COMMUNITY HEALTH PLANNING: A REVIEW OF THE LITERATURE Patrick Lenihan Public Health has rediscovered planning as a component of public health practice. In its 1988 report, The Future of Public Health, the Institute of Medicine (IOM) presents the core public health functions of assessment, policy development and assurance much like a traditional planning cycle. Planning is explicitly mentioned several times throughout the report, which identifies planning as a key enabling activity of the governmental role in public health at the local level. Included among the ten public health organizational practices are several planning activities. These include assessing needs, setting priorities, developing plans and policies to address needs, implementing plans, and evaluating programs. While not new to public health, planning has never had a well defined role that could guide practitioners in the use of planning as intended in the IOM report. This article will attempt to identify from the literature those key elements of planning practice that are most relevant to public health. In his widely used public health text, Pickett (1990) describes planning in public health as multidimensional, ranging from the comprehensive health planning called for by federal health planning legislation of the 1960's and 70's to the narrower managerial planning that goes on as an administrative process to achieve efficiency in most public health agencies. Public health practitioners are probably most familiar with health planning conducted as part of the health education process. Program planning and community assessment are well established components of health education (Dignan, 1992), with a focus on improving the health of defined population groups through a programmed package of services. More recent attempts to formalize planning in public health have resulted in the development of standardized approaches such as APEXPH (Assessment Protocol for Excellence in Public Health) and PATCH (Planned Approach to Community Health). These two planning tools illustrate a variety of planning models now in use. PATCH is very similar to the traditional health education approach to program planning. APEXPH Part II, the Community Process, has easily identifiable elements of comprehensive health planning while Part I, the Organizational Capacity Assessment, follows a traditional strategic planning process. The planning literature has not been very accessible to public health practitioners who wish to adapt approaches successfully used in other fields. Finding a clear role for planning in public health is complicated by the lack of a generally accepted definition of planning (Hyman, 1982). Unlike other public health component disciplines such as epidemiology, planning is a practice based discipline without a well developed theoretical foundation. Definitions and approaches created in practice tend to emphasize characteristics of the practice situations and can vary greatly. This results in definitions suggesting very different types of planning. However, if functional definitions are considered, common elements reappear in most definitions of planning. These include: a future orientation, rationalizing decision making, allocating resources, setting direction, bringing about change, and building consensus and participation. Benveniste (1989) adds organizational learning, handling uncertainty and coordinating independent or loosely coupled organizations in his functional description of planning. These key functional elements are more useful than a single conceptual definition in capturing what is important to public health practitioners. Blum (1981) notes that there are several dozen well known approaches to planning which each emphasize a particular feature. Most writers agree that the seemingly different approaches to planning are related and involve a similar set of activities conducted as part of a cohesive process and differ more in focus, emphasis and how the elements are carried out. At its simplest, planning involves two fundamental steps: 1) an analysis of a situation or problem, and 2) a process of decision-making to determine what to do about it (Hyman). Others add implementation and evaluation as essential steps (Blum). And others yet subdivide these most fundamental steps to create multi-step planning approaches that tend to obscure what they may have in common. Of the many models or approaches to planning, three typify planning in public health and may best inform planning as a public health practice. These are the comprehensive rational approach, advocacy planning and strategic planning. The comprehensive rational approach is the oldest method and has dominated most early planning (Benveniste). The planner using this approach relies on quantifiable information and systematic analysis to clarify goals, generate alternatives, and establish criteria to make choices. Once choices are made and have been implemented the results are then monitored. This approach attempts to rationalize decision making and minimize the role of politics. Public health has been quick to embrace this approach because of its compatibility with strongly held public health values of professional judgement, expert knowledge, and the use of science to inform decision making. Nearly all planning in public health from the legislated health planning of twenty years ago to the use of APEXPH today shows the strong influence of the comprehensive rational approach as evidenced by the heavy reliance on technical aspects of planning in the use of data, epidemiology and quantitative analysis to inform the planning process. Advocacy planning is a bottom-up variation of the comprehensive rational approach, combining community organizing with technical analysis (Benveniste). Using this approach, the planner becomes a change agent to raise awareness and mobilize a population group to solve a community problem or achieve a policy goal. The advocacy approach is most commonly used for planning in health education. Based on the findings of an epidemiologically driven community needs assessment, the health educator or planner organizes community representatives around solving a specific health problem (Dignan). Advocacy planning adds the participation of those being planned for to the planning process but planners or professionals continue to control the process through the technical aspects of planning. Strategic planning is intended to orient an organization to the demands of its environment (Bryson, 1988). Systematic analysis is used to understand external threats and opportunities, and internal strengths and weaknesses. Strategies are then developed to enhance the organization's long term success in reaching its goals. While strategic planning has origins in the corporate world, it is increasingly being used by public agencies, including health departments, facing a rapidly changing environment. More focused and action oriented than comprehensive planning, strategic planning looks for the most important issues in a situation, is concerned with implementation and attempts to integrate organizational actions. Seen largely as a management tool, strategic planning depends less on the technical ability of staff planners and more on the commitment of an organization's most senior managers, especially the chief executive. While relatively new in public health, strategic planning is very relevant to public health for dealing with the challenges raised in the IOM report (Ginter, 1991). While these three approaches cover applications most often encountered in public health, it is important to note that all planning involves similar basic steps and no single approach is adequate for all situations. An eclectic approach which combines elements of a variety of approaches is often recommended (Blum). Further, while there is a general logic to the sequence of steps, planning is iterative, not linear. Starting somewhere other than the very beginning, backtracking, and repeating some steps may yield a better outcome (Blum). The role of politics in decision making has been a major issue both in the planning field and in public health. Although planning is supposed to be an objective process that relies on data to make decisions, the process of decision making can be largely political (Benveniste, Hyman). Pickett agrees with this observation and notes that there has been frustration and confusion in the public health experience with planning over the failure of the comprehensive rational model to overcome politics in decision making. Public health has tended to focus on the technical aspect of planning and has avoided the messier politically oriented process side of planning. This is not surprising given the value placed on scientific knowledge in public health decision making. Thus much of the health planning literature has featured data analysis and needs assessment as if planning were an extension of epidemiology. Both the planning and public health fields have come to accept the political environment in which decisions are to be made and the limits to the effectiveness of a technical approach in this environment. The IOM report notes that "technical knowledge plays a more restricted role in public health decision making than it once did even though we know more." The report goes on to recommend that public health professionals must have both technical and political skills. It is the balance of the technical with the political which makes planning such a useful tool. Several points are made by writers who have considered how this balance can be achieved. First, there is nearly unanimous opinion that regardless of the approach used, planning should be considered a process and not just a collection of methods. As a process, how it is carried out is perhaps more important than the methodologies employed. Participation and involvement of key stakeholders is essential to the success of the process (Blum, Bryson, Benveniste). The nature of participation must be tailored to the particular situation. The role of the staff planner in a participatory process is less controlling and more facilitating. Planning that does not explicitly consider values will not be successful even if it is technically implementable. Values determine the selection of goals and actions, set expectation standards and provide impetus for change. At the values level, planning creates a philosophy that will guide the process and content of planning (Blum). Change is more readily adopted if it is consistent with the values of the adopters. (Benveniste). Achieving consensus and support of participants is as important as good technical analysis for implementation. Benveniste describes a multiplier phenomenon where technical analysis brings credibility that a plan can be implemented and participant support adds legitimacy. Together they create a "bandwagon" effect that increases the implementation probability beyond the individual contributions of technical analysis or support. At its best, planning can be seen as a process of learning and discovery of workable solutions to the problems taken on by planning. Complex problems faced by public health will not be solved by technical knowledge or a cookbook application of some planning approach. The best planning will continue to evolve in practice. The literature and experience of others can provide a useful framework and guidelines, but public health planners must be prepared to adapt these models to their local agencies and communities. References Benveniste, G. (1989). Mastering the Politics of Planning. San Francisco: Jossey-Bass. Blum, H. (1981). Planning for Health, Generics for the Eighties. New York: Human Sciences Press. Bryson, J. (1988). Strategic Planning for Non-profit and Public Agencies. San Francisco: Jossey-Bass. Dignan, M. & Carr, P. (1992). Program Planning for Health Education and Promotion. Philadelphia: Lea & Febiger. Ginter, P., Duncan, W., & Capper, S. (1991). Strategic Planning for Public Health Practice Using Macroenvironmental Analysis. Public Health Reports, 166, 2, 134-140. Hyman, H. (1982). Health Planning, A Systematic Approach. Rockville, MD: Aspen. Pickett, G. & Hanlon, J. (1990). Public Health Administration and Practice. St. Louis: Times Mirror/Mosby College. RE-INVENTING COMMUNITY HEALTH PLANNING Deane Johnson and Terry Altman Public Health Practice Program Office Centers for Disease Control and Prevention The 1990s will become known as the decade the "put the public back into public health." Communities leaders across the country are demanding more accountability and exerting greater involvement in the decision-making functions of their public agencies. Whatever the force or forces driving a resurgence of public interest, community health planning (CHP) is being re- invented and re-defined. Health planning is not a new term nor is it a new idea. It is, however, or renewed importance to public health agencies for it offers the means by which to enhance performance of the core functions of public health and effectively participate in policy-making activities. As health reform continues to dominate the national agenda, it is incumbent upon health departments to participate in the debate in an active and effective manner. If health departments do not represent the public in this debate, who will? While policy-making in health care has always been an active and ongoing endeavor, the nation is now committed to significant change in our health care system. This commitment means that on the national, state, and local levels, policy makers are coming together to decide what will be changed in the health care system and how that change will be achieved. To partake in policy debates, and be a determiner of change rather than a reactor to already accomplished events, agencies and organizations must be recognized members in the policy arena. This means that the agency is recognized as a significant contributor in areas such as, representing key constituent groups; collecting data and conducting appropriate analyses to describe community health needs and priorities, and forming and maintaining partnerships with related organizations in addressing those needs. With the heightened interest, CHP is being defined more broadly than in the past. The Institute of Medicine (IOM) report, The Future of Public Health, recognized the comprehensiveness of engendered in CHP, describing it in terms of "core functions," assessment; policy development; and assurance. This concept was furthered in the American Public Health Associations' publication, Health Communities 2000: Model Standards. The document outlined eleven activities that would fully address core functions.  Assess and determine the role of one's health agency  Assess the lead agency's organizational capacity  Develop an agency plan to build the necessary organizational capacity  Assess the community's organizational and power structures  Organize the community to build a stronger constituency for public health and establish a partnership for public health  Assess the health needs and available community resources  Determine local priorities  Select outcome and process objectives that are compatible with local priorities and the Healthy People 2000 Objectives  Develop community-wide intervention strategies  Develop and implement a plan of action  Monitor and evaluate the effort on a continuing basis These activities describe the range of activities expected of public agencies, not just the "development of a plan." But, more importantly, these activities focus on an increasing community role in public policy decision-making. Agencies actively engaged in community health planning processes must build a strong position for participating in the policy-making arena. The basic tenants of "good" health planning are the same as for effective policy-making: serving as leaders and members of the community and jurisdictional population; providing the scientific expertise and impartiality of a public agency in understanding health needs and priorities; and assuring that the needs of the public are met in the most efficient and effective manner possible through partnerships and area-wide coordination. According to a 1990 survey of local health departments conducted by CDC and the National Association of County Health Officials (NACHO), services and programs relating to policy development functions are not routinely conducted by local health departments. Only 57% of responding local health departments reported active health planning programs. Lack of a health planning program may be due to many factors, but most health departments report that they just don't have the resources and staff to support effective planning processes. The new era of health reform should mean that health agencies are re-assessing the need to commit scarce resources to planning because the reality is that CHP processes offer effective means by which to position an agency or organization to enter and participate in the reform debate. Some commonly reported benefits occurring as a result of community health planning include:  Through a participatory approach, helps the health department forge closer relationships with its community.  Promotes an enhanced understanding of the community's health promotion and disease prevention needs.  Marshals new resources and redirects existing resources to meet community health needs.  Builds partnerships in service delivery and policy development. Community health planning, recognized as an effective process in policy development functions, was demonstrated in a study by C. Arden Miller and colleagues. Fourteen health department directors were asked to consult with their staff and report on the impact of identified "critical events" on the departments' performance of the core functions. The study found that health departments recognize the importance of planning events to policy development. The critical events cited included the Objectives for the Nation for 1990, Model Standards for Community Preventive Services, and the Assessment Protocol for Excellence in Public Health (APEXPH). Each was rated as having positive effects on the core function of policy development. Of interest, the IOM report reported the highest positive ratings for both assessment and policy development functions. It is critical that health departments participate in health reform debates in an active and meaningful manner. Programs that adopt the principles of CHP offer health departments the basis for an important position in health reform. Community health planning is a process which is analytical, participatory, and results-oriented. The purpose of the process is to enable the community to become an active participant and determiner of its public health. It should reflect and embrace these guiding principles.  To be sustainable and truly reflect the public's interest, the planning process should be the responsibility of the official government public health agency for the community.  It is incumbent upon the public health agency to bring an appropriate level of influence, knowledge, and resources to ensure the success of the planning process.  The community must be actively involved in the process, in a timely manner and with binding decision-making responsibility.  Collectively, participants must have official standing, recognized authority, and clearly reflect the community of which they are a member. The Centers for Disease Control and Prevention (CDC) has a long history of commitment to effective planning. They have fostered this commitment with state and local health agencies by making federal staff, many with extensive management expertise, available to state and local health agencies. These staff, consisting primarily of public health advisors and medical epidemiologists, provide the linkage between CDC and state and local prevention programs. More recently, CDC has made available other professionals such as management analysts and statisticians to augment existing resources in public health agencies. The CDC continues to support effective planning processes by working with NACHO and other professional public health organizations to develop the APEXPH document. More recently, CDC expanded its partnership with the Association of Schools of Public Health and their academic researchers by funding development of training products and protocols for evaluating the practice of public health. Beginning fiscal year 1995, federal funding for state-based HIV/STD prevention programs will require active community participation in the planning process. This process will alter the context of CDC relations. The performance focus will demonstrate CDC's increasing commitment to results. Revitalizing the community and refocusing the federal effort are two strategies that will present a variety of state and local opportunities to "strengthen the public health system." COMMUNITY HEALTH PLANNING AT THE LOCAL LEVEL USING APEX Joel Cowan and Joseph Orthoefer Winnebago County Health Department Some of you may remember when there was particular emphasis on new approaches and organization to perform planning for local governments. Acronyms like A 95, PPBS (Planned Programming Budgeting Systems), ZBS (Zero Based Budgeting), CHP (Comprehensive Health Planning), and HSA (Health Services Agency) were commonly heard. Now we have APEX (Assessment Process for Excellence in Public Health) and I-Plan. When PPBS and other systems were first initiated, they were already tested in local health departments before being adopted by city or county governments. The initial attempt to bring order out of chaos, as the cost of health care first began its escalation, was the advent of Comprehensive Health Planning. My first recommendation to the Winnebago County Board of Health was to provide local support to this newly forming planning agency. Local planning then seemed to be our last chance to control health care costs. Those involved remember the extreme difficulty encountered when the CHP and HSA agencies attempted to reign in the special interests. At the time, it seemed the only real authority the HSA's had left was to review and comment on public health grants. With the election of Ronald Reagan to the presidency, all attempts at governmental planning for health care disappeared and the free market was called upon to regulate costs. Some of us who continued to feel that health care is a right thought that the only way to be sure everyone was guaranteed that right was through planning. We continued with the PPBS system in our health departments, utilized advisory committees as provided for the Illinois State Statutes, and attempted to plan for public health services based upon our communities needs. This later led to the publication of "APEX" and the "Model Standards 2000." APEX provided guidance to expedite the planning process while involving the community in a formal way. In the fall of 1992, the Winnebago County Health Department decided to conduct the APEX process. This process seemed particularly appropriate, as it provided for assessment of the organization and community self assessment in a flexible manner. With some modification, we could incorporate the process into ongoing health department planning and organization. To implement the APEX process, the Winnebago County Health Department contracted with the Office of Health Systems Research of the University of Illinois College of Medicine. For internal assessment required by APEX, all Division Heads met to discuss the process under the Health Systems Research coordinator. After an introduction to the process, they were assigned the Capacity Assessment Worksheets to complete at their convenience. At a second meeting the coordinator discussed the meaning of the compiled results with the group. A report was then made to the administration on the findings with recommendations for improvement in areas of weakness. For the community assessment, the coordinator prepared an extensive document on the health of the community, using available statistics. A representative sample of eight people from the Advisory Council to the Board of Health met on four different occasions to review the statistics and complete the worksheets to establish their priorities. The coordinator led the discussions and published the priorities established by the committee, including possible implementation strategies. The assessment was then distributed to all Division Heads and a meeting was held to discuss ways to improve the organization. In areas where outside people or organizations were involved in an action, the Director of the Health Departments and appropriate staff met with such organizations and their staff to attempt to arrive at understandings. The external assessment was presented to the Board of Health at its annual retreat. All statistics presented to the Advisory Council as a basis for the plan were again presented, along with the recommendations developed for presentation to the Board of Health. Each Division Head was provided APEX recommendations so that they might be taken into account in the development of the next fiscal year's program budget. These budgets were then presented to the Board of Health by Division Heads in the annual budget hearings. These budgets were accepted nearly intact by the Board of Health and subsequently by the County Board. We are now in the second year of the APEX process, now called I-Plan, as it has been newly initiated statewide for health departments. We will update the plan this winter. The Advisory Committee has reacted enthusiastically to the manner in which the plan was handled, and many members have expressed a desire to serve on the community committee which will help update the plan. Since all planning must be organized, it is our desire to use the updated version at the next Board of Health retreat and continue the process of change and improvements. In the coming year, we expect to introduce the plan to the County Board and to other community interests so they can assist us in meeting the objectives established in the APEX plan. A LEADERSHIP COFFEE BREAK WITH CLAUDE H. HALL, JR., M.A., M.H.A. COMMUNITY HEALTH PLANNING, MODEL STANDARDS, AND HEALTHY PEOPLE 2000 Shirley F. Randolph, M.S.P.H. Chair, Model Standards Work Group As public health leaders look to the future and contemplate the practice of public health after health care reform, many questions and concerns arise. The transition from the existing system of public health to public health in a reformed health care system will occur over time. And, while the objectives of public health won't change, the emphasis about certain public health activities will. For example, in a reformed system, public health agencies should have the resources to pursue a more vigorous community needs assessment and educational role, which will allow them to concentrate on promoting community decision-making that enhances individual and community health. Such activities will include removing threats to health such as environmental hazards and will assuredly include an emphasis on educational campaigns. How should the public health leader prepare him/herself and the community for the role of public health within a reformed health care system? What tools are available to help us? Are public health agencies and public health leaders prepared to lead their communities into our rapidly approaching future? Exploring the issues prompted by these questions and many more provides an insightful look into how the public health practitioner will need to function as she/he works for the public's health. While community health planning has long been with us, it has taken on new importance and needs to be rediscovered, particularly as health planning relates to using newly developed processes such as Model Standards, APEXPH, PATCH, and Illinois' own IPLAN. The interview with Claude Hall is particularly enlightening as it melds concepts about community health planning with health care reform and the 11 step community planning process upon which Model Standards is predicated. What is the purpose of community health planning? Community health planning should encourage agencies responsible for health to work with and through the community to solve local health problems. Planning centered in the community should clarify what is needed and desired to have a healthy community, what has to be done to achieve a healthy community, what resources must be identified, and how to acquire and use those resources. Who does community health planning and why? A local health department can help or lead the community health planning process; but the community itself must be involved in defining local problems and identifying choices and their potential consequences. Otherwise, the local health department will never be able both to broadly inform the community and mobilize significant numbers of individual citizens to "rally 'round the flag." What is the relationship between the need for and the generation of data to the community health planning process? Definitions of health encompass an increasingly broad spectrum of private and public activities that are provided, delivered, paid for, and monitored by a host of institutions. As our definition of health and the means for intervening to improve health has broadened, to define problems, needs, and the effectiveness of interventions, we must collect and analyze a wide variety of indicators reflecting our individual and collective efforts. Why is community-based health planning so important at this point in our nation's history? At long last, there is a general public outcry to reform our health care system! Yet, the very complexity of our health delivery and financing systems means that any comprehensive effort will require a great variety of strategies and institutional and policy changes, with resultant implications for not only health--translate, medical--care, but also for public health. While political attention focuses on the national and state level, such reforms will not remove from local public health agencies their responsibilities for the core functions of assessment, policy development and assurance. After a bill is written and passed by Congress, it will remain true that all politics and much of public health will remain local. If community health planning is used to define problems, clarify alternatives, and inform as well as involve the public, the local politics of reform and public health both will be served. What does community health planning offer that's relevant, now that our nation is finally moving toward health care reform? A function of public health that will increase in importance in a reformed system is surveillance. The monitoring and evaluation of the performance of new delivery and financing systems in terms of access, quality, cost effectiveness, continuity of care and coordination, and health status outcomes will be vital. More than ever, private sector health care will be held accountable using objectives, indicators and data developed, monitored and analyzed by public health agencies. Does Model Standards support public health's core functions, and why is this important to me as a public health leader in my community? Yes, Model Standards' Eleven Steps offers a comprehensive approach to the performance of assessment, policy development and assurance. Every public health leader must challenge his/her local public health agency to assess and evaluate themselves and their community's needs and resources; inform and educate the public and its leadership, in order for them to become successful advocates for and consensus builders about public health; and then develop, organize, manage, and/or coordinate public and private resources. How can Model Standards help me provide leadership to my community? Leadership may be composed of differing degrees of authority, guidance, and influence. Model Standards thoughtfully used and applied should provide the user with an aura of expertise and legitimization that will command respect and convey authority. Its adaptability enables its user to offer guidance to the community and other agencies that will enable consensus building to proceed and succeed. The consideration given to public health issues and problem-solving strategies in the creation of Model Standards should enable an agency or community leader to build coalitions around strategies, policies and programs that have worked i other communities. Ultimately, all these approaches convey leadership; but to sustain them requires that they be complimented by the managerial and interpersonal skills of the public health agency's director. Does Model Standards have any relevance to IPLAN? If so, what is it and how can Model Standards be used with IPLAN? Yes, IPLAN is Illinois' effort to encourage local performance of organizational capacity assessment, a community health needs assessment, and development of a community health plan using APEXPH and the IPLAN Data System. A local health agency could use the Model Standards Eleven Steps in conjunction with these efforts to establish a process for community involvement and participation, identify health problem areas, analyze community resources for addressing the problems, develop strategies for intervention, and, of course, establish objectives and indicators to monitor progress toward solving or mitigating the problems. Which of the 11 Steps described in Model Standards is the most important step for me to use as a public health leader in my community? OFten, the most important step is simply making the decision to act to solve a "recognized" health problem. After doing so, agency leaders may proceed in a variety of ways, although assessment of the role and scope of the agency and of other community resources may be a common first step. Because every local health department exists within different organizational structures, its authority, resources, and demands for its services may vary widely. Rather than selecting a lock-step approach to planning, each health department leader should assess how his/her agency performs each of the eleven steps, and then proceed as agency and community needs, priorities, and resources allow. Are Model Standards as relevant to small, local public health departments as they are to large public health departments? Absolutely! While problems, resources, and authority vary from jurisdiction to jurisdiction, establishing a rational process for identifying community and agency needs and resources, mobilizing and allocating resources to address priority problems, and evaluating successes and areas for further improvement are all essential parts of any agency's activities. Where an agency's size or resources compel it to focus on surveillance and regulatory efforts, its obligation to involve the medical community--indeed, all parts of the community--in assuring that every citizen has access to preventive and other services is of even greater importance. Model Standards are intended to be selected and quantified as individual circumstances dictate. How can I get started with implementing effective health planning in my community? What processes and products are available to assist me? I won't kid you!! If a local health department is just starting up, I would advocate a somewhat linear progression beginning with agency and community assessment, problem identification and prioritization involving the community, development of strategies for intervention, selection of objectives and indicators, and then the design, implementation and evaluation of programs and systems to achieve the objectives. However, most local public health agencies already exist with well-established authorities, roles, resources, programs and procedures, constraints and a public image. Where to begin is a very local decision that no template or process can make for a public health leader. But, tools to help make that decision are available. In addition to Healthy Communities 2000: Model Standards, APEXPH, and PATCH tools such as The Guide to Implementing Model Standards, Community Strategies for Health, and a Media Relations Handbook have been developed by the Model Standards Project. The Model Standards Project has also begun a Peer Assistance Network designed to link practitioners who have used Model Standards, APEXPH or PATCH with agencies needing consultation and assistance in implementing community-based planning efforts. Excellent monographs on planning, management by objectives, total quality management, and public health program planning and evaluation have been written and published as well. Schools of public health can be valuable partners in using all of these processes and products. Finally, associations like APHA, NACHO, ASTHO, and USCLHO have annual meetings where sessions on these issues explore the literature and activities in the field. Why should my community use this particular method of community-based health planning? Because Model Standards is flexible and provides a linkage to the Healthy People 2000 Objectives. Both Healthy People 2000 and Healthy Communities 2000: Model Standards represents the work products of a remarkable collection of public and private sector experts in promotion, prevention and risk reduction. Model Standards can be used as a capstone for efforts using APEXPH or PATCH, a starting point for management by objectives (MBO) processes used in many public health departments, or as a component of a Total Quality Management (TQM) system. BOOK REVIEW - The Fifth Discipline: The Art and Practice of the Learning Organization, written by Peter M. Senge Reviewed by: J. Maichle Bacon, M.P.H., R.S.; Public Health Administrator; McHenry County Department of Health As important as continuous quality improvement has been in enhancing product and service quality around the world, that subject only comprises a small portion of the real potential of learning organizations as synthesized by Senge. This book is an inspiring, benchmark document for advancing organizational effectiveness; a must read for all leaders and aspiring leaders. What distinguishes outstanding leaders "is the clarity and persuasiveness of their ideas, the depth of their commitment and their openness to continually learning more". This does not mean that such individuals always have the answers, but they do have confidence that together "we can learn whatever we need to learn in order to achieve the results truly desired". Throughout the text Senge provides interesting supportive descriptions on the origin and deeper meaning of various terms, thus enhancing the perspective of important concepts. An example of this is the real meaning of learning, which is commonly accepted as a gaining of information. However, the deeper meaning of learning, from the ancient Chinese, incorporates not only a taking in of information, but also the necessity of constant study and practice. In Senge's words, learning "is the enhancement of capacity for effective action". Learning involves a fundamental shift of mind. "Through learning we reperceive the world and our relationship to it...we extend our capacity to create". And, when this can be expanded to include smaller work group(s) and larger organizational learning, the potential for effectiveness is many-fold greater than just the sum of individuals learning. What distinguishes "learning organizations" from "controlling organizations" is mastery of the basic disciplines for building and sustaining learning organizations: personal mastery, mental models, shared vision, team learning and systems thinking. The synergistic potential in organizational terms is the ability to integrate the practice of these disciplines...as fingers on a hand. Systems thinking, the fifth discipline, provides the cohesiveness to facilitate the functioning of the other four disciplines. Systems thinking is a discipline that essentially restructures how we think, providing a methodical approach to assessing management problems and issues. By using a surprisingly small number of systems archetypes or recurring structures or patterns of organizational behavior, areas of leverage for change (i.e. improvement) can be identified. One of the most fundamental tasks of managers is to focus attention, and where better to focus attention than on the point of greatest leverage, thus avoiding the long term, counter-productive quick- fixes that could otherwise result. This is not a quick, how-to book, but a rich compilation of management and leadership concepts that together provide a roadmap of practices, skills and disciplines to release the untapped potential for organizations to create their own future through collective learning. At the same time, Senge clarifies that this treatise is not the last word on systems thinking and building learning organizations. Leaders must always be alert to additional disciplines or new paradigms altogether. Nevertheless, this book is unparalleled in its review of "state of the art" techniques to grasp and manage the increasingly complex organizational environments that we are all part of. Note about the Author: Peter Senge, PhD, is Director of the Systems Thinking and Organizational Learning Program at MIT's Sloan School of Management. Dr. Senge is also a founding partner of Innovation Associates in Framingham, Massachusetts. FORD-IROQUOIS PUBLIC HEALTH DEPARTMENT COMMUNITY HEALTH PLANNING John A. Pickering, D.Man.M.S. Public Health Administrator The year 2000 is rapidly approaching and with it comes the critical evaluation process of measuring the advances made toward achieving the goals set forth in Healthy People 2000 and Healthy Communities 2000: Model Standards. The community health planning activities represent an integral function of the process. As such, it figures largely in any discussion of public health infrastructure. The Ford-Iroquois Public Health Department, in accordance with state regulation, had been involved in a program planning process since 1979. The opportunity to participate in the Assessment Protocol for Excellence in Public Health (APEX/PH) Demonstration Pilot Site Program provided this Agency with an unrivaled opportunity to develop a comprehensive Community Health Plan (CHP). The description which follows summarizes only that part of the APEX/PH process which directly applied to the development of the CHP and does not address the prior critical issue of internal assessment. At the onset, one would acknowledge that the process used in our demonstration was accelerated because of time constraints necessary to comply with the terms of our agreement with the National Association of County Health Officials, the principal sponsor of APEX/PH. In addition, we received much assistance from Bernard J. Turnock, M.D., M.P.H., then Director of the Illinois Department of Public Health (IDPH) and Ms. J.J. Ellinger, Associate Director, Office of Health Policy and Planning (IDPH) and their staff, particularly in the provision of appropriate data and its analysis. At the beginning of this process, and during each stage, all staff of the agency were aware, informed, and able to input to the activities being undertaken. However, only the senior staff were directly involved in the final development of the CHP. The early involvement of staff made the process more meaningful for the agency as it brought everyone together and fostered a sense of ownership and a desire to "make it work." The IDPH provided us with demographic, socioeconomic, and environmental profiles for our jurisdiction. Causes of death which contributed most to premature mortality, weighted by age at death were also calculated for our area. This data set provided us with actual statistics pertinent to our community. Additional data from local sources was also developed. The next step taken in the process was to analyze the data we had received and developed, identify problems, and continue to build on the APEX/PH Model. Staff of the department worked together to analyze the data and discuss the sources responsible for the health problems identified. Following the problem identification process, a community health committee was established to review these health problems and recommend areas to be targeted for further study. Members of the committee consisted of educators, a physician, individuals from other health and community organizations, and members of the general public. Through focus groups, key informant interviews, surveys, and one-on-one interviews, a repository of information was collected. The community health committee analyzed the compiled data, reviewed the opinions in the interviews and surveys, and discussed the areas which were perceived as health problems in the jurisdiction but did not have substantial data to back up the perception. As suggested in the APEX/PH format, a method to establish priorities which was fair, reasonable and easy was necessary in order to evaluate each health problem fairly and accurately. A modified Hanlon Method was employed for prioritizing. Each problem was reviewed and analyzed in three areas. The first area was the size of the problem. A score of 0-10 was assigned to each problem which reflected the impact that particular health problem had on the targeted population. A score of 0 indicated that the problem had an impact on less than .01% of the population, while a score of 10 indicated that the problem affected 25% or more of the entire population in the jurisdiction. The second area analyzed in determining priorities was the seriousness of the problem. Again, the 0-10 scale was used with problems emergent in nature ranking higher on the scale than those related to economic losses, etc. The score determined appropriate in this area was doubled to reflect the intensity of this area. The third and final area that was used to determine priorities was the area of effectiveness of intervention. Staff members involved in the prioritizing process were asked to rank the problem on the basis of how effective we could be in eliminating the problem should we choose it as a high priority health problem. A score of 0 represented that the intervention measure would be less than 5% effective in preventing the health problem. A score of 9 or 10 would reflect an effectiveness rate of 80% to 100%. Completing this exercise did not conclude the prioritizing process. The involved staff continued the process by assessing each health problem using the PEARL Test. Each problem was assessed for propriety--Is this a health problem? The economic aspects of the problem were discussed to determine if it was economically appropriate for the health department to address the problem. Opinions were presented regarding the acceptability of the intervention into the jurisdiction. Resource availability was discussed and finally ideas regarding the legalities involved regarding intervention measures were presented. All of these steps were necessary in order to prioritize problems in a fair and accurate manner. The community health committee and senior health department personnel jointly discussed the areas selected as priorities and determined strategies to address the prioritized needs. An interesting blend of insights and opinions developed through the integration of public health staff and professionals in other disciplines. A final prioritizing process was completed through open discussions and substantiated evidence collected in each groups prioritizing process. Primary health problems in our jurisdiction were identified through an extensive, collaborative process resulting in an accurate analysis of the area. To complete the APEX/PH process, both the community health committee and the public health department personnel involved in the project completed an analysis of each identified problem. The analysis consisted of listing determinant risk factors associated with the health problem, direct contributing factors associated with the health problem and indirect contributing factors of the identified problem. Through this process, the committee was then able to develop a CHP based upon the year 2000 objectives. The final plan consisted of an outcome objective related to each health problem identified as a priority. Impact objectives and process objectives were also written to reflect proposed activities to reduce the level of the contributing factors resulting in the reduction of the health problem. All involved in the group were delegated assignments to address the goals the plan outlined. The CHP has been presented to the Board of Health for adoption. It is apparent that careful planning is vital to developing community-wide intervention strategies. The APEX/PH process not only directed our department in preparing a plan for the future, but the process itself enhanced the linkages we had with other agencies and the general public. As a result, we now have a union of dedicated citizens and public health personnel working toward a common goal with a true sense of ownership and commitment to achieving the goals set forth in the plan. I encourage any department to work through the process and believe that each one will find the effort a rewarding experience. THE ILLINOIS PUBLIC HEALTH LEADERSHIP INSTITUTE'S YEAR 2 INITIATIVE Elaine Jurkowski, M.S.W. The Illinois Public Health Leadership Institute, in its efforts to assist state and local public health department practitioners develop greater organizational effectiveness, kicked off its Year 2 Institute, in Geneva, Illinois, with a four-day training Institute. The rustic fall colors, combined with the historic ambiance of the Harrington Hotel/Riverwalk Conference Center, set the stage for four days of leadership nurturing and development. The Institute experience was comprised of a variety of training strategies to include case studies, panel discussions, presentations, and small group discussions. The speakers, who represented some of our nation's most influential personalities within the public health arena, set the stage for thoughtful, provocative, and challenging discussions for all participants. C. Arden Miller, M.D., the grandfather of public health core functions and organizational practices, shared insights on the effective application of these within the public health arena. Vaughn Upshaw, M.P.H., a governance consultant, interwove the critical dimensions of governance and its role in public health departments in her presentation, "Effective Public Health Leadership and Governance." Dr. Louis Rowitz, in his "Overview of the Core Functions and Organizational Practices Within a Model of Leadership Development," sensitized participants to the critical role leadership plays within health reform and the public health arena. The session also reinforced the use of the three core functions and ten organizational practices within public health's strategies and mission. "Letterman Style Leadership" describes the style for Dr. Turnock's presentation on the "Top Ten Reasons Why We Need Effective Public Health Leadership." Although this presentation injected definite levity, it also made some critical points about what is lacking within Illinois' cadre of leaders within public health. Leadership theories and their relationship with individual practice was the theme in Dr. Mary Dwyer's presentation on "An Overview of Leadership Theories and Their Relationship to Public Health." This presentation evoked participants to also challenge their perception of gender and leadership. "TQM Within Strategic Planning," critical tools for any leader and manager, regardless of discipline, was highlighted in an energetic workshop by "Management by Design." Kim Ogden-Avrutik and her cohort, Gerry Tobias, framed the concepts of TQM for Public Health and provided a tool kit filled with a potpourri of TQM tools. The intimacy and informality of "Chianti-Restarante" set by focus group leaders Judy Munson, Linda Edwards, and C. Louise Brown, examining "Cultural Diversity in Leadership," created a "safe" group for stories about participants' vulnerabilities as a minority within leadership capacities. Minorities to include gender, race, and language were addressed, and stories shared by participants reflected a definite need for further expos‚ of this critical, sensitive area. Dr. Randy Gordon, representing the Centers for Disease Control in Atlanta, offered an interactive presentation on "The Assessment Role in Practice." His presentation, coupled with Dr. Stephen Joseph's presentation on "Policy Development Practices," established a venue to explore creating organizational effectiveness through the core functions. Dr. Reed Tuxson's energizing presentation on "Assurance Practices: The Assurance Role in Practice in Leadership," not only stimulated participants to consider how they exercise the assurance role within their home agencies, but challenged participants to rethink their strategies. Tuxson's message inspired all to develop creative, new, risk-oriented approaches to assurance through community collaboration. Dr. Marty Wassermann, the author of the Policy Development case used within the Institute, spent an informal evening expanding on his case and experience as a local health officer enacting policy. His story and experiences can be compared to the feelings of children, inspired by the challenging deeds of their elders. Although the three days moved quickly, the activities and opportunities for networking, discussion, fellowship, and dialogue created a cadre of energetic and invigorated public health practitioners. The actual event is one of a series which will occur as a component of the Fellowship training process sponsored by the Illinois Public Health Leadership Institute. Please note: All sessions are available on videotape for viewing. Contact the Leadership Office at 312-996-3658 for further details. AN OVERVIEW OF THE 12-MONTH MEETING Elaine Jurkowski, M.S.W. Managers are people who do things right; leaders are people who do the right thing. Both roles are crucial, but they differ profoundly. -Warren Bennis Bennis' words reflect the tone for the final stage of the year-long Training Institute's twelve month meeting, which was designed to foster skill development, further leadership growth, and affirm the skills of leadership. Looking around at the world faced by the day-to-day functions of leaders in public health, led to the development of the twelve-month agenda. Clinton's Health Reform package, which has been the theme and pervading thoughts within state and local health departments, was addressed by Linda Murray, M.D., M.P.H. Dr. Murray presented some of the thinking of the day, of the proposed Health Plan and its impact for state and local health departments. Her energetic, thought-provoking presentation lent itself to informed discussion on the Health Reform package. The evening concluded with a roundtable discussion which enabled participants to assimilate and synthesize the readings and materials presented throughout the year into practical application. Dr. Rowitz set the tone the following day with his presentation on "The Role of Paradigm Shifts and Leadership." Dr. Rowitz attempted to "Challenge the Process" with shifts in paradigms to challenge the "status quo." Meeting the Healthy People 2000 objectives cannot easily occur without the adoption and use of Model Standards within state and local health department settings. Shirley Randolph, APHA's Speaker of the House, presented an overview of APHA's model standards in her presentation, "The Role of Model Standards Within Organizational Practices and Effective Leadership." Patrick Lenihan, Deputy Commissioner, Chicago Department of Health (CDOH), revisited Dr. George Pickett's concepts of transorganizational leadership and tied it into its role within community health planning. His presentation on Community Health Planning, incorporating a "Transorganizational Approach to Planning," presented a conceptual framework, with practical application through examples of CDOH's AIDS intervention scheme. The afternoon session focused upon a review of the cases prepared by Fellows, and an overview of the impacts the Leadership development process has had for Fellows. The afternoon wrapped up with the development of an Alumni core working group. Polly Daly, Dale Galassie, Georgeen Polyk, and Valerie Webb will serve as representatives on this Alumni committee. YEAR ONE FELLOWS CELEBRATE! Celebrations are critical for transitions, and the recognition of effort put forward are an integral component of Kouzes and Posner's leadership practice, "Encouraging the Heart." In order to celebrate the end of a successful academic year, a graduation ceremony was held in conjunction with the Illinois Public Health Association Conference (IPHA) on September 27, 1993. Fellows were recognized among their peers with a certificate presented by Dr. Louis Rowitz and Dr. Barney Turnock, Directors of the Leadership Institute. In addition, each Fellow received a "report card" which highlighted their own growth over the past year, based upon the Kouzes and Posner Leadership Practices Inventory. Also, Year 1 and Year 2 Fellows had an opportunity to meet their "buddy" for the upcoming year. An alumni group will be formed, and plans are underway to host a training workshop at subsequent IPHA meetings. NEWS & NOTES The Illinois Public Health Leadership Institute proudly congratulates their second cadre of Fellows. A competitive selection process held earlier this year yielded a second cadre of Fellows for the second academic year of the Illinois Public Health Leadership Institute. This successful group of participants include the following individuals: Julie Aamot, Adams County Health Department Celan Alo, MD, Illinois Department of Public Health Connie Ament, Kane County Health Department Janice Attala, St. Clair County Health Department Connie Brooks, DuPage County Health Department Brian Chapman, Chicago Department of Health Joann Chiakulas, Illinois Department of Public Health Danny Davis, Cook County Commissioner Marjorie Ebenezer, Cook County Department of Public Health Raymond Empereur, Lake County Health Department Sandra Ernat, Hygenic Institute & Putnam County Board of Health Alina Fernandez, Chicago Department of Public Health Ester Joo, Illinois Department of Public Health Connie Keelin, Livingston County Health Department Patti Kimmel, Illinois Department of Public Health Cynthia Marvin, Peoria City/County Health Department William Mays, Lake County Health Department Kathleen McDunn, Cook County Department of Health Lennette Meredith, Chicago Department of Health Sharon Mumford, Southern Seven Health Department Peggy Ann Murphy, Jo Davies County Health Department D. Keith Rowley, Illinois Department of Public Health Caryl Safford, DuPage County Health Department Karen Seals, Evanston City Health Department Steven Seweryn, Cook County Department of Public Health Marcos Sunga, MD, Southern Seven Health Department, Board of Health Stan Szczap, DuPage County Health Department Kent Tarro, Macoupin County Health Department Michael Tryon, McHenry County Department of Health, Board of Health Mark Vassmer, Illinois Department of Public Health James Zelko, Will County Health Department In addition, these Fellows will be led by six illustrious Mentors who were selected from a pool of nominees. Congratulations are in order to: C. Louise Brown, Evanston Health Department Richard Grabher, Illinois Department of Public Health Rev. E. Hagemann, President, Illinois Association of Boards of Health Gene Mann, Adams County Health Department Judith Munson, JD, Illinois Department of Public Health Jeff Todd, Illinois Public Health Association Linda Edwards, PhD, Rush University Scholarship recipients for the Leadership Institute's Fellowship Program were awarded to: Janice Attala, St. Clair County Board of Health; Connie Keelin, Livingston County Health Department; Peggi Ann Maher, Boone County Health Department; and Lennette Meredith, Chicago Department of Health. Once again, a special thank you to the sponsoring organizations--namely, The Illinois Association of Boards of Health, The Public Health Administrators Association, and The Illinois Association of Nurse Administrators. Kouzes and Posner's Leadership Practices of "inspiring a shared vision" and "enabling others to act" are two practices which year one Fellow graduates are currently aspiring to facilitate. Lloyd Evans, Executive Director, Logan County Health Department, has recently accepted the challenge to perpetuate the tenets of his leadership training through the Illinois Association of Public Health Administrators. He is currently chairing an Ad Hoc Mentor committee which is looking at cloning the Institute's mentoring model among state health administrators. The initial phase of this project surveyed the organization's membership, who thought this was definitely a good idea. "The mentoring concept allows the new administrator to benefit from the cultivated experience of a seasoned administrator," comments Evans. ANNOUNCEMENTS Welcome!!! The Illinois Public Health Leadership Institute welcomes two new staff members! Diane Knizner, formerly executive assistant to the Deans' Office at the UIC School of Public Health, has joined the Institute to serve as Project Manager. Also, David Belding has joined the Institute to assist in the evaluation components of the program. Farewell. . . Farewell to Ruth Kafensztok, who coordinated surveys and evaluations. Ruth has moved on to share her expertise with the Midwest Latino Health, Research, Training and Policy Center for Medical Treatment Effectiveness Program (UIC Midwest Latina METEP Center). All the best of luck to you, Ruth, in your future endeavors! Ten Secrets of Successful Leadership (Rowitz, 1993) 1. Knowledge 2. Creativity 3. Commitment to a mission 4. Collaboration 5. Entrepreneurial ability 6. Interpreter of information 7. Sets priorities 8. Coalition and team building 9. Excellent management skills 10. Colleague/friend/humanitarian . . . It's coming!!! An upcoming benefit is planned. Look for more details in our next newsletter. . . . They're here!!! See and hear public health leaders talking about topics relevant to your work! Videotapes of the Leadership Institute's conference speakers are now available for rental. Among the featured speakers are: George Pickett speaking on "Public Health Leaders...Of What?"; Bernard Turnock on "The Top Ten Reasons Why We Need Public Health Leadership"; Louis Rowitz on "The Importance of Paradigm Shifts and Leadership"; Shirley Randolph on "The Role of Model Standards Within Organizational Practices and Effective Leadership"; Patrick Lenihan on "Community Health Planning--Incorporating a Transorganizational Approach to Planning"; Margaret Hastings on "Policy Development Practices"; Jocelyn Elders on "The Community Role in Leadership"; and talks by Bill Dyal, Mary Dwyer, Joseph Begando, and Meg Yoak. Contact Beth McQuie at the Leadership Institute (312-996-3658) for more information. We are pleased to announce that the pioneering case study manual in the field of public health will soon be available for purchase. The manual, an outgrowth of the training model devised for the Leadership Institute, contains the guidelines and protocol for case study development, as well as three case studies based on actual public health situations. The cost will be $24.95, which includes shipping and handling; volume discounts will be available. Authors of the cases are Kristine Gebbie, Lillian Mood, and Bailus Walker, Jr. The manual is edited by Judith W. Munson, J.D., staff attorney at the Illinois Department of Public Health and a faculty/staff/mentor of the Leadership Institute. For more information, contact Beth McQuie at the Leadership Institute (312-996-3658). TABLE OF CONTENTS Community Health Planning: A Review of the Literature Re-Inventing Community Health Planning Community Health Planning at the Local Level Using APEX A Leadership Coffee Break with Claude H. Hall, Jr. Book Review: The Fifth Discipline: The Art of Practice of the Learning Organization Ford-Iroquois Public Health Department Community Health Planning Illinois Public Health Leadership Institute's Year 2 Initiative Overview of the 12-Month Meeting Year One Fellows Celebrate News & Notes/Announcements Subscription Information Editors: Louis Rowitz, Ph.D. Naomi Klein, M.P.H. Writers: Elaine Jurkowski, M.S.W. Shirley Randolph, M.S.P.H. Contributors: Terry Altman J. Maichle Bacon Joel Cowan Deane Johnson Patrick Lenihan Joe Orthoefer John Pickering, D.Man.M.S. SUBSCRIPTION INFORMATION Attention Interested Subscribers Leadership--The Illinois Public Health Leadership Institute Newsletter will be moving to subscription in February, 1993. The annual subscription fee will be $15 and a fee of $4 will be charged for individual issues. Additional copies of five or more will be at a charge of $2 per copy. Subscribe now and receive a one year free subscription to the cultural Diversity/Minority Health in Illinois Newsletter and the Illinois Morbidity and Mortality Quarterly Report. If you want to subscribe, please fill out the form below and mail to: The Illinois Public Health Leadership Institute Office The University of Illinois at Chicago School of Public Health (M/C 922) 2121 W. Taylor Street, Room 216B Chicago, Illinois 60612 Name _________________________________________________________________________ Title ________________________________________________________________________ Company/Institution __________________________________________________________ Address ______________________________________________________________________ City ________________________________________ State ___________ Zip ________ Enclosed please find my check in the amount of $15 for an annual subscription to Leadership. Make check payable to The University of Illinois.