CHAPTER 2 ________________________________
Planning and Managing Core Mission Functions in San Diego County, California

The key to success in strategic planning is not so much how the planning is done, but how the planning progresses from strategic thinking to strategic action, from paper to practice. One of the primary purposes of local government is to make real what federal and state governments envision and mandate. In today’s complex, dynamic public sector, it is by necessity and for the benefit of local residents that local governments plan proactively to ensure that what is implemented works and brings maximum value to the citizenry. This chapter describes the infrastructure of San Diego County, California, that makes conversion of strategy to reality possible. We then describe how this works within the county’s Health and Human Services Agency (HHSA) and in several major HHSA initiatives.

The Discipline of a General Management System

In the mid-1990s, San Diego County was near bankruptcy. The state had raided local revenues, and the county was facing increasing demands for services from citizens and had invested in some costly ventures, most notably a money-losing waste-to-energy facility.

Fortunately, a chief administrative officer and his deputy, both executives with private sector experience, helped turn the county’s finances around by organizing the county along business-model lines, selling the losing landfill venture, launching a managed competition for the provision of selected services, and introducing a new framework for operations, the General Management System (GMS), that is still in use today. Continuity in leadership on both the board of supervisors and in county government, unusual for local government, allowed the GMS to take hold and mature. It now underpins a strong five-part planning and management system (see Figure 2-1).

Today, the county has three high-level initiatives (Kids, Environment, and Safe and Livable Communities) that represent priorities the public cares about and to which all departments contribute. A number of required disciplines capture competencies essential to fulfilling these initiatives—such as fiscal stability; a skilled, adaptable, and diverse workforce; and customer satisfaction. These initiatives and disciplines are made real or operational through a budget, departmental operational plans, and executive performance goals. Employee recognition and rewards are also aligned to high-level strategy. More powerful still is the cooperative approach departments take in the resource allocation process, particularly in difficult economic times, by sharing budget dollars and staff resources and aligning activities to advance strategic goals.

A Complex Health and Human Services Agency Grapples with Strategic Alignment

But none of this has come easily. It has taken time to develop this simple, powerful, and mature planning and management system. The challenges are best illustrated by the experiences of HHSA and two recent and interrelated initiatives—a food stamps program and a reengineering of the public welfare eligibility system.

The county embarked upon a major redesign of its health and human services at about the same time it adopted its business model (mid-1990s). Five separate departments—health services, the area agency on aging, public administrator/public guardian, social services, and a local commission for children, youth, and families—were combined under a single executive to create a mega- or super-agency. A wide range of health and social services were to be delivered out of six regions, each with its own regional general manager (see Figure 2-2). The idea was to facilitate the tailoring of services to meet community needs, enhance prevention efforts, and emphasize service integration to support the self-sufficiency of end-users and better health outcomes.

It was by necessity that HHSA managed strategically—realigning a wide range of disparate planning and delivery systems to more efficaciously address what ultimately were common or overlapping programmatic requirements. Given its complexity and its mandate to provide better services for the community without growing in size, such a strategic realignment on the part of the county was a logical choice. After numerous attempts at strategic planning, drawing upon various planning methodologies, a simple hybrid approach was adopted. Based on a multitude of planning goals and more than 700 performance measures, HHSA developed, and still uses, a one-page strategy agenda. Created in 2005, the strategy agenda sorts all agency programs and activities into priority service areas, six mission-critical services, and 17 result indicators. Its beauty is in its simplicity. It has also proven to be a good communication tool. Internally, staff members can see their roles and responsibilities; externally, community members can see that the agency is working toward goals they care about.

The HHSA executive team came up with the framework (vision, mission, priority service areas, and mission-critical services). Significantly, feedback from 17 citizen advisory committees informed the framework. As part of a budget exercise in fiscal year 2003-04, these citizen committees prioritized services, helping executives learn which ones were most essential and valued. Then, focus groups of managers and program experts articulated the measures that would indicate the agency’s progress toward its goals. For example, multiple regions and divisions can show that they contribute to the mission-critical goal of access: Senior service programs link older adults to mental health services, the mental health services division helps ensure adolescents receive outpatient care, and outreach and eligibility staff across multiple programs enroll eligible children and families in health insurance programs (see Figure 2-3).

No fix is complete, however. Challenges persist. One of the most vexing is managing effectively as a matrix organization (see Figure 2-4). There are horizontal and vertical lines of authority, making clarity in direction and robust communication imperative. The advantages of a matrixed organization include unlimited potential for leveraging resources and creative approaches to advance shared results—for example, tapping scarce expertise and assets across organization boundaries that might otherwise not be available in a smaller, stove-piped arrangement. Nevertheless, there may also be confusion regarding who leads, who should contribute, and what the expectations are. This is a continuing struggle.

But as the agency matures, communication channels have deepened, and the agency has begun to build a track record of success through innovation and cooperation. HHSA regularly holds cross-threaded meetings, at which all regions and divisions are represented, at all levels of the organization. When performance goals are established each year, regions and divisions are expected to identify how they will support each other. Special priority initiatives engage everyone.

Theory in Practice

At HHSA, there is a shared sense of responsibility for achieving results, thanks to this simple strategy agenda framework and the GMS discipline undergirding it. Two key initiatives illustrate how this has worked in practical terms.

All Hands Engaged in Priority Food Stamps Initiative

As the number of San Diego County families in economic distress grew, the county’s board of supervisors demanded that staff enroll more eligible households in the county’s food stamps program. Many potentially eligible families in the county were not participating in the program because they were unaware that they qualified for it or were dissuaded by the stigma associated with the program or its complex eligibility process. The original intent of the food stamps program, when it was first piloted in 1939, was to distribute surplus farm-grown goods to low-income families. Over time, the program had been siloed as a public welfare initiative, contributing to its stigma.

To revamp the program, the HHSA director called an all-day, all-hands meeting. Staff from across HHSA and a few from other county departments were assigned to teams to brainstorm strategies, with the goal of promoting nutrition among low-income families while streamlining eligibility and preserving program integrity.

What came of the all-hands meeting? The public health officer saw an opportunity to address poor eating habits and counter obesity, a major problem in San Diego just as it is in the rest of the country. The directors of the mental health and alcohol and drug services departments noted the importance of healthy eating to the recovery of their clients. The Farm Bureau recognized a business opportunity for local growers and farmers’ markets. The board of supervisors developed and accepted a comprehensive Nutrition Security Plan and set a challenging goal for the agency: to increase enrollment of children and seniors in the food stamps program by 50,000 within three years.

The beauty of aligning the participating departments through the GMS is that the same goals appear in the executive performance plans of all regions and divisions that play a part. Because of HHSA’s strategic alignment, it was able to market the food stamps program as both a public health initiative and a self-sufficiency program. This approach was not only innovative, but also allowed the program to return to its roots as a vehicle for promoting healthy eating and helping local agriculture by encouraging the purchase of local fruits and vegetables.

Now, outreach practices borrowed from public health are being used to reach clients. All clients, regardless of where they enter HHSA’s system, are told how to enroll in the program and are offered nutrition education whenever possible. Another county department is helping by equipping local farmers’ markets so they can accept electronic benefit transfer of food stamp dollars.

Reengineering the Eligibility System

A redesign of local business processes was integral to enhancing access to the food stamps program. There was a growing recognition that the eligibility system for all county public assistance programs—Medi-Cal, food stamps, CalWORKs—could not keep pace with future demands. But what actually sparked the business process review (BPR) of eligibility were data showing that San Diego was among the lowest-ranked counties in terms of case-processing productivity. Clearly, there were opportunities for improvement. Looking down the road, the county had to do better; service expectations were only going to increase, while staff levels would, at best, stay the same. The performance gap had to be closed. Midway through this redesign effort, the economy tanked, making the BPR an absolute imperative.

This ambitious eligibility BPR was intended to streamline business processes and make them more efficient. Virtually everyone at HHSA was enlisted or engaged in the BPR in some way. The geographic regions embarked on a series of mini-pilots and projects in individual Family Resource Centers (FRCs) to explore new ways of doing business. This included training workers to process requirements of multiple programs to achieve efficiencies, an effort led by the South Region. The Central Region took the lead on the technology efforts by imaging case records and converting all case information into electronic files. Strategic Planning and Operational Support, HHSA’s policy division, retooled internal support activities, including application support provided to the CalWIN system, the eligibility database system HHSA has been using since June 2006. Related training was expanded and revamped, which required HHSA’s human resources division to coordinate closely with the regions so that staff would be trained to meet the demands of a new operating environment.

The changes have been truly transformational. Personnel have begun to use a task-based, same-day intake model. All FRCs are now transitioning to a paperless case management system. More and more staff will be trained in multiple programs. A new ACCESS customer service center has opened to help customers apply for assistance, update their case information, make appointments, and obtain other services. In this way, customers can avoid unnecessary trips to the FRCs, and requiring that a new organizational culture be reinforced both internally and externally—through training and changes in routine. Workers need to see clients as customers and to treat all customers responsively and respectfully. The work environment must promote learning and receptiveness to new ways of doing business.

The BPR effort is significant because it was initiated at the local level, not by the state, and the new processes were designed in partnership between labor and management. The changes made to the eligibility system that had been used for 30 years were arguably of the “shock and awe” variety. HHSA borrowed from the private sector an emphasis on customer service, just-in-time manufacturing, task-based processing, and cross-training, among other practices. (Here, task-based processing means that cases are broken into tasks and more people touch every individual case, reducing the likelihood that any one case will be lost, backlogged, or handled incorrectly.) At the same time, best practices of the public sector were maintained—namely, transparency and accountability to staff, stakeholders, and the public—throughout the redesign. Continuous measurement and progress reporting were absolute tenets of the project.

The eligibility BPR sparked fears, just as it inspired excitement. For some workers, the redesign was like facing the abyss; they were leaving behind everything they knew. Another challenge was getting staff to think beyond themselves and their own workloads, beyond even their FRCs or regions. While the old culture had allowed, perhaps even encouraged, variations in practice between regions, the BPR requires consistent practices and adherence to processes proven to be most efficient. Staff also had to learn that the system takes precedence and that everyone’s role is to optimize the productivity of the entire system.

The new model passed its first test. As more families sought help in a tough economy, four FRCs were struggling to keep up with the caseloads. Four other high-performing FRCs stepped up—each adopted one of the other four offices. A new system capability, virtual caseloads, enabled cases to be shifted to other offices without having to move staff, improving the efficiency of the entire system. In essence, this is surge capacity—the ability to direct work from one location to another in order to equalize the workload and get a better result—at work. This new capability has tremendous potential, particularly in times of emergency, such as when firestorms devastated the county in 2007. In the future, FRCs in affected areas will be able to redirect or “outsource” the many food stamp applications submitted by families dislocated by fires. Other FRCs will process them remotely.

Once again, GMS discipline was exercised throughout the eligibility BPR. Project milestones became part of executive performance plans and region and division business plans. The HHSA team formulated project metrics at the outset, and these results continue to be monitored to assess progress on key dimensions—customer, process or internal, financial, and human resources. These include measures of progress in training of staff in multiple programs, in cases being imaged, and in case-processing times. Project status reporting should happen early and often, even at the highest levels; the county executive team is given in-depth briefings every quarter.

The Third Dimension: Engaging Citizens and Stakeholders

Engaging citizens is one of the most daunting and difficult aspects of local government reform efforts. Local governments often face distrust from the community regarding redesign or reform efforts, particularly when stakeholders are not convinced that these reforms are about anything other than saving money. This is why project goals and messages must be carefully articulated with the client in mind and with a genuine view of clients as customers.

HHSA has 17 citizen advisory boards composed of stakeholders, some of whom are also subject matter experts, who meet regularly to advise the agency on its initiatives and direction. These citizen advisory boards were consulted and gave HHSA vitally important feedback when the agency strategy agenda, the food stamp initiative, and the eligibility BPR were designed.

It can be far more difficult to directly engage community advocates in systems change. Much can be learned from advocates about client needs and barriers they face in accessing services, but advocates believe their primary responsibility is to serve as the voice of clients and their needs. They can be suspicious of change efforts. For example, advocates wanted the food stamps program to be expanded quickly and broadly throughout the community. These advocates were not as interested in reforming the system.

GMS 2.0

Change doesn’t rest. In fact, change begets more change. Recognizing this, county leadership has taken the GMS to the next level. The GMS framework that undergirds all of the agency’s initiatives and that has established the guideposts for translating vision and strategy into reality has been given a new name in San Diego County—GMS 2.0. GMS 2.0 calls for the same discipline but a more urgent sense of the need to be aware of and prepare for change. Most important, GMS 2.0 calls upon all county employees, regardless of department or position, to look for new and better ways to get things done. Accordingly, the county is heavily promoting the idea of the “knowledge” worker, who is constantly learning and adapting, through desktop trainings, guided discussions between supervisors and staff, and a website offering articles and a variety of other resources.

As the pace of change quickens, local governments cannot wait for federal or state solutions. Nor are federal and state solutions forthcoming in today’s environment, given the limited capacities, resources, and influence of federal and state governments. The local government must act as a strategic player, translating strategic thinking into strategic action, in addition to anticipating and formulating new strategic directions. Locals will make it happen, while being poised for rapid and relentless waves of change.