Transforming a County Health Department

    • July 10, 2008

The Problem: By 1990, the Miami-Dade County Health Department, one of 67 county health departments in Florida, needed a complete overhaul. Charged with providing health and safety services to residents in the eighth largest county in the United States, the health department was burdened with decrepit buildings, outdated technology, and an increasingly demoralized staff plagued by high turnover rates and low employee satisfaction.

The Proposal: Lillian Rivera, RN, MSN, was director of nursing at Jackson Memorial Medical Center in Miami when she visited the Miami-Dade County Health Department in 1990 at the urging of a former colleague who thought she might welcome a new professional challenge. As Rivera assessed the cumbersome health care bureaucracy, her experience as nursing director for the public health care system in San Juan, Puerto Rico, allowed her a rapid analysis: "It was in the twilight zone. It needed a total overhaul."

Citing her passion for public health, Rivera immediately joined the health department and began a 12-year mission to help transform it into a dynamic, progressive organization. She served in various capacities, including executive community health nursing director, in which she was responsible for public health nursing and co-administration of the daily operations of the health department. "The moment I made the transition from the hospital, I said, 'I'm going to do this. This organization will be transformed,' " she says. "It was a total laboratory. You made improvements and you saw the benefits right away. What a great opportunity, to take the organization to that new level."

Grantee Results: Rivera entered the Robert Wood Johnson Executive Nurse Fellows Program in 1999 just before she was named acting executive administrator of the health department. With the grant and mentoring she received as a fellow, Rivera's ability to step up the department's reorganization efforts was expedited. "Being a part of RWJF took me to a whole new level of understanding and learning," she says. "It put us on a fast track to complete the cycle."

Rivera implemented new standards and procedures to govern policies, protocols, professional development and education, medical records, utilization review and strategic planning. She upgraded technology and made certain that employees had the proper tools to do their work, as one her key goals was to engage employees in department objectives and have them be proactive about their work. "When you are trying to improve performance, it is not about brain-washing. It is not about imposition," she says. "You don't impose things on people-you let them know that everything has a purpose. Is it going to make our job easier, better? Will it result in better services? As incremental changes are made, people say, 'Hey, there is a method to this madness.'"

In 2002, the transformation of the Miami-Dade County Health Department was publicly recognized when Rivera and the department accepted the Governor's Sterling Award for organizational excellence. However, Rivera's work was not done. In 2003, she was named administrator of the health department, and in 2006, when she accepted a second Sterling Award, Rivera reported new milestones in the department's transformation: From 2002 to 2006, employee turnover rate dropped 32 percent, overall employee satisfaction increased 18 percent and customer satisfaction increased from 87 to 90 percent.

Grantee Perspective: Today the health department and its 1,000 employees serve over 2.4 million residents in Miami-Dade County, providing nearly 2 million services a year with a budget of $67 million. Apart from a temporary six-month assignment in Tallahassee as deputy to Florida's first surgeon general, Rivera has continued to oversee the department as well as two large community groups-the Consortium for a Healthier Miami-Dade and the Hospital Consortium for Miami-Dade.

In April, Rivera was named the Florida Outstanding Woman in Public Health for 2008 by the University of South Florida College of Public Health. But she credits colleagues and staff for their critical role in the transformation of the health department. "Human resources are your most important asset," she says. "You have to treasure them like gold. They are the ones who will lift you up and take you to another level."

Rivera believes the RWJF fellowship gave her the opportunity to work with health care leaders and experts whom she might never have met. "The networking is unbelievable. The fellows program and my mentor are the gifts that keep on giving, she says. "Nurses really need this type of program. We have a tremendous leadership deficit, and this program really works. It does make a difference."

RWJF Perspective: The Robert Wood Johnson Executive Nurse Fellows Program was created in 1997 to capitalize on the profession's strengths and build the leadership capacity of nursing. "Nurses are in a unique position to serve in leadership roles and contribute to transforming our health care system," says Susan Hassmiller, PhD, RN, RWJF senior program officer. "The executive nurses program is part of the Foundation's building human capital strategy to attract, develop and retain diverse and high-quality leaders and a workforce to improve health and health care."

Lillian Rivera, RN, MSN

Lillian Rivera, RN, MSN
Robert Wood Johnson Executive Nurse Fellow