As noted previously, HHS already receives considerable oversight from multiple organizations—the White House and the Office of Management and Budget, various congressional committees, and even the public- and private-sector stakeholders involved in the delivery of medical care or committed to the health of the public. These groups each have their own agendas and interests and rarely coordinate—and sometimes compete—with each other. The burden of meeting all these demands can make agencies reluctant to engage in a new process, even if it is better, unless it reduces other reporting requirements.

A collateral benefit of the IOM committee’s recommendation that the secretary attempt to build broad consensus around a strong set of longer-term goals would be to counter the tendency of some outside stakeholders to focus on immediate or narrow issues. Shifting this perspective will be difficult, but stakeholders’ understanding and buy-in for at least some longer-term goals could go a long way toward preventing the constant pull of short-term concerns that distract from long-term priorities.

Long-term goals and explicit strategies for meeting them are essential to high performance, as is an appropriate framework for measuring progress. Strategy, one of the “essential management elements” the committee considered, requires government officials to thoroughly consider alternatives, make explicit choices, then marshal resources—time, money, and people—to implement them, whether the goal is to improve department operations and managing costs, or the more ambitious “value creation” discussed in Chapter 4. Measurable goals and time-specific milestones are particularly important in the department’s work, since most of the major issues the department faces are inevitably long-term, and its strategies may take a number of years to unfold.

Development of solid strategies may be more feasible as HHS secretaries’ tenures are becoming longer. People who expect to hold appointed positions for only a year or two are unlikely to launch laborious strategic development and implementation processes that will play out long after their departure. This holds equally true within agencies whose leaders are appointed. The laborious federal appointment process that frequently keeps key positions vacant or with acting directors for months at a time not only hinders HHS performance, but also militates against accountability.7


The length of time it takes to fill an administration’s top 500 jobs has steadily risen. In the Kennedy administration (1960), it took 2.4 months; in the Bush administration (2000), it took 8.7 months (NRC, 2008).

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