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Learn how territorial and freely associated state health agencies can support community health workers and their vital work in this brief.

Centralizing Administrative Functions, with Lessons Learned from Guam Megan Drake-Pereyra Centralizing administrative functions, such as procurement or grants management, is a strategy many organizations utilize. Having administrative functions concentrated with a specific team rather than dispersed or managed within separate teams can work well. There is potential for standardized processes and procedures, increased efficiency and quality, more control and accountability, and consistent data collection and monitoring. This brief details how health departments can utilize existing, evidence-based frameworks to centralize administrative functions and build off lessons learned from others, such as the Guam Department of Public Health and Social Services (Guam DPHSS). Getting Started Considerations When transitioning from a decentralized structure to a centralized structure, it is important to clearly outline the what, why, how, and benefits. Consider the following components to kickstart success: Leadership vision: Start with the leader’s visionary perspective. When the leader allocates sufficient time and consistently reinforces the vision, it allows for the necessary decisions, trust, and support to be established during the transition. Data-driven design: Use data and existing information, such as current standard operating procedures or process diagrams, to understand the decentralized process differences/similarities, and guide effective centralized processes and procedures. Role clarity: Clearly outline and define the new centralized infrastructure, purpose, roles, responsibilities, expectations, and procedures. This helps everyone understand and follow the new processes more consistently, with better results. Performance measures: Establish and use performance measures from the outset (e.g., team knowledge, skills, competency, process time and quality, outcomes, impact, etc.), for insight into the value, or return on investment, of the centralized model. This will help indicate the quantity, quality, and impact of programs/processes. Documentation: Capture and share decisions, vision, goals, structure, standard operating procedures, and relevant details in writing for new team members and users of the centralized functions. Communication: Transparently share plans, timelines, and additional knowledge to maximize utilization and value. Additionally, anticipate and proactively address resistance to change to help everyone embrace and adhere to the new, centralized approach. The Plan-Do-Study-Act Method Change management, quality planning, and process improvement models can also support organizational and process change. For example, the quality improvement methodology, Plan-Do-Study-Act (PDSA), offers an effective framework for centralizing administrative functions and complements many of the aforementioned considerations: Step one, plan, relies on leaders to decide the vision, scope, structure, roles/responsibilities, goals, and purpose of the centralized team. Here leaders establish and reinforce the leadership vision, using existing data to guide the design of the new centralized team. Step two, do, is dedicated to onboarding centralized team members, defining their work processes and procedures, and ensuring effective communication with all stakeholders. This requires thorough documentation and strong communications plans. Step three, study—an often overlooked but crucial building step—is for testing the processes, procedures, roles, and responsibilities, to confirm and build confidence that this centralized structure will yield the desired results. Performance measures provide clarity into what is working well and what is not. Step four, act, is for launching and rolling out the structure, ongoing monitoring of performance, and continuing to educate and coach for successful, sustainable improvements. Lessons Learned from Guam Guam DPHSS, a joint health and social services agency, is working to centralize its administrative functions to reduce inefficiencies and redundancies as well as improve quality and consistency. This has been a big change for Guam DPHSS, but leadership vision, documentation, role clarity, and communication have proven to be key throughout the process. In 2021, Guam DPHSS established a centralized Office of Grants Management (OGM). In its early stages, programmatic teams saw OGM as a regulatory body that would audit and direct their work, while OGM’s true objective was to provide support and ease administrative burden, allowing program staff to focus on accomplishing their goals and deliverables. By clarifying and documenting the vision, roles, and responsibilities as well as focusing on communication, the OGM built trust, addressed specific concerns, and established a shared vision of their role as supportive and helpful. In 2023, Guam DPHSS began the process of establishing a centralized Procurement Management Office (PMO). While Guam DPHSS reorganized and co-located staff into the new, centralized PMO, Guam was undergoing a governmentwide business process improvement (BPI) project focused on procurement—presenting an opportunity for Guam DPHSS to involve new PMO staff and other key DPHSS team members in improving its functions and centralizing the procurement process. Through the BPI project, which utilized PDSA, DPHSS clarified roles and responsibilities, defined work processes and procedures, and developed training and communications plans that supported process improvement and centralization of procurement functions. Guam DPHSS has learned many lessons throughout their journey to create a centralized OGM and PMO, including that change of this magnitude is hard—more specifically, balancing change management while ensuring maintenance of key operations. Ultimately, they found that the aforementioned considerations and methods for getting started were critical in supporting the change to centralized administrative functions. Establishing the Ideal Structure for Administrative Functions Determining if and how centralized administrative functions will work for an organization is multifaceted. An organization’s culture, size, infrastructure (including technology and systems), and workforce and skills all play crucial roles in shaping the ideal structure. The methods and considerations noted previously can help health departments determine and support the best path forward for each unique organization. ASTHO has several additional resources and tools that can support administrative change and improvement. Visit the ASTHO STAR Center to learn more. website yes

Strengthening Public Health Workforce Capacity in Island Jurisdictions Strengthening Public Health Workforce Capacity in Island Jurisdictions A.C. Rothenbuecher, Allison Budzinski, Marta McMillion, Melissa Sever Guam and CNMI leveraged support from ASTHO to improve their public health workforce planning — learn more in this blog post. Strategic workforce planning helps public health agencies stay prepared, attract and retain the right talent, and build flexible systems that can handle change. When done well, it leads to better services, stronger performance, and a healthier work environment. It also saves money by reducing turnover and helps agencies respond to health emergencies or challenges as they arise. A Learning Collaborative Approach For U.S territories and freely associated states, where geography, connectivity, and resources pose unique challenges, strategic planning is especially important. With support from the Public Health Infrastructure Grant (PHIG), the Association of State and Territorial Health Officials (ASTHO) and the Public Health Accreditation Board (PHAB) launched a nine-month Island-Centric Workforce Planning Learning Collaborative to offer support as island health departments strengthen their workforce planning efforts. This pilot included workforce teams from Guam’s Department of Public Health and Social Services and the Commonwealth of the Northern Mariana Island’s (CNMI) Commonwealth Healthcare Corporation, Division of Public Health Services. The learning collaborative gave participating island health departments a chance to build on their strengths while getting tailored support for workforce planning. Through expert guidance, peer sharing, and coaching — both online and in person — participants worked through each step of ASTHO’s Workforce Planning Guide and explored essential workforce components aligned with PHAB’s Standards and Measures for Accreditation. The collaborative took a “start with what you have” approach, building on previous workforce planning efforts, existing data, and plans in both Guam and CNMI while leveraging resources from several national partners in the process. From Resources to Results: Putting Workforce Tools to Work Before the learning collaborative began, ASTHO, PHAB, and the University of Nebraska Medical Center (UNMC) teamed up to streamline and align their workforce planning resources. Early coordination ensured the tools complemented each other and avoided duplication. The ASTHO Workforce Planning Guide served as the foundation, while PHAB’s Workforce Plan Template gave health departments a clear structure to build upon. UNMC’s Public Health Workforce Planning: A Practical Guide and workforce data from the de Beaumont Foundation’s Public Health Workforce Interests and Needs Survey (PH WINS) helped ground planning efforts with practical guidance for facilitators and up-to-date data reflecting current needs and priorities. Callout 1 - Blog - Strengthening Public Health Workforce Capacity in Island Jurisdictions Collaboration Across Islands: Sharing Challenges and Solutions Over the course of the learning collaborative, Guam and CNMI’s public health teams built strong relationships by sharing challenges, exchanging ideas, and celebrating progress. Common issues like limited workforce capacity helped them relate to one another, while differences in structure and resources sparked creative solutions. The peer relationships and connections that were built and strengthened during the collaborative continue. On-Site Support ASTHO visited both jurisdictions to meet with leaders, review progress, and plan next steps — reinforcing the value of ongoing partnerships in workforce development. During the visits, participants revisited the Workforce Planning Cycle, layered in the latest PH WINS data, refined draft plan sections, clarified alignment with PHAB workforce standards, and considered the sustainability of their work beyond the collaborative. The hands-on sessions blended facilitation, coaching, and dedicated writing time, allowing participants to make measurable progress on their plans. What Guam and CNMI Achieved Through the learning collaborative, Guam and CNMI made meaningful progress in their strategic workforce planning efforts. Some near-term successes include: Active Workforce Committees: Both jurisdictions formed or maintained dedicated teams to lead workforce planning efforts. Steps Toward Accreditation: Each agency advanced efforts towards PHAB recognition related to a core domain, “Maintain a Competent Public Health Workforce.” Smart Use of Data: Each agency used human resource, workforce, and PH WINS data to guide decisions and improve planning. Stronger Capacity: Teams gained valuable skills and knowledge to support long-term workforce efforts. Customized Action Plans: Each agency created tailored plans aligned with their unique goals and needs. While Guam and CNMI achieved many similar milestones, each jurisdiction brought its own strengths and strategies to the table. Their different approaches offer valuable lessons for tailoring workforce planning and technical assistance to local needs. Guam emphasized structural development and broad departmental engagement, while CNMI leaned into data-driven decision-making and sustained leadership support. Callout 2 - Blog - Strengthening Public Health Workforce Capacity in Island Jurisdictions What Other Jurisdictions Can Learn The Island-Centric Workforce Learning Collaborative offers practical lessons for other jurisdictions focusing on workforce planning: Start with leadership support and clear roles across teams. Utilize and adapt existing tools and frameworks, like the PHAB Workforce Planning Template, the ASTHO Workforce Planning Guide, and UNMC’s Public Health Workforce Planning: A Practical Guide to jumpstart planning. Request tailored coaching and technical assistance through national organizations such as ASTHO and PHAB. Leverage workforce data, such as PH WINS, to inform decisions and progress. Collaborate across partners to benefit from diverse expertise. Celebrate your wins to build momentum and morale. What’s Next for Workforce Development in CNMI and Guam The success of the Island-Centric Workforce Learning Collaborative highlights what’s possible when public health agencies are supported with the right tools, partnerships, and local context. Guam and CNMI’s progress show that even in resource-limited settings, meaningful change is achievable. Special Thanks - Blog - Strengthening Public Health Workforce Capacity in Island Jurisdictions OE22-2203 PHIG article yes

Strengthening Leadership, Risk Communications, and Preparedness in the Islands Strengthening Public Health Preparedness in the Islands Sidnie Christian, Alyssa Boyea Key strategies in on leadership, risk communications, and preparedness, can help island jurisdictions prepare for and respond to emerging public health threats. ASTHO convened a two-day, in-person workshop in Honolulu from June 25 – 26, bringing together public health preparedness staff from American Samoa, the Commonwealth of the Northern Mariana Islands, the Federated States of Micronesia, Guam, Hawaiʻi, the Republic of the Marshall Islands (RMI), and Palau, as well as federal partners from CDC, the Department of Homeland Security, and the Administration for Strategic Preparedness and Response. The workshop focused on leadership and workforce development, risk communications, administrative preparedness, and more to support island areas as they prepare for and respond to natural disasters and other emerging public health threats, of which emerged key learnings that can benefit all island jurisdictions. Leadership and Workforce Development Leading through change requires transparency, trust, and collaboration. Planned change involves assessing readiness for change, identifying resources needed, securing buy-in, and determining a path forward. However, sometimes change can leave little to no time for preparation. Island jurisdictions have encountered challenges in the face of change, with many workshop participants sharing firsthand challenges around retaining institutional knowledge, infrastructure, and receiving assistance from the mainland United States in a timely fashion. As such, change readiness, succession planning, and effective change management practices are of utmost importance in the islands. Key recommendations and takeaways include: Utilizing a reputable framework, such as Kotter 8-Step Change Model, is pivotal for improving change readiness and change management. Change management frameworks and methods can assist with different types of change including structural change, strategic operational change, people-centric change, etc. Trust is hard to build, but easy to lose. Participants spoke about characteristics of high trust relationships including open communication, consistency, good judgement or expertise, and cultural sensitivity, while low trust relationships characteristics include lack of communication, inconsistency, and lack of teamwork. Succession planning is important to ensure institutional knowledge and capabilities remain in the wake of staff turnover or retirement. Identifying the necessary expertise, skills, and capabilities for each role is vital in the case of unplanned changes in staffing. Promising practices include annual review of critical positions, conducting talent calibration sessions, defining action plans, and obtaining buy-in from leadership and relevant partners. Risk Communications The island jurisdictions face emergencies that require creative response efforts. Both Hawaiʻi and RMI demonstrated innovative approaches in risk communications during COVID-19, finding success in forming critical partnerships, utilizing trusted voices within the community, and bridging communication gaps: Hawaiʻi utilized social media to showcase individuals such as doctors, pastors, social media influencers, and even local sports teams getting vaccinated, and utilized trusted voices to deliver messages. Additionally, they translated their materials into three languages (Marshallese, Samoan, and Hawaiʻian), modeling that no one gets forgotten, the true meaning of “ohana.” RMI created a working group with a mix of partners that curated press releases, educational materials, and sitreps, and served as a liaison between RMI Ministry of Health and Human Services and the community. It also partnered with several media outlets (e.g., radio stations, local papers, and other private sectors) and utilized mass text messaging to spread information quickly. The latter proved to resonate with most island jurisdictions who struggle with staying connected to hard-to-reach populations, namely those in more rural and disconnected communities. RMI was able to connect with these populations through WhatsApp to keep them updated throughout the COVID-19 response. Administrative Preparedness Improving administrative preparedness plans and processes ensure timely and efficient access to needed resources for a public health response. Most workshop participants are currently in the process of updating existing administrative preparedness plans, while some are working with other departments to create and implement new plans. Attendees discussed key partnerships for collaboration including other departments, Medical Reserve Corps, and other volunteer organizations. One common key challenge that emerged was around staffing (e.g., finding qualified people to fill vacancies, hiring process issues, making sure positions are competitive, etc.). To address this issue, island jurisdictions can work closely with other departments or jurisdictional agencies to streamline current processes, establish memorandums of understanding with different partners/facilities to assist with emergency procurement, and ensuring staffing vacancies are competitive and match public health classifications. Disease Forecasting A survey on state and territorial expertise and needs for infectious disease forecasts, models, and other outbreak analytic techniques—implemented by ASTHO with support from CDC’s Center for Forecasting and Outbreak Analytics—revealed that respondents from island jurisdictions experienced several barriers that led to limited use of infectious disease forecasts to inform communication and decision making. Challenges noted include limited software access, limited disease modeling capacity or skills, and lack of uniform reporting systems. Through a discussion-based exercise, workshop participants shared their challenges and considerations for ASTHO and CDC to assist with disease forecasting in the island jurisdictions moving forward. Challenges include but are not limited to: Delays with sending samples to labs and receiving results in a timely manner. Without timely results, it is challenging to take swift action. Lack of staff / staff wearing many hats with limited capacity. In most cases, there is no specific communication plan for disease forecasting within the departments. Communication can be challenging without clear processes and channels. Participants noted the desire for additional disease forecasting training and opportunities for collaboration. They suggested an integrated training session with island epidemiologists and other relevant staff to enhance disease forecasting knowledge and communication, as well as strengthen collaboration. Preparing for and Responding to Climate Events From hurricanes to typhoons to volcanic eruptions, the island jurisdictions are no strangers to the effects of changing climate. Willliam “Brandon” Aydlett, science and operations officer at the National Weather Service, and Shelbi Davis, Senior Analyst on the Environmental Health team at ASTHO, offer the following recommendations to island jurisdictions for preparing and responding to unprecedented climate events, as discussed with workshop participants: Create or update standard operating procedures for various climate related responses unique to the island. Always prepare for a category higher storm than is expected. Consider conducting regular vulnerability assessments to better understand areas where the island or its people may be most susceptible to adverse health impacts from climate events. Jurisdictions can learn from one another and find a sense of camaraderie in their preparedness efforts, much like the workshop participants. For example, one island jurisdiction noted that they currently do not have a warehouse to store equipment but are working on a plan to secure one; another jurisdiction, having recently revamped their warehouse, noted that they could assist their island neighbor in this endeavor and provide lessons learned as well as strategies to help secure a warehouse that will fit their needs. Looking Toward the Future Sharing lessons learned with one another and reflecting on how to apply those learnings in respective communities is crucial. Workshop participants shared their intent to share and utilize resources and information shared throughout the workshop with their leadership and team to begin implementing in their jurisdictions, as well as using strategies and skills learned to enhance partnerships. To all the participants and our Hawaiʻian hosts, we say mahalo. Related Resources Modernizing Infrastructure and Facilities for Readiness and Response | ASTHO PH-HERO Workforce Resource Center | ASTHO ASTHO STAR Center | ASTHO Evidence-Based Strategies to Enhance Public Health Emergency Preparedness and Response | JPHMP article yes

Understanding boundary spanning principles helps public health practitioners recognize the types of boundaries that come naturally when navigating relationships that may involve managing up, down, and across.