Will Humble Professional Development, Wills Blog

2023 AZPHA Conference Summary

Thanks to all of our speakers, poster presenters, conference planners and participants for making our 2023 conference such a success. A big shout out to our scholarship sponsor, Maricopa County Department of Public Health and our other sponsors and exhibitors too.

A special thanks to Sheryl Clements, who donated countless creative hours designing our brochure:

View Our Conference Brochure

Well over 300 persons attended the conference in person. We also had many on-line participants for the plenary sessions and breakouts in Cottonwood. This is our 95th year as an organization… and I can’t think of a better way to celebrate our success as an organization than having such a well-attended conference.

Attendees will be getting an email later today with a plea to complete your conference evaluation. At the end of the survey, you’ll get a FREE DIGITAL BOOK (with a $40 value)! There are two options to choose from and they are first come first serve.

As an AZPHA member you’ll have the opportunity to participate in our book club which will use the Political Determinants of Health.

Conference Survey Demographics and Eval Summary
Will Humble State Legislature, Wills Blog

Senate Director Nominations Committee Fallout

I continue to be bothered by the treatment that Dr. Cullen got at the Senate Director Nominations Committee hearing a couple weeks ago. Last week I sat down and put my thoughts to paper & sent in an op-ed to the Republic and Star. The Republic ran it yesterday and I hope the Star runs it next week.

It felt good to write this opinion piece – even though I know it probably won’t change anything. Here goes:

Senate Committee Doesn’t ‘Vet’ State Agency Nominees. It Sabotages Them
An Arizona Senate committee to review state agency director nominees looked good on paper. But it has turned out to be horrible in practice.

– Will Humble: opinion contributor

I’m a big fan of checks and balances. You might even call me an evangelist.

The founders of the U.S. and Arizona constitutions were careful to decentralize power. Divided government (and the natural tension between the branches) are big reasons why our republic is so resilient and has stood the test of time. 

Legislative branch oversight of the executive branch is essential.

Why? Because legislative oversight of executive agencies builds accountability. Accountability makes government responsive and effective.

When I first heard about the new Arizona Senate Director Nominations Committee, I thought, now there’s a good idea. The new committee might provide more in-depth oversight of nominees to important director positions.

In my experience, the old method of screening director nominations in standing committees often led to cursory candidate reviews.

But what looked good on paper turned out to be bad in practice.

Real bad.

Dr. Cullen’s ‘hearing’ was a sham

Exhibit A comes last week when the newly formed Committee on Director Nominations heard Gov. Katie Hobbs’ nominee for the director of the Arizona Department of Health Services, Dr. Theresa Cullen.  

That “hearing” foreshadowed a brutal, if not impossible, confirmation process more intent on using political litmus tests than vetting candidates’ professional qualifications for important director positions.

Cullen didn’t think COVID politics would derail confirmation

The committee hearing became an airing of grievances about many of the public health policy decisions made during the pandemic by the Pima County Board of Supervisors. Some members of the committee (mainly the chair) disagreed with those policy decisions and held Dr. Cullen responsible.

The committee spent three hours prosecuting Dr. Cullen, only to vote along party lines to deny her advancement.

Their decision to vote her down was clearly made well before the committee hearing. In short, it was a sham hearing.

A talented candidate has been lost

More than 30 medical and public health organizations submitted letters of support to the committee. Dr. Cullen was an ideal candidate to take the reins of an agency that has been sorely lacking in quality director-level leadership for many years.

None of that mattered in the end. 

Sadly, a super-talented director candidate has been lost.

Dr. Cullen has had a decades-long career in health care and public health, having achieved the rank of admiral in the U.S. Public Health Service and assistant surgeon general.

She’s accomplished at running very large organizations with budgets well over a billion dollars. Her professional reputation is one of integrity, accountability and commitment to evidence-based policy.

It’s tough to find good agency leaders

It’s not just Dr. Cullen who received a political litmus test hearing rather than a professional vetting.

Elizabeth Alvarado-Thorson, Gov. Hobbs’ nominee for director of the Arizona Department of Administration, received the same treatment this week, this time about abortion of all things.

These positions are not easy to fill. They need a very specialized set of skills and expertise.

In some cases, folks moved their families across the county to Arizona, only to get caught in political quicksand upon their arrival. That quicksand hurts our ability to retain qualified staff within these agencies and makes it harder to recruit additional local and national leaders. 

The committee is running off talent

Today, bitter partisanship and the way the Directors Nomination Committee is being managed is delaying director installations and sabotaging the opportunity to recruit talented and qualified candidates to key posts.

If the committee leadership were to change their objective and vet the professional qualifications for the director positions, their work would be providing a valuable service.

As it stands, the committee is basically just running off talent that Arizona state agencies desperately need.

That’s not checks and balances. It’s sabotage.

The problem isn’t the new committee. The problem is the way the committee is being led.

If it doesn’t change, and quick, we’re all in a heap of trouble and ordinary Arizonans will be the ones that suffer.

Will Humble is executive director of the Arizona Public Health Association and served as the director of the Arizona Department of Health Services for Gov. Jan Brewer (2009 – 2015). Reach him at [email protected].

_______

Note: I got a nice email from former ADHS Director Suzanne Dandoy on Saturday (1975-1980) in response to the piece. Thought some of you would enjoy it. Here it is:

Thank you for writing the article about political hearings on candidates to head state agencies, particularly the state health department.  I was the director of that department 1975-1980 (long before your time) and had to meet some strange qualifications in existence in the 1970s. 

I left the position at the request of Bruce Babbitt after he became Governor; I had been selected by a previous governor.  Five years later I became director of the state health department in Utah, where I served for 7 years and left by my own choice, to become Deputy Director of the Virginia state health department.

In all 3 states politics played a decisive role in what I did.  However, the politicalization of public health was certainly increased by the Covid pandemic.  I am glad not to be a health director any longer; I retired in 2000. 

You did all of us a favor by writing the opinion piece. Of course, I am not sure it will do any good.  We shall see what happens when Governor Hobbs selects another candidate for the position at the state health department.

– Suzanne Dandoy, M.D., M.P.H.

Editorial Note: I delivered the Scottsdale Progress in ’75 & ’76 and always had a transistor radio hanging from my handlebar. I listened to KOY back then which had a lot of news breaks. Dr. Dandoy was frequently on the radio talking about public health stuff like hepatitis or TB or whatever. 

I think I may have become interested in public health as a career because of listening to the broad interesting stuff she talked about on the radio.

Will Humble Professional Development, Wills Blog

2023 AZPHA Conference Summary

Thanks to all of our speakers, poster presenters, conference planners and participants for making our 2023 conference such a success. A big shout out to our scholarship sponsor, Maricopa County Department of Public Health and our other sponsors and exhibitors too.

A special thanks to Sheryl Clements, who donated countless creative hours designing our brochure:

View Our Conference Brochure

Well over 300 persons attended the conference in person. We also had many on-line participants for the plenary sessions and breakouts in Cottonwood. This is our 95th year as an organization… and I can’t think of a better way to celebrate our success as an organization than having such a well-attended conference.

Attendees will be getting an email later today with a plea to complete your conference evaluation. At the end of the survey, you’ll get a FREE DIGITAL BOOK (with a $40 value)! There are two options to choose from and they are first come first serve.

As an AZPHA member you’ll have the opportunity to participate in our book club which will use the Political Determinants of Health.

Conference Survey Demographics and Evaluation Summary
Will Humble Professional Development, Wills Blog

AZPHA Conference Sold Out… but We’ll Have a Virtual Option for Some Sessions

Our AzPHA conference on Thursday, February 23 is sold out, but we have a free virtual option to view our plenary sessions.

Addressing Health Disparities:

Building Infrastructure & Engaging the Next Generation of Public Health Leaders

View Our Conference Brochure & Agenda

Desert Willow Conference Center

4340 E Cotton Center Blvd, Phoenix, AZ 85040

Thursday, February 23, 2023

Here’s the link for virtual attendees to view the conference:

http://www.azwebcasting.com/sodexo/azpha2023/index.html
Simply use your regular email to sign in and then use this Password: azpha2023

(You don’t need to be registered for the conference to gain access to the virtual portions)

On-line plenary sessions include the programming between 8:45am and 10am; 12:30pm – 1:30pm; and 3:15 – 4:15pm.

Conference Brochure and Agenda
Will Humble State Legislature, Wills Blog

Legislative Session Update

We’ve officially passed the bill introduction deadline in both Chambers, meaning any new bills that come out must either be offered as a strike everything amendment or introduced with the permission of the House Speaker or Senate President.

A total of 1,625 bills have been introduced so far, and if this session is anything like years past, less than 25% of those will ultimately make it to the finish line to become new laws. The House attempted to pass a ‘continuation’ budget this week, but the measure failed on the House floor as one member of the majority, Rep. Liz Harris (R-13), voted against the budget. At this point, a path forward on budget negotiations is unclear, and we are likely in for a long session as this process unfolds.

We’ve signed in support and opposition to several bills this week. You can review our bill tracking spreadsheet to see our updated positions. I’ve signed up to speak at the podium to support SB1710, in the Senate Health Committee next week. That bill would move the Arizona State Hospital out of ADHS. The Superintendent and new agency would report to an independently appointed governing board.

See this for why this governance reform is necessary: 

How the Arizona State Hospital is Regulated & the Need for Governance Reform: A Primer

I’ll also be speaking in favor of HB2625 in the House Regulatory Affairs committee, which would require ADHS to visit licensed residential care facilities at least once per year – ending the opportunity for deem-status licensing via a 3rd party for these classes of facilities.

Will Humble Professional Development, Wills Blog

AzPHA President Musings

– Kelli Donley Williams

It’s no secret that Dr. Paul Farmer is one of my public health heroes. He and his colleagues at Partners in Health helped transform the way international health programs are designed. From his perspective that community health workers should be paid a living wage, to fighting for patented drugs to be sold at cost to countries battling drug-resistant tuberculosis and HIV, Dr. Farmer brought humanity to humanitarian work. He loved being with people, whether that was rural Haiti, Peru, Cuba, or treating forgotten prisoners in Russian jails.

Last year, AzPHA members were invited to participate in reading “Mountains Beyond Mountains,” by Tracy Kidder. Kidder followed Dr. Farmer for months, traveling with him around the world to see first-hand how the Partners in Health approach to public health and international aid was saving lives. The book club brought together AzPHA members across Arizona, and included lively conversation about Dr. Farmer and our own challenges in public health system change.

Imagine my delight when one of the book club readers and AzPHA member, Jason Zibart, reached out recently to say the town of Benson was looking at access to behavioral health services differently as a result of Dr. Farmer’s work. Zibart was approached by town officials who’d seen the Netflix documentary about Partners in Health called, “Bending the Arc.” They recognized that students in their public schools and other citizens didn’t have adequate access to behavioral health services. They wanted this to change.

On Thursday, Feb. 2, 2023 Benson Unified School District announced the opening of The Sunshine House Project. A former church has been converted into a community behavioral health location and will offer a physical space for providers to meet with Benson residents and provide psycho-educational groups for students, parents and support personnel. This new access point will bring critical services to a rural corner of our state. Read more here.

Our thanks to Jason and others in Benson who made this possible. And always, our admiration and gratitude to the late Dr. Farmer and those at Partners in Health. His influence and ability to improve healthcare lives on.

Keep your eyes open for upcoming news about the 2023 AzPHA book club. We hope you’ll join us. It’s a great way to meet other members and to hear about great public health work happening in Arizona.

And finally, if you’re interested, Tracy Kidder has another great book out recently that may be of interest. “Rough Sleepers” follows the story of Dr. Jim O’Connell’s work bringing healthcare to unsheltered folks in Boston.

Will Humble Professional Development, State Legislature, Wills Blog

Of Politics & Public Health

Governor Hobbs nominated Dr. Theresa Cullen to serve as her Director for the Arizona Department of Health Services. We believe Dr. Cullen has precisely the right skill set, talent, motivation, and personality to lead the Department.

The newly formed Senate Director Nominations committee held a confirmation hearing for Dr. Cullen last Thursday afternoon. After more than 4 hours, the committee voted, along party lines, to recommend that the Senate not confirm Dr. Cullen.

See AzPHA’s Letter Supporting Dr. Cullen’s Confirmation

The hearing felt more like a prosecution than a hearing designed to determine qualifications of a candidate for an important job.

You can view the hearing here. It starts off with an eloquent opening statement from Dr. Cullen. The committee was respectful at first. However, when the committee began the question period, the ‘questions’ quickly transitioned to become an airing of grievances about many of the public health policy decisions made during the pandemic, often decisions made by the Pima County Board of Supervisors for which they held Dr. Cullen responsible.

Perhaps the most difficult part for me was the very end. After the committee had already voted against her, Senator Hoffman launched into a several minute monologue of insults. I’m not recommending that you watch the ‘hearing’, but if you do, just watch the last 10 minutes to get a flavor for how cruel it was. I mean, what’s the point of continuing to attack her character and integrity after he had already achieved his objective: to secure a no vote from the committee?

The decision of Thursday’s Committee isn’t final, only the full Senate can reject her nomination. However, I think it’s unlikely that two Republicans will break from the committee recommendations and confirm her.

Sadly, it looks like a super-talented director candidate has been lost in the process. Dr. Cullen has had a decades long career in health care and public health, having achieved the rank of Admiral in the U.S. Public Health Service as well as being an Assistant Surgeon General. She is accomplished at running very large organizations with complex missions with budgets well over a billion dollars. Her professional reputation is one of integrity, accountability, and commitment to evidence-based policy.

Most recently, she has been serving as the Director of the Pima County Health Department, where she has become intimately familiar with ADHS’ mission – including first-hand experience identifying the agency’s strengths and weaknesses. That experience would have been super-important in informing internal interventions to improve the agency’s effectiveness.

Dr. Cullen is an ideal candidate to take the reins of an agency that has been sorely lacking in quality director-level leadership for many years.

ADHS has a very diverse and complex mission, from the responsibility to ensure the health and safety Arizonans in thousands of licensed facilities, the stewards of millions of vital records like birth and death certificates, nutrition assistance (via Women Infant and Children’s program), food safety, infectious and chronic disease epidemiology, newborn screening, running the Arizona State Hospital, and much more.

An agency with such a diverse and complex mission requires a leader with determination, curiosity and a commitment to evidence based public health policy. It also requires someone committed to recruiting, retaining, and training talented staff and building accountability within the organization at all levels.

Dr. Cullen was precisely the right person for the job.

Arizona would have been (and still would be) fortunate to have Dr. Cullen at the helm of the Arizona Department of Health Services. We still urge the full Senate to confirm her nomination, but in today’s polarized and politicized environment that is sadly unlikely.

Editorial Note: There two categories of persons who are attracted to being in jobs like the Director of ADHS. One category are persons who are interested because it provides a unique opportunity to use the resources and authority of the department to achieve better health for Arizonans. A second category of people are those who might be attracted because it just seems like a good paying job, is an opportunity to boost their pension, or is an opportunity to ‘be somebody’.

My fear is that quality, accomplished candidates who are interested in the post for the right reasons – people who want to help use the resources and authority of the agency to improve health – will no longer be interested in the position after seeing this new confirmation process. Sadly, we may now be left with candidates not interested in the job for the right reasons.

Will Humble Public Health, Wills Blog

AzPHA Supports Dr. Theresa Cullen’s Confirmation

See AzPHA’s Letter Supporting Dr. Cullen’s Confirmation

Governor Hobbs has nominated Dr. Theresa Cullen to serve as her Director for the Arizona Department of Health Services. Her confirmation hearing will be held on Thursday, February 9, 2023. We believe Dr. Cullen has precisely the right skill set, talent, motivation, and personality to lead the Department.

ADHS has a very diverse and complex mission, from the responsibility to ensure the health and safety Arizonans in thousands of licensed facilities, the stewards of millions of vital records like birth and death certificates, food assistance through the Women Infant and Children’s program, food safety, infectious and chronic disease epidemiology, running the Arizona State Hospital, and much more.

An agency with such a diverse and complex mission requires a leader with determination, curiosity and a commitment to evidence based public health policy. It also requires someone committed to recruiting, retaining, and training talented staff and building accountability within the organization at all levels.

We believe that Dr. Cullen is precisely the right person for the job.

With more than 27 years of public service experience, Dr. Cullen has consistently demonstrated a strong work ethic and a passion for accountability and fidelity to ethics. She has an impressive career path including having achieved the rank of Rear Admiral and Assistant U.S. Surgeon General.

Most recently, she has been serving as the Director of the Pima County Health Department, where she has become intimately familiar with ADHS’ mission – including first-hand experience identifying the agency’s strengths and weaknesses. That experience will be important in informing internal interventions to improve the agency’s effectiveness.

Her professional reputation is one of integrity, accountability, and commitment to evidence-based policy.

Arizona would be fortunate to have Dr. Cullen at the helm of the Arizona Department of Health Services and we urge you to confirm her nomination as Director.

Will Humble Assurance & Licensure, State Legislature, Wills Blog

Does ADHS’ Substandard Performance Regulating Long-term Care Facilities During the Ducey Administration Call for a System Overhaul or Just More Accountability?

Arizona has a hybrid public/private assurance model for regulating the care at nursing homes and assisted living facilities and homes. Facilities in both categories have the option of having the state health department surveyors come out for an annual inspection to evaluate their adherence to state licensing rules or hire a 3rd party contractor (that they pay for) to come out for a certification visit.  That paperwork can then be turned in to the state in lieu of a state survey. That’s called “deemed status” licensure ARS 36-425. Note: Nursing homes who bill Medicare/Medicaid can’t do accreditation in lieu of state licensure inspections because of the contracts they have with CMS.

Complaint investigations (which often provide valuable information to identify poor or dangerous care) have always been the responsibility of ADHS – and those complaint investigations can’t be outsourced to 3rd parties.

CMS’s Assurance Role

In addition to the ADHS-driven regulatory process, the Centers for Medicare & Medicaid Services (CMS) has an assurance process for facilities that care for Medicare or Medicaid members for which they are the payer. CMS doesn’t regulate the facilities per-se (CMS doesn’t have the authority to issue a state license), but they do want to make sure they’re paying for quality care. CMS has their own care standards which they call Requirements of Participation.

Note: CMS is often the primary payer for care in nursing homes – but they don’t pay for assisted living services.

CMS doesn’t come out to Arizona to verify whether a facility is adhering to their standards. Instead, they contract with state health department inspectors (ADHS) to verify whether a facility is adhering to their requirements of participation standards. ADHS has a contract with CMS to do annual inspections to verify whether a facility is adhering to CMS’ standards.

Not all nursing homes take Medicare/Medicaid funds – and facilities that don’t take CMS money don’t need to comply. Because CMS doesn’t pay for care in assisted living centers and homes, they don’t get inspected by ADHS for CMS standards (just the state licensing requirements).

What Would SB1293 Do?

A legislator is proposing a measure SB1293 which would also outsource complaint investigations. The bill would charge ADHS with contracting with a 3rd party certification organization to do all the annual inspections and complaint investigations. It’s unclear to what standard the 3rd party would hold the facility to (state licensing rules?). ADHS would use their licensing fees to hire the 3rd party.

Here are the specific provisions in SB1293:

  • By July 1, 2024, ADHS would contract with a 3rd party to conduct all inspections, complaint investigations and survey duties for assisted living & skilled nursing facilities.
  • The contracted 3rd party would inspect each facility twice per year and conduct supplemental inspections in response to complaints. All inspections would be unannounced.
  • It would also take away the deemed-status provision currently in law that allows facilities to hire their own certification entity and turn that in for deemed status licensure (a good thing).
  • Facilities would also be required to post a sign in each patient’s or resident’s room with information about how to make a complaint regarding abuse or neglect (a good thing).
  • The 3rd party ADHS hires would be required to file an annual report regarding the condition of all long-term care facilities, inspection and survey results and the disposition of complaint investigations.

Why the Effort to Overhaul the System?

There’s a great deal of frustration among legislators and the public regarding ADHS’ performance regulating nursing homes during the Ducey Administration (specifically, while Cara Christ was Director and Colby Bower was running Licensing).

See: Auditor General’s Office Produces Scathing Review of ADHS’ Nursing Home Complaint Investigations During the Director Christ Era

A 2019 Arizona Auditor General Report found, among many other things, that ADHS (during the Director Christ era) failed to investigate, or timely investigate or resolve many long-term care facility complaints. The report laid out 4 key areas where performance improvement was needed. The state legislature even followed through, giving the agency an additional $1.6M to hire staff, however, Christ/Bower used very little of that money and made very little progress correcting the problems found.

In fact, a follow-up report issued in 2022 concluded that the agency had not implemented any of the required changes, and also found these disturbing findings:

  • Between 7/1/19 and 4/21/21 ADHS (under the leadership of former Director Christ and Assistant Director Colby Bower) lowered the priority level of 98% of their open high priority complaints, giving them months more time to investigate and giving the appearance they were making improvements (high risk complaints need to be done in 10 days vs months for the others).
  • ADHS leadership CLOSED 79% of those former high priority complaints without ever doing an investigation.
  • ADHS leadership CLOSED 82% of high priority facility self-reports after changing them to medium and then closing without an investigation.
  • In the second half of 2019 (before the 1st auditor general report) ADHS had classified 42% of nursing home complaints as high risk. After the report was published – the % of complaints classified as high risk dropped to only 4% (July – Dec. 2020).
  • ADHS did not post complaints on AZCARECHECK (the public disclosure site) unless there was an investigation…  but because they closed out most complaints without an investigation, thousands of those complaints never made it to their website- further greatly limiting the ability of family members to make informed decisions.

Is SB1293 the Answer to ADHS’ Substandard Performance During the Ducey Administration?

It’s easy to see why legislators would be frustrated with ADHS’ performance during the Ducey/Christ Administration. After all, assuring adequate care for Arizona’s most vulnerable persons is among state government’s most important responsibilities. It’s also easy to see why it’s attractive to some legislators to outsource the work to 3rd parties after they observed several years of substandard performance by the executive branch.

CMS pays for about 60% of Arizona’s federal and state survey process. As such, overhauling the statute would also require CMS to approve the changes that SB1293 would make. Note: No other state has done a total privatization of the survey process.

The question becomes: Is the system irreparably broken and in need of a complete overhaul or is a better answer to hold ADHS accountable for their regulatory responsibilities?

I would argue that the primary problem isn’t the existing statutory framework for regulating long term care facilities. Rather, poor senior agency leadership and the failure of the Governor’s office to hold ADHS accountable for making the corrections identified in the 2019 Auditor General’s report that is the primary problem.

So, What’s a Better Solution? 

I suggest the Legislature exercise vigorous oversight authority of the executive branch (ADHS) charging the Department with quarterly reports of their progress followed by an in-depth Arizona Auditor General’s Office to assess the agency’s progress.

 

If ADHS performance doesn’t improve, perhaps the reforms in SB1293 need to be implemented…  but it would be inefficient to make drastic statutory changes when all that was needed was better agency leadership.

Will Humble Professional Development, Wills Blog

Do You Have a Renewed Interest in Serving in State Government Now that We Have New Executive Leadership?

Consider Serving On a Board or Commission

Perhaps now that we have new leadership in the Governor’s Office you also have a renewed interest in serving on one of the many Boards and Commissions in Arizona? Serving on a board or commission gives you a chance to make a significant contribution to the governance of Arizona by lending your experience, judgment, and ability. Here’s some background about ways you can serve.

Board & Commissions are independent bodies consisting of members who are appointed by Governor Hobbs (there are a few exceptions however). Appointments are created statute enacted in the State Legislature or by an Executive Order.

There Are 220 Active Boards & Commissions in Arizona:
Boards and Commissions List

There are two types of boards and commissions: regulatory and advisory. Regulatory boards oversee the licensing, handle complaints, and enforce disciplinary actions of individuals or industries that fall within the jurisdiction of the board’s authority. For example, a complaint filed by a patient against a physician would be reviewed, investigated, and appropriately acted upon by the Arizona Medical Board.

Advisory boards, develop policy and makes recommendations to public officials on how to address specific issues. For example, the Civil Rights Advisory Board investigates and holds hearings on infringements of Arizona civil rights laws and then advises the civil rights division of the Attorney General’s Office.

Time commitment varies depending on the board. Most boards meet once a month for four to six hours, with some added preparatory work needed. However, there are many boards that meet quarterly or even as little as twice a year. Most Board members serve terms that range from two to seven years for most boards and commissions, while other members serve ‘At the pleasure’ of the Governor.

How to Apply

You can apply online from the Governor Hobbs’ Boards & Commissions Website. In the application you can describe the kinds of boards you’re interested in. A vacancy list is also available on the Governor’s Boards and Commissions Website which is updated monthly with current board positions.

Submit an Application
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