of the weeds” of the pandemic and focuses on a future vision for the organization and its leadership role in community health.

Public health strategic planning can be an intense and time-consuming process, but it’s worth the investment to do it right, because departments with a solid plan will be better positioned on several important fronts:

• Better able to justify funding levels and attract new funding
• Better able to answer critics in government and media
• Better able to quantify a positive impact in the community
• Better able to attract and activate community partners
• Better able to motivate and manage team members

Based on our 25-year history in public health strategic planning, we suggest a process focused on three all-important questions.

Question 1: Where Are We?

Any plan, by definition, is focused on the future, but the best strategic plans are firmly rooted in the here and now. Without taking the time to really understand Point A, public health leaders will never know the proper route or resources to reach Point B.

Over the past 25 years, Ascendient has developed a four-step process to help local health departments answer the all-important question of “Where are we?” We begin with statistics, consider the broader setting, then layer on surveying, and end with a detailed SWOT analysis. This is a process that any public health department can use, with or without the support of outside consultants.

Statistics

Strategy can’t be defined in a vacuum. Every need or opportunity is relative, so it’s critical that public health leaders understand the context in which they operate. The right statistics allow you to measure your county’s health indicators against other counties in the state and around the nation.

Your Community Health Assessment is the place to start because it’s rich in data and directly tied to strategic planning. If your CHA numbers are a little dated – or not as robust as you hoped – you can do a quick refresh using three publicly available data sets:

• County Health Rankings (CHR) from the Robert Wood Johnson Foundation offers county-level data on 35 health factors and health outcomes.
• The Social Vulnerability Index (SVI) from the CDC includes 16 variables that are searchable down to the level of individual Census tracts.
• The Area Deprivation Index (ADI) from the University of Wisconsin ranks individual neighborhood “deprivation” on a scale of 1 to 100 using factors such as income, education, employment, and housing quality.

Even with all that data, you’re still only halfway to answering the “Where are we” question. It’s great to know where your community stands, but you also have to know where you stand as an organization. In our strategic planning engagements, we analyze dozens of internal datapoints such as staffing ratios, staff turnover, funding sources and trends, program costs, program utilization, and so forth. You can’t chart a path forward without a detailed understanding of your starting point.

Setting

Statistics are a must, but they can only provide a snapshot, while health and healthcare are more like an epic movie. To really keep up, you need a sense of the larger story – how the environment is changing and what that could mean for your community. At Ascendient, when we’re engaged for public health strategic planning, we typically analyze six to twelve key trends affecting our clients, including demographic shifts, healthcare expenditures, chronic disease rates, and federal priorities and innovations.

Keeping up with national forces that impact local health and healthcare might just be the most time-consuming part of the entire strategic planning process. Every day, hundreds of thousands of words are published on the latest data and trends. At the very least, it’s worth keeping up with the public health channel from KFF Health News and of course The Nation’s Health, published by APHA.

Just absorbing all the information can be overwhelming, but it’s not enough: The real value lies in connecting the dots to get a clear picture of the threats and opportunities emerging within a two- to five-year time frame. National conferences might help at a high level, but trends can play out very differently in a local context. Our best tip: If you’re not ready for a full consulting engagement, at least reach out to several firms to inquire about a customized, day-long education session for your executive leaders. (Better yet, ask local hospitals if they’d like to share the cost.) It’s a one-time investment that can help provide you with direction for years to come.

Surveying

Surveying the local healthcare landscape can be fairly straightforward, thanks to an IRS requirement that nonprofit hospitals must publish a triennial Community Health Needs Assessment (CHNA). Reviewing these assessments is a good way for public health leaders to “gut check” their priorities for outreach, access, and health factors. Of course, an individual hospital may have different priorities than the county overall, but it’s always a good exercise to talk through those differences and justify the county’s position.

In addition to surveying the landscape, we also recommend surveying leaders in the community, including education, public agencies, nonprofits, healthcare, and major employers. A good survey would include about 10 to 15 questions, focused mostly on perceptions and awareness of the health department:

• What do you think we do best?
• Where do we most need to improve?
• What do you think of our staff?
• How are we doing with community partnerships?

There is no substitute for this kind of primary research, and an independent research team is an absolute necessity for getting transparent, useful feedback. If an outside consulting firm is too much of a budgetary stretch, we recommend reaching out to a local university for help in designing, fielding, and analyzing your community leaders survey. However you go about it, this is one of the smartest investments you can make in public health strategic planning, because your SWOT analysis depends on clear, honest survey responses.

SWOT Analysis

This is where everything comes together to answer the question “Where are we?” By clustering key research findings under the headings Strengths, Weaknesses, Opportunities, and Threats, public health leaders can begin to visualize their strategic position.

If the nomenclature seems redundant or unclear, it can be helpful to remember that Strengths and Weaknesses are internal to the organization, while Threats and Opportunities are part of the external environment. To unpack that further with a few examples:

• Strengths are internal positives, such as effective grant writers or strong community awareness
• Weaknesses are internal negatives, such as outdated IT or duplication of services
• Opportunities are external positives, such as a growing population or new federal funding programs
• Threats are external negatives, such as wage inflation or new Covid outbreaks

At Ascendient, we like to plot Strengths, Weaknesses, Opportunities, and Threats on a matrix to create a kind of “heat map” for our public health clients.

By this point, it should be clear why good research is so important. If you haven’t done the hard work of gathering good inputs – statistics, setting, and surveys – you won’t have the outputs needed to populate your heat map. Even with good research, you’ll need to think carefully about where you fall on the matrix, because each quadrant has its own “strategic mindset” regarding growth, investment, programming, and so forth.

Question 2: Who Are We?

Traditional public health strategic planning models often start by asking “who” rather than “where,” but we believe that misses the point. “Who are we?” is about the vision, mission, and values of the organization, and those things can’t be defined in a vacuum. We always recommend that health departments first do the hard work of understanding their environment and then define themselves within that context. Sometimes the three terms are used interchangeably, but we think it’s important to keep the differences in mind:

Vision is the most aspirational and high-level. It’s about what the community will look like if you execute flawlessly on your public health strategic planning. The focus is usually external – another reason why it makes sense to start by asking “Where are we?” You have to really understand your community as it is now in order to have a clear vision for what it could look like in the future. For instance, if your research shows that health outcomes in your county are strongly predicted by demographics and geography, then your vision statement might read like this:

We envision a county where all residents lead healthy, productive lives regardless of race, ethnicity, gender, or Zip code.

 

Mission is about what you’re doing every day to help achieve your vision for the community. This is where the verbs come in – the language is still aspirational, but it stresses action at the same time. Again, the mission statement is informed by the research you did to answer the “Where are we?” question. So, for instance, if you learned that community leaders perceive the health department as operating in a bubble, an effective mission statement might look like this:

In collaboration with community partners, we work to deliver excellent public health services that are equitable and empowering for all.

 

Values set forth what you believe in and how you will behave as you work to execute the mission. The values statement is your moral compass, so you’ll want to check it regularly. Internally, that means staff surveys, as we’ll discuss below. Externally, once again, you’ll want to look at your community research. Is the department perceived as being opaque or arbitrary in its decisions? If so, maybe a value like “transparency” or “accountability” is in order.

The temptation with a values statement is to cram in so many adjectives that it becomes impossible to keep track of them all. We urge our health department clients to settle on just three or four values that are most meaningful and measurable, then come up with a one- sentence description of each. Take these values, for instance, drawn from an actual engagement:

• Proactive – We are committed to anticipating the needs of those we serve by being prepared and acting on the plans we establish to meet those needs.
• Collaborative – We work together as an organization, with community partners, and with our customers.
• Compassionate – We are committed to serving our community and each other with respect, kindness, fairness, and equity.

Vision, mission, and values are typically established at the leadership level, with varying levels of participation by staff – but that doesn’t mean staff can be left out of the public health strategic planning process entirely. Team members have a unique view of the organization that can’t be surfaced through secondary research or community leader surveys. “Who are we?” is a question that can’t be answered accurately without input from many employees.

Staff surveys can be extremely wide ranging, but at the very least we recommend questions related to:

• Values
• Direction
• Impact
• Strengths
• Weaknesses

Even more than surveys of community leaders, confidentiality is key to getting honest, useful answers from staff surveys. If you don’t have an established relationship with a consulting firm, this is another area where the local university might offer targeted support.

Question 3: Where Are We Going?

At this point, you know your community and your organization based on solid research, so all that’s left is to define exactly how you’ll use the expertise and resources of the organization to change the community for the better – in other words, to answer the all- important question, “Where are we going?”

With a set of strategic drivers plus operational mile markers, you’ll have a roadmap that can clearly answer the question for employees, residents, lawmakers, and other stakeholders.

There’s nothing strategic about moving in 100 directions at once – you’ll only exhaust your resources (and your people) without making any measurable progress. Instead, think of a vehicle with four-wheel drive: Your strategy is the engine that sends power to all the wheels, and you make progress because the wheels are turning together in the same direction.

Strategic Priorities

We use the term “strategic priorities” to reinforce that sense of curation and coordination. Your priorities are the three or four top action items that rationalize all of your programming and move you toward your vision for community health. Priorities are action-oriented, so we like to start them with a verb, as in these examples taken from an actual client:

• Transform public health service delivery
• Enhance community awareness and experience
• Promote a culture of innovation and engagement

If you’ve walked carefully through the entire planning process, your priorities should emerge organically from the SWOT analysis. How can you build on your strengths and opportunities? What steps can you take to shore up weaknesses and minimize threats? Look for patterns and groupings that allow you to consolidate many bullet points into just three or four strategic drivers. In the example above, just three priorities emerged from 24 individual bullets on the SWOT analysis.

Not sure you have the priorities right? We urge our clients to explicitly lay out their rationale with a series of statements showing why each item was selected and how it will contribute to the mission. For instance, if the strategic priority is “Enhance community awareness and experience,” the rationale might look like this:

• Supports the mission of providing excellent public health services by making customers aware of the services we offer
• Recognizes that increased demand is crucial to the mission
• Recognizes that customer experience is key to continued demand
• Offers the chance to use partner relationships to build awareness
• Reminds us to be aware of different channels and messages needed to reach various sub-groups within the community
• Reminds us of the importance of meeting customers “where they are”
• Forces us to think about customer experience and how we measure satisfaction

The discipline of spelling out your rationale for each strategic priority is important. Take the time to be comprehensive and thoughtful in connecting the priority to your mission, but be careful that you’re not forcing the fit. If your rationale statements require inordinate time and thought, it could be a signal to re-think that particular priority.

Priority Metrics

Strategy is great, but it’s not much use without some operational mile markers to ensure you’re headed in the proper direction at the proper speed.

Many health departments do their planning on a three-year cycle, so your “finish line” is probably already established. The trick for each strategic priority is to decide how you’ll measure progress toward that goal – what to count, how often, and how much improvement you want to see along the way. That’s where priority metrics come in.

Going back to our example above, think about the second priority, “Enhancing community awareness and experience.” We would work with clients to come up with a set of metrics for measuring both awareness and experience, then establish baselines, goals, and timelines for each metric. For instance, webpage traffic is a good indicator of awareness, so we might set the goal of doubling traffic from the current baseline of 1,000 unique monthly visitors. If that’s the three-year goal, we might also establish interim goals along the way – say, 1,400 monthly visitors this year and 1,750 next year, on our way to 2,000.

On the “experience” front, customer satisfaction surveys are an obvious starting point, so we’d look for baseline figures – how many customers are completing surveys, along with current survey results – then set goals for improvement.

Here’s an example showing how a strategic driver might look with its related metrics:

How many such metrics do you need? There is no firm rule, but we like to aim for four to six metrics on each strategic priority.

Quality is at least as important as quantity when it comes to measuring progress. It’s not enough to just to have six metrics per priority – you also want to be sure those measures are aligned with your vision, mission, and values. For instance, if equity is part of your vision for a healthier community, ask yourself how you are building equity measures into your operational markers. Web traffic can’t be your only indicator of awareness because many households in under-resourced communities don’t have Internet access. That’s why we target increased neighborhood meetings in the example above. Likewise, there are probably pockets of your community that don’t speak English. How can you measure the experience of those residents if your customer satisfaction survey is available in only one language?

Conclusion

Increased public scrutiny can be both a threat and an opportunity. Now more than ever, public health departments need to show that they are relevant, proactive, and well connected to the communities they serve. The rigor and discipline of the strategic planning process offers the perfect chance to:

• Get out of the weeds
• See yourself through your customers’ eyes
• Forge stronger bonds in the community
• Reflect on mission, vision, and values
• Connect programs to purpose

For more than a quarter century, Ascendient has been a leading ally and advisor to public health departments across the country. If you’re ready to update your strategic plan in light of today’s social, economic, and political realities, we would welcome the chance to discuss your needs. Please contact us for more information.