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7 The Transition Once you get the ear of a politician, you get something real. The highbrows can talk forever and nothing hap- pens. People smile benignly on them and let it go. But once the politician gets an idea, he deals in getting things done. Many are extraordinarily able in devising political plans that hold water, not only in the matter of votes but administratively. Frances Perkins 1 Discussions about the role of the secretary in leading a department as large, diverse, and complex as HHSâand preparing it to meet twenty- first century challengesâvividly illustrated for committee members the difficulty of the position. Yet, every few years, a new individual must take up the task, expeditiously learning from predecessors and stake- holders in a process that might unfold like the scenario presented in Box 7-1. The recommendations in the preceding chapters of this report present a secretary with a long agenda, and no clear indication of what should be done today, next week, next month, or next year. This chapter is not meant to be a rigid blueprint and was not part of the committeeâs state- ment of task. But, understanding how important the transition period for new secretaries is, and how much they must do in a short time to âhit the ground running,â the committee believed it necessary to translate some of its general thinkingâabout creating value, about vision and goals, about alignment and accountability, about workforce, and about the other topics that were subjects of its recommendationsâinto tangible sugges- tions for action. 1 Frances Perkins, âThe Roots of Social Security,â address delivered at the Social Secu- rity Administration, Baltimore, Maryland (October 23, 1962). Perkins, the first female Cabinet member, was secretary of labor during the entirety of Franklin Rooseveltâs presi- dency and a chief architect of Social Security. 147
148 HHS IN THE 21ST CENTURY BOX 7-1 The Secretary-DesignateâA Scenario The phone rings, and a senior leader in U.S. domestic or health policy, relax- ing at home on the Saturday evening after Thanksgiving, answers. The Presi- dent-elect is calling to ask this widely respected individual to serve as the twenty-first secretary of the U.S. Department of Health and Human Services. The request elicits an enthusiastic, âI will be honored to serve.â Even though this call was not a surprise, the new secretary-designate feels a mix of excitement and trepidation. The excitement comes from having the opportunity to bring direction and transformative ideas to the $2 trillion health sector. The trepidation lies in the challenge of bringing order to a de- partment with a $737 billion budget and 300 programs. Soon the briefing process is under way. The appointee must simultane- ously prepare to lead the department and for confirmation hearings: â The appointee listens carefully to current agency heads and many oth- ers, learning innumerable details about the current organization and leadership of the 65,000-person department. â Courtesy visits to Capitol Hill are arranged, and it feels as if the political aspects of the job are building to hurricane force. The appointee hears from many interest groups voicing suggestions about changing pro- grams and operations and warnings against creating new levels of bu- reaucracy and splitting up or combining agencies. â Mounds of reports, memoranda, budgets, organizational charts, and academic papers shape the topography of the secretary-designateâs temporary Washington office. â The appointee focuses on developing the departmentâs budget for the next fiscal yearâthe largest budget of any agency in the history of the United States or, for that matter, any other country. â The appointee interviews candidates for the team that will run the de- partment. Some current executives want to stayânot always the most ef- fective ones; interest groups recommend various candidates; congressional committee chairs propose their top aides; and the Presi- dent-electâs transition team and others put forward individuals, some with little familiarity with the substance of health policy or the health sci- ences. By January 19, the next secretary has barely had time to think. But that day, the Senate recognizes the appointeeâs round-the-clock preparations with a vote in favor of confirmationâa signal of confidence in the nomineeâs ability to make a positive difference. The next day, as the new chief architect of U.S. health policy, the appointee attends the inaugural ceremony, and somberly takes the oath of office in the presence of immediate family. Then the real work begins.
THE TRANSITION 149 TRANSITION STEPS Table 7-1 presents informal advice for achieving a successful transi- tion to a new secretaryâs tenure. Most of the steps correspond to recom- mendations contained in this report or originated in discussions of the committee or the summary of interviews with former secretaries, in- cluded as Appendix G.
TABLE 7-1 Transition Steps 150 Step Initial Steps: The First 90 Days Remarks 1 Build the team (Chapters 3 and 5). Organize and staff the Office of the Secretary and make key appointments. Set a standard of excellence, ensuring scientific and administrative integrity; include career officials to build trust and use knowledge; hold regular meetings to jointly review budget and operations; pro- mote long fixed terms for key science heads. 2 Determine early policy priorities (Chapter 2). These will drive âfirst 100 daysâ decisions and first-year budget, which is likely the best opportunity for initiating major program reforms and will set the standard for fu- ture budgets. Priorities should reflect a consensus of top HHS officials, the White House, and Office of Manage- ment and Budget, and should include strategies for health reform. 3 Engage with Congress (Chapter 6). Begin dialog with Congress around the ânew compact.â What is desired and feasible in terms of accountability for key goals, including making progress on health reform, in exchange for greater flexibility? Encourage the Senate to expedite confirmation hearing for agency heads. 4 Initiate assessment of key challenges and process to define vi- Too many interests will be involved to complete this sion, mission, and goals (Chapter 2). strategic planning work quickly, but it should be con- ducted expeditiouslyâofficials should treat this as a pri- ority. Reach out to an array of key individuals within and outside government. Use a variety of communications media to build support around challenges and priorities. 5 Align the team with the initial policy priorities and, when devel- Practice effective internal communications about chal- oped, the vision, mission, and goals (Chapter 3). lenges and priorities. All agency heads and program di- rectors should be accountable for ensuring alignment. Identify gaps and overlap among programs.
6 Establish a process for making policy and operational decisions Put into place a decision-making process that is rigorous, (Chapter 3). clear, efficient, and establishes accountability for results. 7 Commission work on the analytic framework for department- Start teams on specific tasksâe.g., assessing utility and wide data, evaluation, and information system (Chapter 6). overlap of data already collected across agencies, elimi- nate duplicative or underused data; develop feedback loops so that agencies that can use data from another departmental unit can receive it; initiate discussions with other public- and private-sector entities that collect re- lated information on data sharing. Involve privacy experts from the beginning. 8 Commission development of an HHS workforce development The department is only as good as its people, and an ade- strategy (Chapter 5). quate pipeline for recruiting highly qualified staff must be ensured. Step Intermediate Steps: The First Year in Office Remarks 1 Complete assessment of key challenges and process to define and Be as inclusive as possible in order to secure buy-in and promulgate vision, mission, and goals (Chapter 2). increase the likelihood that the vision, mission, and goals will be lasting; set the stage for building coalitions. 2 Reorganize HHS structure if necessary (Chapter 3). The presumption in this report is against major reorgani- zation, but some change may be needed to meet goals and align operations. Reorganization efforts suggested include reducing the number of positions reporting directly to the secretary, and unifying FDA and USDA food safety ac- tivities within HHS. continued 151
3 Work with the White House and Congress from the outset of Health reform cannot be successfully achieved without 152 health reform efforts (Chapter 2). the cooperation of the White House, Congress, and the department. The department should play a major role in national health reform efforts because it will ultimately inherit the responsibility of implementing any health reform legislation that is enacted. 4 Review plans and obtain funding for an improved information Commission rapid review of the current information sys- system (Chapter 6). tem; identify reporting capacity needed and gaps in capa- bilities; develop a plan for investments and staging, with attention to security, simplified access, and usability, among other priorities. 5 Seek to secure predictable funding of the science agencies (Chap- The NIH, CDC, FDA, and AHRQ must be able to under- ter 3). write multiyear investigations and campaigns. 6 Evaluate the state of public health, and ensure its vitality and Conduct a review of the adequacy of the public health strength (Chapters 3 and 5). workforce, and charge agency heads to review how pub- lic health principles, including health promotion and dis- ease prevention, can be more fully integrated into their activities. 7 Evaluate the state of science in HHS, and ensure its vitality and Constant threats are that the scientific workforce will lack strength (Chapters 3 and 5). the resources and credibility necessary to engage private- sector scientists authoritatively, that agency decisions will reflect politically preferred social values rather than valid and reliable findings, and that programs will calcify rather than adjust to new findings and demonstrated best practices. 8 Develop a strategy for assessing value in health services Establish a plan to review current public and private ef- (Chapter 4). forts assessing the costs, effectiveness, and impacts of different preventive and treatment methods and ways of organizing care as a first step in identifying opportunities
for integrating data and gaps in information. Develop a plan for moving forward on highest priority topics. 9 Develop or review the national strategy on the HHS and health Assess problems in numbers, geographic location, spe- workforce (Chapter 5). cialty mix, and diversity of health professionals and re- searchers, including the performance of health professions training programs in resolving these imbal- ances. Within the department, make it easier for private- sector experts to spend time in HHS and for HHS senior staff to gain private-sector experience and other means to maintain the vigor of the departmentâs senior workforce. 10 Simplify operations (Chapter 6). Examine HHS programs from the perspective of indi- viduals who use themâhealth care providers, state and local health departments, researchers, patients and fami- lies, manufacturers and distributors of regulated products, and so on. 11 Prepare first âHealth of the Nationâ report (Chapter 6). This year and thereafter, a concise report to Congress provides an opportunity to talk about progress toward the vision for the nationâs health, resolving key health chal- lenges and barriers to further improvements. Steps Toward Continuity: Throughout The Step Secretaryâs Tenure Remarks 1 Continuously insist on alignment (Chapters 2 and 3). The tendency will be for programs to fall out of align- ment. 2 Maintain policy and operational decision-making processes Clear consistent decision-making processes will be re- throughout all programs (Chapter 3). quired throughout the secretaryâs tenure so that decisions are responsive, timely, and contribute to the departmentâs accountability for results. continued 153
3 Promote coordination between public health and health care Medicare and Medicaid reimbursement should not con- 154 (Chapter 3). flict with evidence-based public health strategies. 4 Work closely with Congress and the White House as national The department should provide leadership by making health reform options are developed (Chapter 2). departmental data available to inform reform options, facilitating the assessment of options, providing depart- mental resources to help resolve problems, communicat- ing to the public, and implementing enacted reform legislation. 5 Treat state and local health departments as partners (Chapters 3 Technical assistance sometimes will be needed to help and 4). state and local agencies meet HHS expectations, and two- way communication will help ensure that HHS programs are practical and implemented. 6 Launch the new data system (Chapter 6). Phase in access by user categories. Include data from other public and private sources, and continue to seek feedback on usability and usefulness. 7 Use plain language in documents and communications Department communications should be culturally compe- (Chapter 4). tent, jargon free, and avoid legalistic language; strategic communications should be part of the secretaryâs plan- ning and policy process at all times. 8 Promote electronic information capabilities, including electronic Help the health care system move into the twenty-first health records (Chapters 4 and 5). century; this can be done through public-private partner- ships, incentives or, if necessary, federal mandates.
9 Reward staff performance and innovation (Chapter 5). This will require a systematic approach and constant ne- gotiations with the Office of Personnel Management and other authorities. 10 Invest in the training of biomedical and health researchers of all In large measure, this is the future of the nation. disciplines (Chapter 5). 11 Continue emphasis on âvalueâ in health care (Chapter 4). As new study findings emerge, ensure that they are pre- sented to providers and the public in easily usable form; continue work with public- and private-sector entities to encourage ongoing research in key areas. 12 Continue reporting to Congress on the health of the nation This opportunity to engage Congress in the progress (Chapter 6). made in reaching departmental goals is important in achieving greater accountability for the department, a cornerstone of the new compact with Congress. 155
156 HHS IN THE 21ST CENTURY Throughout this report, the committee has acknowledged the tremendous challenges facing the men and women who agree to serve as secretary of HHS. Yet, the importance of these challenges offers strong motivation to accept such a difficult role. The committeeâs goal was to make the secretaryâs work easier and to ensure that incumbents could be successful, through adoption of some general principles woven intoâ and throughoutâthe foregoing recommendations. â¢ Simplify competing prioritiesâThe department has so many current and potential responsibilities that the secretaryâs ability to lead a high-performance department is in jeopardy. A compelling and widely agreed-upon vision for the nationâs health, mission, and goals will help the secretary and the department focus on the most important work. â¢ Build consensus on goalsâBroad agreement about goalsâand greater accountability for achieving themâshould reduce external pressure, including from Congress, to take on âone more responsibilityââespecially without the resources necessary to meet it. With current budgets, only so much can be realistically accomplished. â¢ Rely heavily on âbest evidenceââAnother way to focus efforts is by looking to science and research for guidance. Policy decisions should be made, insofar as possible, based on evidence of what works. Decisions about program design, implementation, and continuation similarly should be based on evidence of what worksâthus the importance of the proposed accountability system. Where scientific opinions differ, the department must have a credible, transparent mechanism for resolving disputes. â¢ Use department leverage to improve the health care systemâ The department has unequalled influence over the nationâs entire health care system and needs to use that leverage to encourage (a) systemwide use of the most effective and efficient prevention and treatment modalities and mechanisms for delivery of care (âbuilding value into the systemâ), (b) implementation of health information technology, and (c) an emphasis on health promotion, disease prevention, and primary care. â¢ Seek meaningful, broad-reaching health reformâInevitably the department will be drawn into planning for health reform. Its data and expertise will make essential contributions. A primary focus of health reform discussions will be ways to control costs,
THE TRANSITION 157 and the secretary must ensure that reform ideas are comprehensive and address how to improve care, not just pay for it. At the same time, the secretary must ensure that the system that results continues to serve Americans who are elderly, disabled, and poor. â¢ Look for partners everywhereâTodayâs health challenges require new, more effective collaborationsâwith Congress, with the White House and other federal departments, with state and local government and public health agencies, with health care professionals and providers, with health care leaders worldwide, with the private sector, and with the public.