By contrast, the Government Accountability Office (GAO) has observed that it generally takes government entities five to seven years to successfully complete major change initiatives (GAO, 2004).

Although most recent secretaries caution against embarking on a major reorganization, even a secretary who wanted to do so would encounter the growing number of restrictions Congress has placed over departmental operations, job descriptions, and details of program delivery. Negotiating those restrictions—many of them statutory—would be another lengthy process of uncertain outcome (see Appendix G).

Even without major structural change in the department, the committee saw many opportunities for improved alignment and performance and for building more value into departmental operations. As noted, HHS is a large, complex enterprise with many constituencies, each of which wishes that the department’s activities and performance would meet its particular needs; collectively, these external forces create the complex environment that the secretary must skillfully navigate.

Organizational management literature is replete with advice and tools related to improving efficiency and effectiveness. A widely used management framework that the IOM committee found useful during its deliberations takes into account the following seven essential elements, distilled from research in the private sector (Waterman et al., 1980):

1. Strategy—the ways in which an organization achieves its ends

2. Structure—how tasks and people are organized to accomplish the work and what they are responsible for

3. Systems—the formal processes and procedures the organization uses to plan, allocate resources, measure performance, manage information, and so on

4. Staff—the organization’s human resources

5. Skills—its distinctive attributes and capabilities

6. Style—how both top management and the overall organization operate