5
Leadership Commitment
to Workforce Health
“Health programs are most effective when organizations are ideologically and practically committed to supporting them, and when their successful execution is built into the very framework of the overall mission.”
—National Business Group on Health (2006, p. 2)
The importance of leadership commitment to the health of the workforce cannot be overstated. In contrast with the military and other organizations in which senior leadership has risen through the ranks, agency heads in civilian federal agencies are political appointees, many of whom have never worked within that organization or even the federal government. Thus they lack an intimate knowledge of workforce issues within the organization. Additionally, as political appointees, their time in office usually is quite limited, so efforts may be focused on a few key agenda items. This political reality is unlikely to change; nonetheless, a Secretary who recognizes the critical importance of a healthy, high-functioning workforce has the opportunity to enable the creation of safety and health policies and processes that can endure, eventually catalyzing the transformation to a culture of health that is itself resilient in the face of the dynamic nature of agency leadership. This chapter provides an overview of the current strategic approach to workforce health at the Department of Homeland Security (DHS) and makes the case for a new workforce health protection strategy guided by a unified vision and supported by deeply committed senior leadership.
THE NEED FOR COMMITTED LEADERSHIP
Commitment of high-level leadership is crucial to the development, implementation, and sustainability of all organizational initiatives, including those related to workforce health. As discussed in Chapter 3, leadership commitment has played an important role in the development of successful
workforce health protection programs in the government agencies and private organizations examined by the committee. So, too, can departmental leadership committed to the workforce help institute a culture of health throughout DHS. Without committed leaders, workforce health programs may lag behind other initiatives deemed more important to leadership.
Although commitment of leaders at the highest levels is critical to creating a lasting program, such an endeavor cannot succeed without the commitment of leadership on the ground. As noted by the National Institute for Occupational Safety and Health (NIOSH) (2008, p. 1), supervisors and managers at all levels “are the direct links between the workers and upper management and will determine if the program succeeds or fails,” and therefore must be engaged in the process. High-level leadership that demonstrates vocal and active commitment to protecting workforce health will help initiate a culture of health throughout the department, while leaders that interact with the workforce will help diffuse and sustain such a culture.
THE CURRENT STRATEGIC APPROACH TO WORKFORCE HEALTH AT DHS
Although merged under the DHS umbrella, component agencies operate in a decentralized manner. The desire for autonomy to fulfill unique mission requirements creates tension between components and headquarters elements. The role for departmental leadership, then, is to ensure that components unite around a common mission. As described in the Department of Homeland Security Strategic Plan: Fiscal Years 2012-2016 (DHS, 2012, p. 2), the vision that guides the department is “a homeland that is safe, secure, and resilient against terrorism and other hazards.” To ensure that this vision is realized, DHS has five specific missions: to prevent terrorism and enhance security, to secure and manage the nation’s borders, to enforce and administer the nation’s immigration laws, to protect cyber networks and critical infrastructure, and to build resilience to disasters (DHS, 2012). Each of the operating components contributes to one or more of these missions.
The accomplishment of these missions requires a strong and mature DHS. A 2010 DHS bottom-up review identified as one of three principal areas for focus the need “to strengthen the department’s ability to execute its mission responsibilities, run itself, and account for the resources that have been entrusted to it” (DHS, 2010a, p. 2). Meeting this need requires efforts to improve management, policy, and functional integration, but also to ensure that the DHS workforce is engaged and ready to carry out the above missions. To this end, the Strategic Plan includes a goal to enhance the DHS workforce by improving employee health, wellness, and resilience. Under this goal, five expectations are listed:
- Sustain established programs like the DHSTogether employee and organizational resilience initiative.
- Implement Workplace Wellness programs, including employee resilience training.
- Create a standardized, metrics-driven health program to support the unique needs of our operational workforce.
- Implement frontline medical programs to support operational missions, staffed and supported with appropriate training and equipment.
- Establish a department program to harness the insights and innovations of the DHS workforce. (DHS, 2012, p. 25)
Cascading from the DHS Strategic Plan are the goals laid out in the Office of Health Affairs’ (OHA’s) Strategic Framework, one of which is to “protect the DHS workforce against health threats” (DHS, 2010b, p. 19). Under this goal, strategic objectives for OHA include
- unifying and standardizing the occupational health and workforce health protection activities across the department, which includes consolidating occupational medicine contracts, administering a department-wide medical quality assurance program, and developing guidance for personnel programs (fitness-for-duty, return-to-work, medical screening, and immunization programs and medical exam protocols);
- building resilience across the DHS workforce; and
- supporting DHS operational medical forces.
Germaine to this report as well is OHA’s goal to “provide expert health and medical advice to DHS leadership” (DHS, 2010b, p. 12). In addition to providing advice to the Secretary and the Federal Emergency Management Agency (FEMA) Administrator, as required by statute, OHA provides policies and guidance to DHS components regarding the quality and standards of the health care offered by the department to those in its workforce, as well as to those in its care or custody.
The authority of the Chief Medical Officer (CMO) to deliver on the above objectives, goals, and strategies was initially provided in DHS (2008) Delegation #5001, Delegation to the Assistant Secretary for Health Affairs and Chief Medical Officer. However, the committee saw no evidence that this direction has been either renewed or enforced or that the CMO is held accountable for meeting the strategic objectives intended to support the Secretary’s goal of improving employee health, wellness, and resilience.
Notably absent from the DHS Strategic Plan is a strategic objective to reduce injuries and illnesses throughout the department through traditional
occupational safety and health practices—this despite the fact that DHS has the highest rate of occupational injury and illness of all cabinet-level federal agencies and that more than one-third of its employees who responded to the Federal Employee Viewpoint Survey indicated that they do not feel protected from health and safety hazards on the job (OPM, 2012). It is important to note that occupational injury and illness rates are not uniformly high across all DHS component agencies (OSHA, 2013). This variability is related to the differing missions and operational conditions faced by employees in different component agencies, but it also reflects variability in components’ employee health, safety, and medical programs. The committee concludes that DHS lacks a unified vision and comprehensive strategy for ensuring the delivery of key health, safety, and medical support services department-wide in a consistent and coordinated manner. Although a DHS Workforce Strategy was issued to improve and integrate employee recruitment, development, and retention efforts (DHS, 2011), the strategy does not address the promotion and protection of employee health, safety, or resilience as a critical means of sustaining an engaged workforce.
A COMMITMENT TO WORKFORCE HEALTH
As discussed in Chapter 3, assessments of employee health and safety programs in both the private and public sectors have demonstrated significant increases in employee morale, efficiency, and effectiveness with the implementation of robust programs fully supported by leadership (Cecchine et al., 2009; Isaac, 2013). Strong leadership providing clear direction is necessary to both the design and delivery of the health, safety, and medical policies and programs of a large, diverse organization such as DHS. A formal strategy, guided by a vision statement directly linked to the organizational mission, can provide that direction while also demonstrating the commitment of top leadership to employee health, safety, and resilience. Despite strategic aspirations to improve employee health, safety, and resilience, the committee found no evidence of a defined strategic plan for achieving that outcome or processes put in place to hold department leadership accountable for doing so. The committee believes that DHS leadership should make a clear and high-level statement of the value of protecting and enhancing the health and safety of its workforce—a key role and responsibility of DHS leadership for which ultimate responsibility lies with the Secretary. Therefore, the committee believes that the Secretary should lead efforts to infuse health and safety into the DHS culture and operational framework.
Recommendation 1: Demonstrate leadership commitment to employee health, safety, and resilience through a unified workforce health protection strategy.
The Secretary of the Department of Homeland Security (DHS) should demonstrate a robust commitment to the safety, health, and resilience of the workforce, essential to mission readiness, by adopting and promoting a unified workforce health protection strategy. To guide this strategy, the committee recommends the adoption of the same vision statement proposed by the Institute of Medicine Committee on Department of Homeland Security Workforce Resilience:
“A ready, resilient and sustainable DHS workforce working to ensure a safe, secure, and resilient nation.” (IOM, 2013, p. 65)
Visible leadership commitment to this vision, demonstrated routinely across all levels of DHS, is essential to success. Heads of federal agencies have ultimate responsibility for their employees. Therefore, the strategy should communicate the Secretary’s commitment to the health, safety, and resilience of those charged with achieving the DHS mission, while holding leadership of the component agencies accountable for implementing and adequately resourcing workforce health protection programs that are consistent with DHS policies and standards.
Suggested Goals for a DHS Workforce Health Protection Strategy
To ensure accountability, the strategy proposed above should include specific measurable goals and objectives with associated performance metrics. The committee suggests the following goals:
- Consistently and significantly increase the number of DHS personnel who are engaged and medically ready to participate fully in operations and achieve the goals of their mission.
- Maintain an operationally ready medical workforce to support planned and contingency operations and to ensure that timely care is available to those in DHS care and others impacted by DHS operations.
- Ensure that all medical services provided by DHS employees and contracted support staff during work hours meet medical quality standards.
- Provide all DHS employees with a safe, healthy, and productive working environment.
- Support the timely recovery and return to work of injured and ill employees.
- Develop an information technology and informatics capability to enable real-time situational awareness regarding progress toward the above goals.
Implementation
Because the strategy will address issues that span health and personnel programmatic areas and will require input and buy-in from component leadership, the committee recommends that the DHS Health, Safety, and Medical Council (reconstitution of which is addressed in Recommendation 6) be charged with development of the strategy, which should then be signed, adopted, and promoted by the Secretary. The Council should, during periodic meetings, receive updates on progress toward the strategic goals and update the strategy as needs and challenges evolve. The committee believes the existing DHS Workforce Strategy could serve as a model for a workforce health protection strategy and intends the two to be complementary in helping DHS achieve its mission through development, support, and protection of its workforce.
Due diligence required in the development of a new strategic approach includes
- characterization of the current capability to deliver health, safety, and medical services in each component;
- determination of component-specific critical and ongoing health, safety, and medical program needs;
- development of a plan for closing the gaps in capability/capacity (e.g., personnel, training, licensure);
- identification of best practices that can be expanded to other operational units as appropriate;
- development and launch of a health performance metrics tool to ensure leadership accountability; and
- development of a communication strategy to convey the commitment of DHS to the health and safety of its employees.
The information in this report on the current capability of DHS to deliver health, safety, and medical services is intended to assist the Secretary in addressing several of the above requirements.
Ensuring Accountability
There are two common mechanisms by which decentralized organizations like DHS can ensure that a central vision and strategy are adopted by its component agencies: (1) centralized budgetary control, and (2) incorporation of measures of performance toward departmental strategic goals into component leadership performance evaluations. Budgetary control is not centralized at DHS; components receive separate appropriations from Congress. However, DHS does use a planning, programming, budget, and
execution process (see Figure 5-1) to link resource allocations to departmental strategic goals and objectives (DHS, 2006). In this process, the execution of departmental strategy is monitored through metrics to link expenditures with expected performance toward each of the strategic objectives. Such metrics can be included in annual performance evaluations as a means of holding department leadership, including component heads and the CMO, accountable for program execution. To ensure accountability at all levels, program-level goals and performance measures should cascade down from those at the strategic level and should be tailored to the individual’s level of responsibility.
FIGURE 5-1 DHS planning, programming, budget, and execution process.
SOURCE: DHS, 2006.
The committee suggests that implementation of the proposed workforce health protection strategy follow the approach used for the DHS Workforce Strategy. DHS components should develop action plans describing component-specific activities in support of the strategic goals and objectives, using clear and measurable metrics to demonstrate progress. Component health leadership should provide reports on progress toward the achievement of component goals and objectives to the CMO and the reconstituted Health, Safety, and Medical Council. The Secretary should direct component leadership to include workforce readiness, as a key outcome of the strategy, in their performance plans.
To track successful execution of the strategic plan as required for the planning, programming, budget, and execution process and to ensure leadership accountability, DHS requires a multivariate tool for assessing performance across the department. A balanced scorecard is one example of a multivariate tool that has been used for these purposes by a number of federal agencies, especially within the Department of Defense (DoD). Originally, this tool was intended to enable business performance evaluation from four different perspectives: financial, customer, internal business, and innovation and learning (Mohamed, 2003). As Rohm (2008) explains, the intended purpose of the balanced scorecard, and therefore how it is used, varies between people and organizations. Whereas some management experts view the balanced scorecard as “simply a performance measurement framework for grouping existing measures into categories, and displaying the measures graphically,” others view it as “a robust organization-wide strategic planning, management and communications system … that align[s] the work people do with organization vision and strategy, communicate[s] strategic intent throughout the organization and to external stakeholders, and provide[s] a basis for better aligning strategic objectives [action plans] with resources” (Rohm, 2008, p. 1). The committee takes that latter view, believing the balanced scorecard readily lends itself to a strategy map for the overall organization and could be used to help align DHS and its components behind a shared vision of success for occupational health and operational medicine.
Major components of a balanced scorecard system include engaged leadership; interactive communications and change management; vision and mission; core values; organizational strengths and weaknesses; customers and stakeholders; customer value proposition; strategic objectives; strategy mapping; performance measures, targets, and thresholds; strategic initiatives; performance information reporting; department and individual scorecards; rewards and recognition programs; and evaluation (Rohm, 2008, p. 2). By linking the key components through use of a balanced scorecard approach, the agency will be able to benchmark its progress and improve its performance.
There are several advantages to using a balanced scorecard approach to evaluate strategic objectives, processes, and technology. The approach enables leadership to evaluate whether objectives are being met; permits stakeholders to determine near-, mid-, and long-term objectives; and supports strategic action to match desired outcomes (Bowen, 2011). The disadvantage is that forethought is required to determine the desired metrics and link them to specific goals and objectives (Bowen, 2011). A critical issue in the use of the balanced scorecard approach is that information being tracked must be applicable to the needs of components as well as the overall department; otherwise, the metrics will be meaningless. A core set of metrics may apply to all DHS components, but some metrics applicable to the specific components and their missions may need to be developed.
The committee believes that with periodic reviews of the scorecard at the department and component levels, leadership will be held accountable and ensure action to meet selected targets, as well as to create an environment that is conducive to learning and continuous improvement. The value of a scorecard system comes from continuous refinement, discovery, and analysis. The Coast Guard’s Health Services Strategic Plan (USCG, 2011) provides a useful model for the use of a balanced scorecard to track progress toward specific objectives for strategic goals (see Appendix C).1
Effecting Organizational Change
In large, complex organizations, there are three major forms of organizational control—first-order, second-order, and third-order. First-order control comes through direct supervision; second-order control is exerted through the use of standards (e.g., standard operating procedures); and third-order control, arguably the strongest form, is achieved through culture (Sutcliffe, 2013). All three forms of control will be necessary to ensure the DHS-wide adoption of forward-looking policies for prevention, health protection, and performance. As expressed by the Institute of Medicine’s Committee on Department of Homeland Security Workforce Resilience, leadership, communication, and culture are the foundational elements needed to support DHS in its efforts to achieve its full potential (IOM, 2013). Leadership plays a vital role in creating the cultural identity (i.e., norms and values) that drives organizational performance (Gantner, 2012). Ingraining the value of a safe, healthy, resilient, and ready workforce in the
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1The committee does not intend to suggest that DHS should adopt the specific metrics included in the Coast Guard’s measurement framework but provides it only as an example of a tool that can be used for tracking progress on strategic goals and objectives and for accountability purposes. Many of the metrics used by the Coast Guard would be specific to that agency and would not be appropriate for other DHS components.
culture of DHS will require commitment, concerted effort, and consistent communication from the Secretary regarding the vital importance of workforce health protection.
Bowen, R. 2011. Weighing the pros and cons of balanced scorecards. http://www.brighthub.com/office/finance/articles/70687.aspx (accessed December 20, 2013).
Cecchine, G., E. M. Sloss, C. Nelson, G. Fisher, P. R. Sama, A. Pathak, and D. M. Adamson. 2009. Foundation for integrating employee health activities for active duty personnel in the Department of Defense. Santa Monica, CA: RAND Corporation.
DHS (Department of Homeland Security). 2006. Performance budget overview: Fiscal year 2006. Washington, DC: DHS.
DHS. 2008. Delegation to the Assistant Secretary for Health Affairs and Chief Medical Officer. Delegation Number 5001. Washington, DC: DHS.
DHS. 2010a. Bottom-up review report. July. Washington, DC: DHS.
DHS. 2010b. The Office of Health Affairs strategic framework. Washington, DC: DHS.
DHS. 2011. Department of Homeland Security workforce strategy: Fiscal years 2011-2016. Washington, DC: DHS.
DHS. 2012. Department of Homeland Security strategic plan: Fiscal years 2012-2016. Washington, DC: DHS.
Gantner, R. K. 2012. Workplace wellness: Performance with a purpose. Moon Township, PA: Well Works Publishing.
IOM (Institute of Medicine). 2013. A ready and resilient workforce for the Department of Homeland Security: Protecting America’s front line. Washington, DC: The National Academies Press.
Isaac, F. 2013. Work, health, and productivity: The Johnson & Johnson story. Presentation to IOM Committee on DHS Occupational Health and Operational Medicine Infrastructure: Meeting 2, June 10-11, Washington, DC.
Mohamed, S. 2003. Scorecard approach to benchmarking organizational safety culture in construction. Journal of Construction Engineering and Management 129(1):80-88.
NBGH (National Business Group on Health). 2006. Improving health: An employer tool kit. Washington, DC: NBGH.
NIOSH (National Institute for Occupational Safety and Health). 2008. Essential elements of effective workplace programs and policies for improving worker health and wellbeing. 2010-140. Atlanta, GA: Centers for Disease Control and Prevention.
OPM (U.S. Office of Personnel Management). 2012. 2012 federal employee viewpoint survey results: Department of Homeland Security agency management report. Washington, DC: OPM.
OSHA (Occupational Safety and Health Administration). 2013. Federal injury and illness statistics for fiscal year 2012: End of year totals. https://www.osha.gov/dep/fap/statistics/fedprgms_stats12_final.html (accessed November 11, 2013).
Rohm, H. 2008. Using the balanced scorecard to align your organization. Balanced Scorecard Institute 1-15.
Sutcliffe, K. 2013. Organizational effectiveness at DHS: Designing to deliver. Presentation at IOM Committee on DHS Occupational Health and Operational Medicine Infrastructure: Meeting 3, July 8, Washington, DC.
USCG (U.S. Coast Guard). 2011. Office of health services strategic plan (2011-2015). Washington, DC: USCG.