Organizational effectiveness audit of the Department of Health and Human Services

Audit of Organizational Effectiveness

Department of Social Services

Effectiveness audit: The Department of Health and Human Services

Organization to be analyzed

The Department of Health and Human Services is the umbrella organization within the U.S. government devoted to improving the welfare of citizens through various wellness promotional efforts. Its website proclaims that "the Department of Health and Human Services (HHS) is the United States government's principal agency for protecting the health of all Americans and providing essential human services, especially for those who are least able to help themselves" (About, 2013, HHS). The HHS focus is on the 'human' dimension of healthcare. This means that it has made a commitment to partnering with state and local offices to promote various health initiatives, such as disease containment and preventative medicine. This ensures that health needs can be met in an individualized manner, given that different groups and people have different health needs over their respective lifecycles.

According to the HHS website, "the Department's programs are administered by 11 operating divisions, including eight agencies in the U.S. Public Health Service and three human services agencies" (About, 2013, HHS). Such agencies include the Food and Drug Administration (FDA), the Centers for Disease Control (CDC), and National Institute of Health (NIH). Measuring the effectiveness of the organization requires attention to the following core components:

1. Motivation: Alignment of actions with stated goals

2. Productivity: Ability to achieve those goals

3. Diversity: Representing the interests of persons from historically-discriminated against groups as well as the majority population

4. Group development: The fostering of groups within the agency that address critical health concerns

5. Team building: Creating productive dialogue within departments as measured by the ability to address critical health initiatives

6. Collaboration and coordination with outside contractors: Creating productive external dialogue as measured by the completion of critical health initiatives

7. Decision-making: The ability to come to effective results-oriented decisions

8. Communication processes: The ability to communicate within government and to the public

9. Power and politics: The ability to support effective legislation and initiatives to improve human health

10. Organizational culture: The support of dynamic change vs. stasis

Motivation

The current leadership of the HHS has shown a willingness to address some major demands currently placed upon the nation's health infrastructure. It was the agency responsible for overseeing the reforms of the nation's healthcare system through the Affordable Health Act. HHS Secretary Kathleen Sebelius has been unflagging in her motivation to implement the law. "In her zeal to make the health care law work, Ms. Sebelius has tested the limits of her authority. After Congress refused to provide as much as she wanted for a nationwide campaign publicizing the new insurance options, she shuffled money between government accounts and sought cash from outside groups" (Pear 2013:1). Because many states have refused to set up their own health insurance marketplaces, one of the provisions of the law, HHS has taken over this task, further expanding the federal government's role in the healthcare system (Pear 2013:1). However, to facilitate acceptance and to counteract critics of what is seen as federal interference, "instead of defining a uniform national set of essential health benefits, she has allowed each state to specify the benefits that must be provided in 10 broad categories" (Pear 2013:1).

HHS has also been highly motivated in bringing into action the First Lady's 'Let's Move' campaign for young people, in the fight against childhood obesity. The Let's Move initiative involves partnerships with schools, parents, and other community and faith-based organizations, in an effort to reduce childhood obesity. "The [obesity] numbers are even higher in African-American and Hispanic communities, where nearly 40% of the children are overweight or obese" (Initiatives, 2013, HHS). The rapid expansion of this initiative, which began only in 2010, is testimony to the ability to command organizational resources and the HHS motivation for change. HHS thus has shown a willingness to participate in setting health-related goals and to support them with meaningful policies, demonstrating true motivation and commitment to the current administration's articulated health objectives.

Diversity

The issue of health affects all Americans, regardless of gender, socio-economic class, sexual orientation, ethnicity, or religion. Thus, the mission of HHS is by definition extremely broad. It is true that some of the HHS services are specific to issues that affect the poor in greater proportion, or certain population groups. For example, Indian Health Service (IHS) specifically addresses the needs of Native Americans and the National Institutes of Health (NIH) has subdivisions which address sufferers of various conditions and diseases, spanning from rare genetic disorders to women's health issues. Other components of HHS are more general, such as the FDA (Food and Drug Administration) which oversees the safety of all Americans in terms of the foods they consume and the drugs they use.

HHS is an EEOC employer, underlining the belief that a diverse workforce is often more sensitive to the concerns of employees. Given that historically the needs of specific groups such as African-Americans and women have been overlooked in medical research, the need to present a diverse face to the public is especially acute. The current head of HHS is female but more importantly the different divisions of HHS specifically note when maternal care and other group-specific needs are addressed within the overview of the agency scope. For example, even the very general component of the HHS entitled Health Resources and Human Service Administration specifically has areas devoted to maternal and women's health.

As noted in its official vision statement, HHS has a particularly important role in aiding persons who are disadvantaged due to socio-economic status. Poverty can cause health problems due to stress and a lack of affordable, healthy food as well as exacerbate the effects of unrelated health issues. Preventative medicine is particularly important in mitigating the effects of poverty, a fact acknowledged by HHS.

Group development

Collaboration within the agency is a vital component of serving its mission. Health-related programs require the participation of a variety of groups, including those devoted to research, information-gathering, program design, and program implementation. For example, part of the responsibilities of the CDC encompasses dealing with seasonal flu outbreaks: informing the public about the need for flu shots; tracking the spread of the disease through recorded health data; and using that data to make future responses more relevant constitute some of the core components of the program. The availability of informational resources also ensures that technology can facilitate fulfilling this mission and has created the need for new subdivisions within the organization to specifically avail the CDC of technology to communicate to the public as well as keeping metrics about the spread of the disease itself (Seasonal influenza, 2013, CDC).

However, there has been criticism of some HHS agencies for insufficient group development to address health needs. The FDA, for example, has been subject to a slew of criticisms regarding its lagging behind on approving new drugs for life-threatening diseases as well as its inability to effectively monitor food and drug safety, and to track the dissemination of contaminated foods. "FDA needs to, among other things, improve the data it uses to manage the foreign drug inspection program, conduct more inspections of foreign establishments, systematically prioritize and track promotional materials for review, and adopt management tools to ensure that drug sponsors comply with regulations on the presentation of clinical trial results" (FDA facing increasing criticism and calls for reform, 2009, AACR). Food recalls, the approval of drugs with controversial side effects and the approval of genetically-modified salmon have brought forth allegations that the FDA is insufficiently concerned with consumer health and is overly subject to industry pressures. In the latter instance, "genetically engineered to grow twice as fast as their unaltered brethren, the fish pose no significant environmental threat to the United States when grown in landlocked tanks, says the FDA" but environmentalists worry about the overall implications for the environment (Ledford 2013).

Team building

Fostering dialogue between different departments of the HHS is also vital. Many of the stated missions of the agency cannot be limited to a single component and require the facilitation of dialogue between work teams. For example, the missions of the CDC and NIH frequently overlap regarding research into the treatment of communicable diseases: both demand rigorous, peer-reviewed literature to provide guidance to individuals and state and local public health agencies with how to deal with infections. HHS was able to coordinate with state and private when the new flu strain H1N1 threatened a pandemic. HHS was able to work with scientists to rapidly develop a vaccine almost immediately and work with healthcare organizations to provide advice about safe ways to deal with the outbreak and to disseminate the vaccine in the most effective fashion possible (Voices of power: HHS Secretary Kathleen Sebelius, 2009, The Washington Post).

Collaboration and coordination with outside contractors

Although HHS is a federal agency, a large proportion of the activities of the organization are actually allotted to the states. HHS may provide guidance and advice regarding the administration of programs, but must work closely with states to ensure that federal aid is spent effectively. For example, to lower costs and better align the Medicaid (the federal healthcare program for the poor) and Medicare objectives when dealing with the elderly, the U.S. Department of Health and Human Services (HHS) created an Alignment Initiative to provide faster state access to Medicare data to support care coordination" for Medicare patients (Ledford 2013).

Decision-making

It has also been alleged that insufficiently clear definitions of the scope of the FDA has impeded making effective decisions and inhibited the creation of effective policies in a number of areas, most notably food. For example, while the FDA is in charge of food safety in certain areas, the USDA is in charge of others such as meat safety, which can cause a conflict when there is a question of authority. "Food safety oversight is largely, but not exclusively, divided between two agencies, the FDA and the USDA. The USDA mostly oversees meat and poultry; the FDA mostly handles everything else, including pet food and animal feed. Although this division of responsibility means that the FDA is responsible for 80% of the food supply, it only gets 20% of the federal budget for this purpose. In contrast, the USDA gets 80% of the budget for 20% of the foods. This uneven distribution is the result of a little history and a lot of politics" (Nestle 2008: 145).

This also means that the ability to reach and implement effective decisions of the FDA and other branches of government in charge of policy related to human health is frequently compromised: while the FDA, to support human health, may wish to issue a guideline to eat fewer refined grains, because the USDA represents the interests of farmers, it will oppose such a measure, given it will eat into (no pun intended) farmer's profits. Even encouraging people to eat less can impact the economy and thus be opposed by corporate and financial interests; encouraging schools to have gym class that cuts into academic class time may threaten the goals of the U.S. Department of Education. Thus, given the broad outreach of healthcare policy and permeation into every facet of human life, no matter how motivated to enact changes, actual specific decision-making to create more effective policies may be stymied by politics.

Communication processes

Communication within the HHS is considered to be serious enough to be addressed by the NIH in one of its own publications. It notes that when communicating with other agencies "oversight representatives would like to be assured that the reviewers of research programs are objective, experienced, and expert -- again, a communication issue. Oversight bodies have expressed an inability to see or understand how those qualities are validated by agencies, and they have asked for improved communication about the procedures" (Implementing the government performance and results Act for research: A status report, 2001, National Academy of Sciences). Concerns about objectivity have been expressed regarding FDA tests of drugs and other substances -- for example, the FDA recently declared the chemical often found in plastics called bisphenol A, or BPA, to be safe, and the quality of the research caused both Republicans and Democrats alike to question this finding. "The FDA hired a private consulting group with strong industry ties to perform some of its analyses of BPA," in contrast to a peer-authored journal article in the Journal of the American Medical Association which "linked BPA to heart disease and diabetes in adults" (Szbao 2008).

Regardless of one's personal feelings about the issue, this indicates the degree to which the FDA has failed to convince the public about its ability to prioritize the value of human health. Recalls of foods which took place long after many people had been sickened, questions about the objectivity of peer-reviewed drug trials, and even the widespread concern and misinformation about the Affordable Care Act all indicate a need for more effective inspections and pressure upon corporate entities as well as better communication with the public on the part of HHS about such critical issues. Agencies must attempt to communicate important information to the public, such as the importance of the seasonal flu shot by the CDC and product recalls on the part of the FDA.

Power and politics

HHS has strongly supported recent legislation designed to improve human health as well as an expansion of current funding for health initiatives. Its current secretary has been highly praised for her advocacy of provisions of the Affordable Care Act. However, with many of its functions, HHS has limited authority because it must share power with the states. Medicaid, the healthcare program for those living beneath the poverty line, is a state-run program and provisions vary between states for participants' eligibility. The CDC is reliant upon states providing data regarding communicable diseases. Furthermore, because the HHS has traditionally represented marginalized persons -- those who are sick or poor -- this has tended to weaken its influence politically, versus federal agencies which have the interests of the wealthiest and most powerful segments of society at heart.

Organizational culture

The organizational culture of certain components of the HHS has been criticized for being unduly sensitive to the influence of large corporations. "Hundreds of Food and Drug Administration (FDA)…employees who work with food safety said public health has been harmed by their agencies deferring to business interests… scientists and inspectors responsible for food safety have personally experienced political interference in their work, and that's bad for public health" (FDA and USDA scientists say U.S. food system needs strengthening, 2010, Union of Concerned Scientists).Many of the functions of HHS have the responsibility of being 'watchdog' organizations. But a lack of funding combined with the powerful nature of the interests who have a vested interest in less vigilance regarding safety has created an organizational culture which lacks objectivity and the ability to take a controversial stance. "More than 300 respondents (25%) [of FDA workers] said they personally experienced corporate interests forcing their agency to withdraw or significantly modify a policy or action designed to protect consumers in the past year [in a recent study]" (FDA and USDA scientists say U.S. food system needs strengthening, 2010, Union of Concerned Scientists). The sprawling nature of the mandates of HHS means that there is often contradictions in its actions, given that on one hand it is charged with protecting consumers and patients but on the other hand it is dependent for information upon third-party organizations (such as drug companies that do research or pharmaceuticals being brought to market) with an interest in the outcome.

Conclusion

When there is public pressure to 'get things done,' HHS has been able to use concern about public health to enact change. It has motivated people to get flu shots, encouraged people to reform their diets to some extent, and has attempted to coordinate with the states to implement the Affordable Care Act. However, HHS' ability to stand up to powerful outside interests when regulating healthcare, food, and drugs remains more questionable. Thus, while meeting relatively specific goals (such as influenza containment) seems to be one of the agency's strengths, the long-term need to stand up to outside interests such as drug companies and large food conglomerates when dealing with the health needs of Americans remains more questionable, at least in terms of public perceptions, as is its ability to communicate with the public to educate it about many health-related issues, including food recalls and nutrition.